Nursing Health History Assessment Quiz

What type of nursing diagnosis is 'readiness for enhanced communication' an example of?

A wellness nursing diagnosis

In the nursing diagnosis 'impaired physical mobility', the word 'impaired' is an example of:

A descriptor

When assessing Mr. Fletcher, what is the first appropriate assessment technique for data collection?

Interview him

Which of the following are defining characteristics for the nursing diagnosis 'impaired nutrition (more than body requirements)'?

Patient’s weight is 10 to 20% more than his ideal height and frame Signup and view all the answers

What would be considered a realistic short-term goal for Mr. Fletcher to achieve prior to the next visit?

To remove two foods that are high in cholesterol from his diet Signup and view all the answers

What step should the nurse take to avoid incorrect inferences and ensure that the data from Mr.Fletcher’s assessment are accurate?

Validate data with the patient Signup and view all the answers

When clustering Mr.Fletcher’s data, what should the nurse do?

Organize cues into patterns that enable the nurse to identify nursing diagnoses Signup and view all the answers

Which of the following statements BEST describes a nursing diagnosis?

A clinical judgement about individual, family, or community responses to actual and potential health problems or life processes Signup and view all the answers

Why would the nurse choose to use a standard formal nursing diagnostic statement for Mr.Fletcher?

To standardize and communicate patient problems and nursing interventions Signup and view all the answers

What is the first nursing intervention to correct when watching Mr. Fletcher take his own blood pressure?

Mr. Fletcher has wrapped the blood pressure cuff too loosely Signup and view all the answers

Which is an example of an expected outcome statement written for Mr. Fletcher in measurable terms?

Patient will take his blood pressure daily and report systolic pressures over 140 mm Hg Signup and view all the answers

What is required for a collaborative intervention to assess Mr. Fletcher for peripheral arterial disease?

Multidisciplinary team intervention Signup and view all the answers

If the primary nurse wants to help Mr. Fletcher assess his peripheral arterial disease, what might be a collaborative intervention?

Consulting with a vascular specialist to aid in diagnosing and managing the condition Signup and view all the answers

What should the primary nurse prioritize when completing an individualized written care plan for Mr. Fletcher?

Collaborating with the patient and family in the development of the plan Signup and view all the answers

Which of the following interventions is an example of a specific life-saving measure that the primary nurse may implement?

Recognizing the signs of stroke in a patient Signup and view all the answers

How would the nurse use to evaluate the long-term impacts of teaching Mr. Fletcher how to take an antilipemic medication?

Ensure that Mr. Fletcher is scheduled for blood work that includes a fasting lipid panel monthly Signup and view all the answers

What objective evaluative criteria would the nurse use to judge Mr. Fletcher’s response to the care provided?

Goals and expected outcomes outlined in the care plan Signup and view all the answers

If Mr. Fletcher remains hypertensive despite taking prescribed medication, what should be the primary nurse’s initial action?

Ask Mr. Fletcher whether he is taking other medications such as NSAID therapy Signup and view all the answers

According to Kuhn, scientific advances are most likely to happen when creative individuals do which of the following?

Approach a problem in a new way Signup and view all the answers

The central idea characterizing the McGill model for nursing is that it:

Focuses on health rather than on illness or treatment Signup and view all the answers

Building upon a psychoanalytic perspective, theorist Hildegard Peplau considered which of the following as fundamental aspects of nursing practice?

All of the above Signup and view all the answers

The distinctive contribution that Canadian theorist Evelyn Adam made to nursing’s thinking at the time was a conceptualization of the essence of nursing as:

A helping process Signup and view all the answers

The idea that nursing theorists drew specifically from systems theories was to consider the human being as:

A whole and component parts in intricate interaction with one another Signup and view all the answers

What best describes a theory in the context of nursing?

Provides a systematic view of explaining, predicting, and prescribing phenomena Signup and view all the answers

In the early enterprise of theorizing about nursing practice, who was primarily driving the process?

Nursing educators Signup and view all the answers

What were the four basic steps involved in the original form of the nursing process?

Assessment, planning, intervention, evaluation Signup and view all the answers

Which concepts formed the metaparadigm structure of nursing theories?

Person, environment, health, and nursing Signup and view all the answers

What was the main focus of attention for early nursing theorists?

