Nursing Fundamentals Quiz
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Questions and Answers

A nurse is assessing a patient who is at risk of falling. What is the primary purpose of conducting a fall risk assessment?

  • To determine the patient's insurance eligibility for rehabilitation services.
  • To diagnose the risk of falling and guide nursing interventions. (correct)
  • To identify potential safety hazards in the patient's environment.
  • To document the patient's medical history for legal purposes.
  • In which order should a nurse prioritize patient health problems, according to Maslow's hierarchy of needs?

  • Love and belonging, self-esteem, physiological, safety.
  • Physiological, safety, love and belonging, self-esteem. (correct)
  • Safety, physiological, self-esteem ,love and belonging.
  • Self-esteem, love and belonging, safety, physiological.
  • Which intervention is an example of a nurse-initiated intervention?

  • Educating the patient on deep breathing and coughing techniques. (correct)
  • Consulting with a physical therapist for the patient.
  • Administering prescribed pain medication to the patient.
  • Ordering a complete blood count (CBC) for the patient.
  • What is the primary purpose of the 'cognitive' competency in nursing practice?

    <p>To solve problems, make decisions, and teach patients effectively. (D)</p> Signup and view all the answers

    A nurse is using electronic health records. What ethical/legal responsibility is most important when documenting nursing interventions?

    <p>Recording all nursing interventions in a timely and accurate manner. (A)</p> Signup and view all the answers

    What is the main goal of the QSEN (Quality and Safety Education for Nurses) initiative in nursing?

    <p>To promote evidence-based practice and quality improvement in nursing care. (D)</p> Signup and view all the answers

    Which aspect of the nursing process involves reflection to determine the effectiveness of the nursing care plan?

    <p>Evaluation (B)</p> Signup and view all the answers

    Why is timely and accurate communication vitally important in healthcare, especially regarding patient records?

    <p>It ensures effective coordination of care and patient safety. (A)</p> Signup and view all the answers

    A patient recovering from a stroke has limited mobility on their left side. Which intervention would best address the expected patient outcome of improving their independence in performing daily activities?

    <p>Providing assistive devices and training for one-handed techniques. (C)</p> Signup and view all the answers

    An elderly patient with a history of arthritis reports increased joint stiffness and pain. Considering lifespan considerations and factors affecting mobility, what would be the most appropriate initial intervention?

    <p>Suggesting gentle range-of-motion exercises and application of heat to the affected joints. (B)</p> Signup and view all the answers

    A patient who has been on bed rest for an extended period is now starting to ambulate. Which physiological effect of immobility should be the primary concern when planning interventions?

    <p>Decreased muscle strength and endurance, leading to increased risk of falls. (A)</p> Signup and view all the answers

    A patient with a spinal cord injury at the thoracic level is experiencing impaired mobility. Which intervention is the most appropriate to enhance their mobility and independence?

    <p>Providing instruction in wheelchair mobility skills and upper body strengthening exercises. (C)</p> Signup and view all the answers

    A patient reports difficulty with plantar flexion after a foot injury. Which activity would be most directly affected by this limitation?

    <p>Pointing the toes downwards. (A)</p> Signup and view all the answers

    Which of the following is the MOST critical initial step a nurse should take to mitigate biases during patient assessment?

    <p>Using standardized assessment tools to ensure objectivity and consistency in data collection. (D)</p> Signup and view all the answers

    During data interpretation, a nurse identifies a discrepancy between a patient's reported pain level and their observed behavior. What should the nurse do FIRST?

    <p>Reassess the patient's pain using a different pain scale and observe for nonverbal cues. (C)</p> Signup and view all the answers

    A patient is diagnosed with 'Risk for Infection related to surgical incision, as evidenced by redness and swelling at the site.' Which part of this nursing diagnosis represents the etiology?

    <p>Surgical incision (C)</p> Signup and view all the answers

    Which action demonstrates effective validation of nursing diagnosis?

    <p>Discussing assessment findings and potential diagnoses with the patient to confirm their relevance and accuracy. (A)</p> Signup and view all the answers

    A medical diagnosis of pneumonia indicates the presence of an infection in the lungs. What is the MOST appropriate nursing diagnosis that addresses the patient's response to this condition?

    <p>Impaired gas exchange related to fluid accumulation in the lungs. (D)</p> Signup and view all the answers

    A patient is diagnosed with 'Acute Pain related to surgical incision as evidenced by a pain rating of 7/10 and guarding behavior.' What is the MOST appropriate nursing intervention based on this diagnosis?

    <p>Provide pain medication and non-pharmacological comfort measures. (C)</p> Signup and view all the answers

    What is the PRIMARY goal of using the SOAPIER format (Symptoms, Objective, Assessment, Planning, Implementation, Evaluation, Revision) in patient documentation?

