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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