How to organize and make sense of general nursing knowledge and apply this knowledge to an individual clinical case Signup and view all the answers

Which of the following would be considered an independent nursing intervention?

Complete a chest X-ray to look for signs of heart failure and Obtain an order for new antihypertensive medication from the nurse practitioner. Signup and view all the answers

What is the primary focus when a nurse asks Amil, 'How do you feel about yourself?'

Self-esteem Signup and view all the answers

Which question would be appropriate to assess Amil’s satisfaction and dissatisfaction associated with role responsibilities and relationships?

What are your responsibilities in your family? Signup and view all the answers

What action would help increase Amil’s self-awareness?

Establishing a trusting nurse–patient relationship that allows him to explore his thoughts and feelings Signup and view all the answers

Apart from physiological stability and pain control, what other nursing interventions are necessary when caring for a patient after a mastectomy?

Interventions to improve the patient’s self-concept Signup and view all the answers

Why are adolescents specifically mentioned as being at risk for body image disturbance?

Due to hormonal changes during puberty Signup and view all the answers

Which of the following is an accurate statement about body image?

Body image includes actual and perceived perceptions of one’s body. Signup and view all the answers

What age group is particularly vulnerable to stressors that can affect an individual’s identity because it is a time of great change?

Adolescents Signup and view all the answers

What is the possible outcome when a person does not maintain a clear, consistent, and continuous consciousness of personal identity?

Identity confusion Signup and view all the answers

The nurse is assessing a 16-year-old who has been diagnosed with a sexually transmitted infection. Which of the following may be associated with risk-taking behaviors such as unprotected sex?

Poor self-esteem Signup and view all the answers

What critical thinking component is involved when the nurse reviews the literature about COPD in older patients and therapeutic communication principles?

Knowledge application Signup and view all the answers

When developing a discharge plan for a patient with COPD, what should the nurse advise the patient to expect?

Develop respiratory infections easily Signup and view all the answers

In what order, from first step to last step, should the nurse explain the pursed-lip breathing technique to the patient?

Relax your neck and shoulder muscles, Breathe in normally through your nose for two counts, Pucker your lips as if you were going to whistle, Breathe out through pursed lips for four counts Signup and view all the answers

What might be causing the patient's inability to sleep, fatigue during the day, and trouble concentrating after her husband's death 6 months ago?

Depression Signup and view all the answers

The nurse sits down to speak with the patient, whose husband died 6 months ago. The patient reports that she is unable to sleep, feels very fatigued during the day, and is having trouble concentrating. The nurse asks her to clarify the type of trouble she is having, and the patient explains that she cannot concentrate or even solve simple problems. The nurse records the results of her assessment, describing the patient’s condition as ineffective coping. This conclusion reflects the nurse’s use of:

Inference Signup and view all the answers

Based on the primary/priority concern in the case study, which body system(s) should the nurse most thoroughly assess?

Cardiovascular system and respiratory system Signup and view all the answers

Given the arterial blood gas results, what should the nurse do first?

Assess the patient’s vital signs Signup and view all the answers

When the nurse uses an institution’s procedure manual to confirm how to insert an IV line, which level of critical thinking is being used?

Basic critical thinking Signup and view all the answers

As the nurse enters a patient’s room, she observes that the IV line is not infusing at the ordered rate. The nurse checks the flow regulator on the tubing, looks to see whether the patient is lying on the tubing, checks the connection between the tubing and the IV catheter, and then checks the condition of the site where the IV catheter enters the patient’s skin. She readjusts the flow rate and the infusion begins at the correct rate. This is an example of:

problem solving Signup and view all the answers

Assessment

What are the patient’s desired health outcomes? Signup and view all the answers

Nursing Diagnosis

What is the patient’s health-related concern? Signup and view all the answers

Planning

What actions will help the patient achieve their desired outcomes? Signup and view all the answers

Implementation

How can I help the patient achieve their desired outcomes? Signup and view all the answers

Evaluation

How will I know if the patient has achieved their desired outcomes? Signup and view all the answers

Inference

Observe patterns and formulate conclusions Signup and view all the answers

Evaluation

Select criteria to assess the effectiveness of nursing interventions Signup and view all the answers

Explanation

Defend your conclusions Signup and view all the answers

Self-regulation

Ask how you can improve your clinical performance Signup and view all the answers

OPen-Mindedness

Consider opposing points of view Signup and view all the answers

Natalie has found a qualitative article that has recommendations for how to implement a falls-preventions program. She would like to determine whether she can use these findings in her own practice. Which question will help her determine this?