    <p>To provide a structured and comprehensive approach to documenting patient care and progress. (B)</p> Signup and view all the answers

    Which scenario exemplifies a nurse applying data clustering during the diagnostic process?

    <p>A nurse organizes a patient’s symptoms, vital signs, and medical history to identify patterns and potential problems. (A)</p> Signup and view all the answers

    A nurse is conducting a nutritional assessment on a newly admitted patient. Which assessment parameter primarily addresses the body's ability to utilize ingested nutrients?

    <p>Physiological factors affecting nutrient absorption and metabolism (C)</p> Signup and view all the answers

    During a nutritional assessment, a nurse identifies several risk factors related to a patient's social determinants of health (SDOH). Which of the following nursing interventions best addresses these SDOH risks?

    <p>Referring the patient to community resources that provide food assistance and address socioeconomic barriers (A)</p> Signup and view all the answers

    A patient's lab results show a serum albumin level of 3.0 g/dL. How should the nurse interpret this result in the context of the patient's nutritional status?

    <p>Low albumin levels can indicate malnutrition or inflammation (D)</p> Signup and view all the answers

    Which principle is MOST important to follow when documenting in a patient's chart?

    <p>Ensure documentation objectively reflects the patient's condition and care provided. (D)</p> Signup and view all the answers

    A nurse is assessing a patient at risk of malnutrition. Which physical examination finding is a sign of malnutrition?

    <p>Edema and muscle wasting (A)</p> Signup and view all the answers

    During a patient handoff, which element is MOST critical to communicate to the oncoming nurse?

    <p>Potential urgent situations and necessary client care directives for the next few hours. (A)</p> Signup and view all the answers

    Which nursing action is most important when ensuring confidentiality during therapeutic communication?

    <p>Obtaining informed consent before sharing information (A)</p> Signup and view all the answers

    Which action BEST protects confidential patient information when using electronic medical records?

    <p>Logging off the computer before leaving the workstation. (A)</p> Signup and view all the answers

    What is the primary role of a nurse acting as an advocate for a patient?

    <p>Supporting the patient's decisions and ensuring their rights are respected (B)</p> Signup and view all the answers

    What is the PRIMARY goal of the orientation phase in a therapeutic nurse-patient relationship?

    <p>To introduce the nurse, establish expectations, and set client goals. (A)</p> Signup and view all the answers

    In the SOAPIER method of documentation, what does the 'A' stand for?

    <p>Assessment (C)</p> Signup and view all the answers

    A patient presents with a flat, circumscribed area of skin discoloration that is less than 1 cm in diameter. Which type of primary lesion is this?

    <p>Macule (D)</p> Signup and view all the answers

    Which component is essential for establishing positive therapeutic communication with a patient?

    <p>Displaying empathy and understanding (A)</p> Signup and view all the answers

    Which of the following practices would be MOST effective in maintaining the confidentiality of a patient's Protected Health Information (PHI)?

    <p>Shredding printed client information immediately after it's no longer needed. (D)</p> Signup and view all the answers

    A patient is exhibiting signs of dysphagia during mealtime. Which nursing intervention is most appropriate?

    <p>Position the patient upright and provide thickened liquids (B)</p> Signup and view all the answers

    Which of the following findings indicates abnormal skin turgor?

    <p>Skin remains elevated for an extended period after being pinched. (D)</p> Signup and view all the answers

    Using the SBAR communication tool, a nurse is calling a doctor about a patient. Which part of SBAR would include the patient's vital signs and current medications?

    <p>Background (A)</p> Signup and view all the answers

    You observe a superficial skin elevation formed by free fluid within the skin layers. Which primary lesion is most likely present?

    <p>Bulla (D)</p> Signup and view all the answers

    During which phase of the therapeutic nurse-patient relationship would a nurse summarize the goals achieved and discuss the patient's feelings about the relationship ending?

    <p>Termination Phase (A)</p> Signup and view all the answers

    Which of the following is an example of a secondary skin lesion?

    <p>Scale (C)</p> Signup and view all the answers

    A patient has an area of intact skin with persistent redness that does not blanch when pressed. Which stage of pressure injury is this?

    <p>Stage I (B)</p> Signup and view all the answers

    A patient is diagnosed with a Stage III pressure injury. What is the defining characteristic of this stage?

    <p>Full-thickness skin loss not involving underlying fascia. (C)</p> Signup and view all the answers

    Which of the following circulatory factors is most critical for maintaining healthy integumentary function?