What is the transferability of the findings? Signup and view all the answers

Since Natalie was looking for fall-prevention programs that have been evaluated, she could consider a knowledge synthesis project, with the assistance of a nurse researcher. Which type of knowledge synthesis project may be most applicable in addressing her PICO question regarding the effectiveness of falls-preventions programs in acute care?

Meta-analysis Signup and view all the answers

Why is evidence-informed decision making important to Natalie?

It entails the use of knowledge based on research studies and takes into account a nurse’s clinical experience and patient preferences. Signup and view all the answers

Natalie wanted to learn about the lived experiences and perspectives of older persons who have experienced multiple falls. What type of research would she conduct?

Qualitative research Signup and view all the answers

If Natalie was unable to find the answer to her practice question in the literature, she should consider:

Working with a researcher to conduct research to answer her practice question Signup and view all the answers

It is important that Natalie critically appraise or evaluate any of the literature she finds for quality. This ability is referred to as:

Research literacy Signup and view all the answers

Because Natalie was looking for interventions to prevent falls, she would frame her literature search question using:

PICO Signup and view all the answers

Why was Natalie using evidence-informed decision making to improve her practice and the practice of others in preventing falls? Because it:

Has been found to improve patient care Signup and view all the answers

define cue

information that a nurse obtains through the use of senses. Signup and view all the answers

define inference

one's judgment or interpretation of those cues. Signup and view all the answers

medical diagnosis

The identification of a disease condition on the basis of his specific evaluation of physical signs, symptoms, the patient's medical history and the results of diagnostic tests and procedures Signup and view all the answers

diagnostic reasoning

a process of using assessment data about a patient to logically explain a clinical judgement Signup and view all the answers

Match

Nursing process = a cognitive framework through which the nurse aims to identify, diagnose, and treat actual and potential health issues and challenges of patients from a holistic perspective. Nursing process step = assessment, analysis, planning, implementation, and evaluation. The steps are unified and continuously relate to each other. It guides clinical judgement, decision making and reflective nursing practice. assessment = the purpose is to gather client data and establish client database. it is to collect, verify, analyze, and communicate. Planning = involves the creation of a formal plan that prescribes strategies and alternatives to obtain the expected outcomes. Signup and view all the answers

Various sources of data.

Primary = ): Nurses should always ask patients if they want their family involved during their physical assessment because usually, they are able to tell when changes are occurred in the patients. They also make observations about the patients’ need that can affect the way care is delivered. Secondary = They provide information to patients frame of reference, so like illness conditions. This is relevant to literature and nurses experience, so like accepted common commonality some patients with similar physical and emotional responses. Tertiary = Example patients’ description of the presenting problem and medical history narratives of health experiences. 111 = 111 Signup and view all the answers

Nursing diagnosis like goals, expected outcomes or both and specific nursing interventions. It quickly identifies the patient's clinical needs and situation.

Nursing care plan Signup and view all the answers

Identify three types of nursing diagnosis.

Risk diagnosis Health promotion diagnosis Wellness diagnosis Signup and view all the answers

types of nursing diagnosis

actual risk wellness and promotion Signup and view all the answers

diagnoses present a current client problem "state of health problems" "problems exists right now"

actual (problem focused) Signup and view all the answers

Example of what? Impaired Skin Integrity related to immobility as evidenced by redness and excoriated skin on right heel

actual Signup and view all the answers

Three components of Actual

Diagnostic label Related/risk factors clinical manifestations Signup and view all the answers

Diagnostic label related to the problem evidenced by the signs and symptoms

actual Signup and view all the answers

diagnoses are if a client does not have a diagnosis but data reveal a risk for its development. This allows the nurse to focus on reducing factors for a ____

risk diagnosis Signup and view all the answers

developing problem; high degree of probability but it has not happened yet

risk Signup and view all the answers

two components of risk diagnosis

diagnostic label related/risk factors Signup and view all the answers

example of what?

Risk for impaired skin integrity related to immobility Signup and view all the answers

Opportunities for enhancement of a healthy state (health promotion and disease prevention) or increase well being – Actualize health potential – May not reflect current health levels (they can be used in any state) • Ex. Opportunity to enhance skin integrity. • Ex. Readiness for enhanced..

wellness and health promotion Signup and view all the answers

exists to develop, refine, and promote terminology that accurately reflects nurses’ clinical judgements

NANDA international Signup and view all the answers

Focus on client’s actual or potential response to a health problem and Allows nurses to focus their care (assess, identify problems, prioritize problems, intervene)

Nursing diagnosis Signup and view all the answers

Diagnosis Purpose: Develop a client-centered plan of care which meets the unique needs of the client

True Signup and view all the answers

Use quotation marks for a client’s statement, do not paraphrase

subjective information Signup and view all the answers

Use proper terminology and measurements

objective information Signup and view all the answers

Are subjective or objective data that can be directly heard or observed by the nurse • Example: What the client says or what the nurse can see, hear, feel, smell, or measure.

Cues Signup and view all the answers

Are the nurse’s conclusions or interpretations of the cues • Example: A nurse observes the cues that an incision is red, hot and swollen; the nurse makes the inference that the incision is infected.

Inferences Signup and view all the answers

Organize information into ‘clusters’ • Set of signs and symptoms you group together in a logical way – Recognize patterns and trends – Improves with knowledge and experience

Analysis Signup and view all the answers

To ensure accuracy, eliminate biases, misperceptions and errors in data collection

verification Signup and view all the answers

Example of Interview + Examination

Nursing Health History

Extensive data collection

Get the ‘whole’ picture of client’s health and well being

Data collected includes:

methods of data collection Signup and view all the answers

methods of data collection

interview examination diagnostic and lab data Signup and view all the answers

who is the primary source of data?

clients Signup and view all the answers

secondary source of data?

family or caregivers Signup and view all the answers

Clients’ perceptions about their health problems. • Only clients can give this

subjective symptoms Signup and view all the answers

Observations or measurements made by the data collector. Ex. Assessment of a client’s wound , description of client behaviour

objective signs Signup and view all the answers

to gather client data and establish a client database?

assessment Signup and view all the answers

steps for assessment?

collect verify analyze communicate Signup and view all the answers

Not necessarily linear: Cyclic and dynamic

For all client systems: Client, families, communities

Interpersonal and collaborative

Goal and problem-oriented

Permits creativity

Feedback and evaluation necessary

characteristics of the nursing process Signup and view all the answers

A problem-solving approach to identifying, diagnosing, and treating the health issues of patients.

Systematic approach to delivering nursing care

Allows nurses to think critically

nursing process Signup and view all the answers

Implementation = Occur by coordinating care delivery, providing health teaching and health promotion activities to the patient. While consulting with other health care providers. Within the scope of practice of the registered nurse. objective data = observations or measurements of a patient's health status. So, this is to inspect of the condition of a wound. Description of an observed behavior and measurement of blood pressure are examples of objective data. subjective data = Our patients verbal descriptions of their health concerns. They are obtained through the health history and the nurse’s questions. In the explanation the patient provides. Only patients provide subjective data. evaluation = the patient’s response to the selected interventions and determines whether the interventions were effective. Signup and view all the answers

Diagnostic level/related factors and risk factors and defining characteristics (signs and symptoms)

components of a nursing diagnosis statement Signup and view all the answers

in order: nursing phases, problem prioritization, establish client goals, and expected outcomes, identify interventions, select interventions, write the health care plan.

process of planning phases Signup and view all the answers

Ex: Acute pain related to injury of right arm as evidenced by client stating 10/10 pain, client moaning and guarding of arm

nursing diagnosis Signup and view all the answers

client's response to health issue ex. pain, self-care, impaired skin integrity

diagnostic label Signup and view all the answers

One or more probable causes of the health problem.

acute Signup and view all the answers

One or more factors putting the client at risk of getting the health problem

risk Signup and view all the answers

Are the cluster of signs and symptoms that indicate the presence of a particular diagnostic label.