    <p>The heart's ability to pump blood effectively. (C)</p> Signup and view all the answers

    What circulatory requirements are needed for healthy skin?

    <p>Heart must pump adequately, circulating blood volume must be sufficient, arteries and veins must be patent (B)</p> Signup and view all the answers

    Flashcards

    Common problems in assessment

    Issues like incomplete data, poor communication, and equipment failure.

    SOAPIER documentation

    A method for thorough documentation: Symptoms, Objective, Assessment, Planning, Implementation, Evaluation, Revision.

    Data Collection

    Process of gathering comprehensive data from assessments and interviews.

    Data Clustering

    Organizing collected data into patterns to identify trends or abnormalities.

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    Data Interpretation

    Analyzing grouped data to understand patient conditions and issues.

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    Problem Identification in nursing

    Recognizing actual or potential health issues based on data analysis.

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    Nursing Diagnosis

    Defines health problems, their causes, and supporting evidence.

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    Nursing Interventions from diagnoses

    Developing goals and interventions based on assessment findings.

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    Data Importance in Nursing

    Data helps identify the scientific causes behind patient conditions and guide diagnosis.

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    Maslow's Hierarchy in Nursing

    A method to prioritize patient health problems based on basic human needs.

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    Nurse-Initiated Interventions

    Actions a nurse can take independently to address patient needs without a doctor's order.

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    Physician-Initiated Interventions

    Actions that require a doctor's orders to be carried out by the nursing team.

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    Collaborative Interventions

    Actions taken in cooperation with other healthcare professionals for patient care.

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    Evaluation in Nursing Process

    The step that assesses whether the nursing plan and interventions are effective.

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    Importance of Accurate Documentation

    Timely and accurate recording of patient care prevents errors and ensures effective communication.

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    QSEN Competencies

    Quality and Safety Education for Nurses competencies that guide nursing care implementation.

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    Key principles of charting

    The essential guidelines for effective medical charting include accuracy, thoroughness, conciseness, objectivity, and timeliness.

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    SBAR

    A communication framework used for concise information transfer: Situation, Background, Assessment, Recommendation.

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    SOAPIER

    A method of nursing documentation including Subjective, Objective, Assessment, Planning, Implementation, Evaluation, Reflection.

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    PIE

    An efficient nursing documentation method: Problem, Implementation, Evaluation.

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    Patient handoff components

    Essential information during patient transfer: demographics, medical diagnosis, health status, plan of care, recent progress, urgent directives.

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    Protecting patient confidentiality

    Measures to safeguard patient information, including securing logins and shredding documents with personal health information.

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    Phases of therapeutic nurse-patient relationship

    The relationship includes three phases: Orientation, Working, and Termination, each with specific goals and activities.

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    Therapeutic communication challenges

    Obstacles faced during effective therapeutic interactions, including barriers in understanding and emotional responses.

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    Mobility

    The ability to move freely and control one's body position.

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    Normal Musculoskeletal Functions

    Includes full range of motion: flexion, extension, rotation, etc.

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    Types of Exercise

    Anaerobic vs aerobic and isontonic vs isometric types of exercise.

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    Factors Affecting Mobility

    Includes lifestyle, musculoskeletal integrity, and age among others.

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    Effects of Exercise vs Immobility

    Exercise enhances physiological function; immobility negatively impacts health.

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    Normal integumentary findings

    Normal skin color is pink, warm, with good turgor and smooth texture, no lesions.

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    Abnormal integumentary findings

    Abnormal skin shows red, white, blue, black colors, coldness, poor turgor, and presence of lesions.

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    Primary lesions

    Skin lesions that appear first, including macules, papules, nodules, and wheals.

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    Macule

    A macule is a circumscribed, flat, nonpalpable change in skin color.

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    Stage I pressure injury

    A Stage I pressure injury shows persistent redness of intact skin.

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    Stage II pressure injury

    Stage II shows partial-thickness skin loss with exposed dermis.

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    Stage III pressure injury

    Stage III shows full-thickness skin loss without underlying fascia involved.

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    Factors affecting integumentary function

    Heart function, blood volume, and vessel patency affect skin health.

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    Therapeutic Communication

    A form of communication focused on the needs and well-being of the patient.

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    Informal Contracts

    Agreements between the therapist and patient about expectations during communication.

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    Nutritional Assessment Components

    Includes interview, physical exam, and lab tests to evaluate nutritional status.

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    Risk Identification

    Assessing factors that may affect a patient's nutrition, like SDOH and lifestyle.

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    Malnutrition

    Inadequate nutrition determined by assessments revealing deficiencies or excesses.

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    Physical Exam Measurements

    Key metrics like BMI and calorie count used to assess nutritional health.