For actual nursing diagnoses, subjective and objective data

For risk nursing diagnoses, there are no defining characteristics as the client is ‘at risk’

Example: As evidenced by moaning and facial grimacing

defining characteristics Signup and view all the answers

The ‘priority nursing diagnosis’ is the most pertinent for the client

True Signup and view all the answers

what priority? Physiological or psychological issues that affect safety, circulation or oxygenation or address basic human needs • Focus on first!

highest Signup and view all the answers

What priority?

Not necessarily linked to illness or prognosis • Related to client’s future well-being • Long term health care needs

lowest Signup and view all the answers

what is the focus of your intervention?

expected outcomes and goal Signup and view all the answers

goals of care are:

client centered short-term goal long-term goal Signup and view all the answers

Smart?

specific measurable attainable realistic time bound Signup and view all the answers

any treatment, based upon clinical judgment and knowledge, that a nurse performs to enhance client outcomes

nursing intervention Signup and view all the answers

Is an intervention performed through interaction with the client.

direct care Signup and view all the answers

Is an intervention performed away from, but on behalf of, the client, such as interdisciplinary collaboration

indirect care Signup and view all the answers

three types of nursing interventions?

nurse initiated physician initiated/independent collaborative Signup and view all the answers

Also called independent nursing interventions – Does not require orders or directives from other health care professionals – Grounded in evidence-informed decision making

nurse initiated Signup and view all the answers

lso called dependent nursing interventions – Requires orders or directives from physicians – Treating or managing a medical diagnosis Nurse needs to recognize and question errors

physician initiated Signup and view all the answers

Also known as interdependent – Require combined skill and knowledge of various health care providers – Examples: • Dietician, social worker, physiotherapy etc. Nurse needs to recognize and question errors

collaborative interventions Signup and view all the answers

Clinical Practice Guidelines and Protocols • Agency specific intervention, BPGs, – Medical directive or standing order • Pre-approved and signed orders by physician – Nursing Intervention Classification System • Common interventions for NANDA diagnoses

types of standard nursing interventions Signup and view all the answers

Involves the actual performance of planned interventions. Requires – Preparation by the nurse – Specific set of skills

implementation Signup and view all the answers

implementation: required skills

cognitive interpersonal psychomotor Signup and view all the answers

Involves assessing the patient's response to interventions and determining whether the interventions were effective

evaluation Signup and view all the answers

an important aspect of the nursing process because conclusions drawn from the _____ determine whether the nursing interventions should be terminated, continued, or changed.

evaluation Signup and view all the answers

types of evaluation?

ongoing intermittent terminal Signup and view all the answers

Is done while or immediately after implementing a nursing order; it enables the nurse to make on-the-spot modifications in an intervention.

ongoing evaluation Signup and view all the answers

Performed at specific intervals (i.e. once a week), shows the extent of progress toward goal achievement and enables the nurse to correct any deficiencies and modify the care plan as needed.

Evaluations continues until the client achieves the health goals and/or is discharged home nursing care.

ongoing evaluation Signup and view all the answers

Indicates the client’s condition at the time of discharge. It includes the status of goal achievement and is an evaluation of the client’s self-care abilities with regard to follow-up care. Most agencies have a special discharge record for _______.

terminal evaluation Signup and view all the answers

identify goal

collect data to determine if goal has been met

interpret and summarize findings

document

terminate, continue or revise care plan

evaluation process Signup and view all the answers

A theory is best understood as a set of assumptions or propositions that becomes useful when it does which of the following?

A theory is best understood as a set of assumptions or propositions that becomes useful when it does which of the following? = Provides a systematic view of explaining, predicting, and prescribing phenomena The metaparadigm concepts that formed the structure of concepts that nursing theories were concerned about included: = The person, environment, health, and nursing The idea that nursing theorists drew specifically from systems theories was to consider the human being as = A whole and component parts in intricate interaction with one another Adolescents are at risk for body image disturbance. Which of the following is an accurate statement about body image? = Body image includes actual and perceived perceptions of one's body Signup and view all the answers