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    Abnormal Nutritional Findings

    Indicators from assessments that suggest poor nutritional status.

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    Study Notes

    Foundational Nursing Concepts

    • Clinical judgment is the outcome of critical thinking, evident in decisions nurses make to provide the best evidence-based care.
    • Clinical reasoning is a process involving analyzing information to make decisions about patient care, emphasizing a disciplined, active, multidimensional approach.
    • Critical thinking is a purposeful, disciplined process of analyzing and evaluating information and drawing conclusions.
    • The nursing process includes assessment, diagnosis, planning, implementation, and evaluation.
    • Different types of nursing assessments include admission, focused or problem-orientated, and time-lapse assessments.
    • Emergency assessments address urgent patient needs in crisis situations.
    • Organising frameworks are essential for assessment data, like the functional health approach, head-to-toe model, and body systems model.
    • Objective data is observable, measurable facts, while subjective data describes what the patient states.

    Data Collection Methods

    • Observation uses senses to gather data about a patient.
    • Interviews are discussions eliciting subjective data, including open and closed-ended questions.
    • Physical assessment techniques include palpation, inspection, percussion, and auscultation.
    • Data validation involves cross-checking information from different sources and considering patient history and context, employing clinical reasoning and collaborating with other healthcare professionals.
    • Data analysis processes include clustering and interpretation of collected data, leading to nursing diagnosis formulation through identifying and analysing patterns, trends, and variations.
    • Identifying common data collection problems includes inaccurate or incomplete information, communication breakdowns, and equipment malfunctions.

    Nursing Diagnoses, Interventions, and Evaluation

    • Medical diagnoses identify diseases, while nursing diagnoses focus on the patient's response to health and illness, solvable with nursing interventions.
    • Diagnoses are used to develop patient goals.
    • Nursing interventions are structured plans to address patient problems that are derived from the assessment.
    • Nurse-initiated, physician-initiated, and collaborative interventions reflect different roles and responsibilities in patient care.
    • Prioritizing patient health problems is based on the patient's needs, often using Maslow's Hierarchy of Needs.
    • Implementing nursing strategies includes coordinating plans, executing interventions, providing education, and employing equipment.
    • Evaluation involves measuring the effectiveness of interventions and monitoring changes in the patient.

    Documentation and Records

    • Clear and accurate documentation is crucial for communication among healthcare professionals and for patient care continuity.
    • The purpose of nursing records includes communicating details of care, tracking changes in patient condition, and providing a historical reference.
    • Important principles for documentation include accuracy, thoroughness, conciseness, objectivity, timeliness, and a structured format such as SBAR or SOAPIER.

    Communication

    • Accurate and timely communication is vital in healthcare, with clear and concise records facilitating collaboration.
    • Principles of clear communication include accuracy, thoroughness, brevity, objectivity, and timeliness.

    Nutrition

    • Nutritional assessments involve interviews and physical examinations, including risk identification and dysfunction identification to ensure efficient patient care.
    • Documentation processes include outlining guidelines to ensure effective communication and identify critical components of documentation.
    • Factors affecting nutrition include various patient needs, demographics, and habits affecting the overall nutritional state.

    Mobility

    • Mobility is the ability to move oneself, control one's body position, and perform activities of daily living (ADLs).
    • Normal mobility depends upon the musculoskeletal system, including full range motion, joint flexibility, muscle tone, and strength.
    • Assessment of mobility involves understanding normal and abnormal functions of the musculoskeletal system and various factors affecting those processes.
    • Evaluation of mobility problems includes appropriate interventions to improve mobility.

    Cardiovascular, Respiratory and Metabolic Functions

    • Immobility affects the efficiency of cardiovascular function leading to risks like blood clots, decreased heart rate, and blood pressure.
    • Factors affecting mobility are considered for intervention, and appropriate equipment and strategies are essential.
    • Measures to improve mobility and related interventions based on the clinical picture and assessment data are used.

    Skin Integrity/Wound Healing:

    • Healthy skin is pink, warm, and elastic; abnormal skin has changes in color, texture, and turgor among other factors.
    • Assessments include history of allergies, exposure to skin irritants, existing skin conditions, and current symptoms like lesions, inflammation, and pain.

    Risk Assessment

    • Risk factors are considered critical for patient care and safety in healthcare settings, and are evaluated during the patient care plan process.

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    Nursing 270 Exam 1 PDF

    Description

    Test your knowledge on essential nursing concepts, including fall risk assessments, Maslow's hierarchy of needs, and ethical responsibilities in documentation. This quiz covers key interventions and communication strategies vital for patient care in nursing practice. It's an excellent way to reinforce your understanding of foundational nursing practices.

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