What is the nurse assessing for when she or he asks the client, “How do you feel about yourself?” = self-esteem Which of the following questions would be appropriate to assess the client's satisfaction and dissatisfaction associated with role responsibilities and relationships? (Select all that apply) = What are your responsibilities in your family?/What are your relationships like with your relatives? A nurse uses an institution's procedure manual to confirm how to change a patient's nasogastric tubing. The level of critical thinking the nurse is using is = Basic critical thinking The nurse asks a patient how she feels about her impending surgery for breast cancer. Before the discussion, the nurse reviewed the description in his textbook of loss and grief in addition to therapeutic communication principles. The critical thinking component involved in the nurse's review of the literature is = Specific knowledge base Signup and view all the answers

A patient had hip surgery 24 hours ago. The nurse refers to the written plan of care, noting that the patient has a device collecting wound drainage. The physician is to be notified when the accumulation in the device exceeds 100 mL for the day. When the nurse enters the room, the nurse looks at the device and carefully notes the amount of drainage currently in the device. This is an example of

assessment Signup and view all the answers

The nurse completes a nursing health history with her client. In order to avoid incorrect inferences and ensure that the data are accurate, the nurse's next step is to:

validate data Signup and view all the answers

The nursing diagnosis readiness for enhanced communication is an example of:

a wellness nursing diagnosis Signup and view all the answers

data clustering = organization of data to classify and focus on the correct problem. close ended questions = limits answers to one or two words. "yes or no" assessment = collection and verification of data subjective data = clients perception about themselves Signup and view all the answers

assessment data = information that is descriptive, concise, and complete without inferences or interpretive statements. verification = comparison of data with another reliable source to confirm accuracy directive interview = organized conversation with a client to obtain information database = information about a clients needs, health problems, and responses to these problems. Signup and view all the answers

Organized knowledge about nursing to enable nurses to use it in a professional manner

nursing theory Signup and view all the answers

nursing theory = Aims to describe, predict and explain the phenomenon of nursing and provides foundations of how we practice as nurses nursing theory allows to: = are representations of the beliefs depicted by the theory (also known as a conceptual framework) and often help to introduce the theory into practice what is a model? = View client situations from a certain perspective, organize data, provides a method to analyze and interpret information nursing metapradigm = a group of theories which represents how our profession functions Signup and view all the answers

types of theories

grand theory middle range prescriptive descriptive Signup and view all the answers

Broad in scope, provide structural framework to direct nursing science (aka more narrow range theories)

grand theory Signup and view all the answers

Explains, relate and sometimes predict why a phenomenon occurs (ex. Helps explain nursing client assessment)

descriptive Signup and view all the answers

More limited scope, address specific phenomenon and reflect nursing practice

middle range Signup and view all the answers

Address nursing interventions (treatment) and help predict the consequences of an interventions

prescriptive Signup and view all the answers

types of theoretical models

practices based needs interactionist systems Signup and view all the answers

environment conducive to healing: was characterized by a commitment to evidence-based care, holistic principles, patient advocacy, professionalism, infection control, and education.

florence nightingale practice base Signup and view all the answers

14 basic human needs

virginia henderson needs Signup and view all the answers

interpersonal relationship between client and nurse?

hildegard interactionist Signup and view all the answers

what points to the holistic view of care?

nursing metaparadigm Signup and view all the answers

four components of mental image

body image role performance personal identity self-esteem Signup and view all the answers

Develops partly from others attitudes and responses and partly form the individuals

self-esteem Signup and view all the answers

components of role performance

role conflict role strain role ambiguity role overload Signup and view all the answers

role ambiguity = One person assumes two roles which are contradictory or mutually exclusive role conflict = Expectation are unclear and people do not know what to do or how to do it role strain = Frustration related to a role expected of the person that does not fit or feel right role overload = having more roles or responsibilities that is manageable. Signup and view all the answers

Conscious sense of individuality and uniqueness

Continually evolving

personal identity Signup and view all the answers

the degree to which a person identifies as male, female, or some combination

gender identity Signup and view all the answers

predominant gender preference’s of a person’s sexual attraction over time

sexual orientation Signup and view all the answers

How that person’s standard and performance compared to others and to one’s ideal self

self-esteem Signup and view all the answers

The process of purposefully thinking back or recalling a situation to discover its purpose or meaning. Reflection is necessary for self-evaluation and improvement of nursing practice.

reflection Signup and view all the answers

A process and as a set of skills; an active, organized, cognitive process used to carefully examine one's thinking and the thinking of others

critical thinking Signup and view all the answers

critical thinking levels

basic complex commitment Signup and view all the answers

critical thinking components

specific knowledge base experience competencies attitudes standards Signup and view all the answers

specific knowledge base = Education (sciences, theory, humanities, behavioural, nursing sciences) – Important to admit limitations in your knowledge experience = Clinical experiences (nursing school and professional employment) – Other work experiences general compentencies = Scientific Method, Problem Solving, Decision Making specific competencies = Diagnostic reasoning, clinical inference, and clinical decision making/ Determining health status of patient after you have gathered all important assessments (physical, social, psychological) Signup and view all the answers

determine how a critical thinker approaches a problem or a situation that requires some kind of decision-making. – For example, when a patient complains of anxiety before undergoing a diagnostic procedure, the curious nurse explores possible reasons for the patient’s concerns

attitudes Signup and view all the answers

What ‘attitudes’ are important for nurses to have? (Curiosity, independence, fair-mindedness, aware of self-limits, integrity, perseverance, confidence)

True Signup and view all the answers

is the integration of the most informative research evidence with evidence from expert clinical practice, client preferences, professional clinical judgment, and other sources to produce the best possible care for clients

evidence informed practice Signup and view all the answers

Information derived from research and scientific evaluation of practice

evidence Signup and view all the answers

defined by the CNA as “an ongoing process that incorporates evidence from research findings, clinical expertise, client preferences and other available resources to inform decisions that nurses make about clients”

evidence informed decision making Signup and view all the answers

types of evidence

research non research evidence patient focused evidence Signup and view all the answers

nursing diagnosis = Clinical judgment about individual, family, or community responses to health care problems or life processes that is within the domain of nursing medical diagnosis = The identification of a disease condition on the basis of a specific evaluation of physical signs, symptoms, the patient's medical history, and the results of diagnostic tests and procedures. 111 = 111 222 = 222 Signup and view all the answers

Nursing Health History Assessment Quiz

Questions and Answers

What type of nursing diagnosis is 'readiness for enhanced communication' an example of?

In the nursing diagnosis 'impaired physical mobility', the word 'impaired' is an example of:

When assessing Mr. Fletcher, what is the first appropriate assessment technique for data collection?

Which of the following are defining characteristics for the nursing diagnosis 'impaired nutrition (more than body requirements)'?

What would be considered a realistic short-term goal for Mr. Fletcher to achieve prior to the next visit?

What step should the nurse take to avoid incorrect inferences and ensure that the data from Mr.Fletcher’s assessment are accurate?

When clustering Mr.Fletcher’s data, what should the nurse do?

Which of the following statements BEST describes a nursing diagnosis?

Why would the nurse choose to use a standard formal nursing diagnostic statement for Mr.Fletcher?

What is the first nursing intervention to correct when watching Mr. Fletcher take his own blood pressure?

Which is an example of an expected outcome statement written for Mr. Fletcher in measurable terms?

What is required for a collaborative intervention to assess Mr. Fletcher for peripheral arterial disease?

If the primary nurse wants to help Mr. Fletcher assess his peripheral arterial disease, what might be a collaborative intervention?

What should the primary nurse prioritize when completing an individualized written care plan for Mr. Fletcher?

Which of the following interventions is an example of a specific life-saving measure that the primary nurse may implement?

How would the nurse use to evaluate the long-term impacts of teaching Mr. Fletcher how to take an antilipemic medication?

What objective evaluative criteria would the nurse use to judge Mr. Fletcher’s response to the care provided?

If Mr. Fletcher remains hypertensive despite taking prescribed medication, what should be the primary nurse’s initial action?

According to Kuhn, scientific advances are most likely to happen when creative individuals do which of the following?

The central idea characterizing the McGill model for nursing is that it:

Building upon a psychoanalytic perspective, theorist Hildegard Peplau considered which of the following as fundamental aspects of nursing practice?

The distinctive contribution that Canadian theorist Evelyn Adam made to nursing’s thinking at the time was a conceptualization of the essence of nursing as:

The idea that nursing theorists drew specifically from systems theories was to consider the human being as:

What best describes a theory in the context of nursing?

In the early enterprise of theorizing about nursing practice, who was primarily driving the process?

What were the four basic steps involved in the original form of the nursing process?

Which concepts formed the metaparadigm structure of nursing theories?

What was the main focus of attention for early nursing theorists?

Which of the following would be considered an independent nursing intervention?

What is the primary focus when a nurse asks Amil, 'How do you feel about yourself?'

Which question would be appropriate to assess Amil’s satisfaction and dissatisfaction associated with role responsibilities and relationships?

What action would help increase Amil’s self-awareness?

Apart from physiological stability and pain control, what other nursing interventions are necessary when caring for a patient after a mastectomy?

Why are adolescents specifically mentioned as being at risk for body image disturbance?

Which of the following is an accurate statement about body image?

What age group is particularly vulnerable to stressors that can affect an individual’s identity because it is a time of great change?

What is the possible outcome when a person does not maintain a clear, consistent, and continuous consciousness of personal identity?

The nurse is assessing a 16-year-old who has been diagnosed with a sexually transmitted infection. Which of the following may be associated with risk-taking behaviors such as unprotected sex?

What critical thinking component is involved when the nurse reviews the literature about COPD in older patients and therapeutic communication principles?

When developing a discharge plan for a patient with COPD, what should the nurse advise the patient to expect?

In what order, from first step to last step, should the nurse explain the pursed-lip breathing technique to the patient?

What might be causing the patient's inability to sleep, fatigue during the day, and trouble concentrating after her husband's death 6 months ago?

Based on the primary/priority concern in the case study, which body system(s) should the nurse most thoroughly assess?

Given the arterial blood gas results, what should the nurse do first?

When the nurse uses an institution’s procedure manual to confirm how to insert an IV line, which level of critical thinking is being used?

Assessment

Nursing Diagnosis

Planning

Implementation

Evaluation

Inference

Evaluation

Explanation

Self-regulation

OPen-Mindedness

Natalie has found a qualitative article that has recommendations for how to implement a falls-preventions program. She would like to determine whether she can use these findings in her own practice. Which question will help her determine this?

Why is evidence-informed decision making important to Natalie?

Natalie wanted to learn about the lived experiences and perspectives of older persons who have experienced multiple falls. What type of research would she conduct?

If Natalie was unable to find the answer to her practice question in the literature, she should consider:

It is important that Natalie critically appraise or evaluate any of the literature she finds for quality. This ability is referred to as:

Because Natalie was looking for interventions to prevent falls, she would frame her literature search question using:

Why was Natalie using evidence-informed decision making to improve her practice and the practice of others in preventing falls? Because it:

define cue

define inference

medical diagnosis

diagnostic reasoning

Match

Various sources of data.

Nursing diagnosis like goals, expected outcomes or both and specific nursing interventions. It quickly identifies the patient's clinical needs and situation.

Identify three types of nursing diagnosis.

types of nursing diagnosis

diagnoses present a current client problem "state of health problems" "problems exists right now"

Example of what? Impaired Skin Integrity related to immobility as evidenced by redness and excoriated skin on right heel

Three components of Actual

Diagnostic label related to the problem evidenced by the signs and symptoms

diagnoses are if a client does not have a diagnosis but data reveal a risk for its development. This allows the nurse to focus on reducing factors for a ____

developing problem; high degree of probability but it has not happened yet

two components of risk diagnosis

Example of Interview + Examination

Nursing Health History

Extensive data collection

Get the ‘whole’ picture of client’s health and well being

Data collected includes:

Not necessarily linear: Cyclic and dynamic

For all client systems: Client, families, communities

Interpersonal and collaborative

Goal and problem-oriented

Permits creativity

Feedback and evaluation necessary

A problem-solving approach to identifying, diagnosing, and treating the health issues of patients.

Systematic approach to delivering nursing care

Allows nurses to think critically

What priority?

Not necessarily linked to illness or prognosis • Related to client’s future well-being • Long term health care needs

Performed at specific intervals (i.e. once a week), shows the extent of progress toward goal achievement and enables the nurse to correct any deficiencies and modify the care plan as needed.

Evaluations continues until the client achieves the health goals and/or is discharged home nursing care.

identify goal

collect data to determine if goal has been met

interpret and summarize findings

document

terminate, continue or revise care plan