Nursing Process and Clinical Judgment Quiz

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Questions and Answers

Which component of the nursing process involves setting the goals of care and desired outcomes?

Diagnosis

Implementation

Assessment

Planning (correct)

What does patient-centered care primarily emphasize?

Using standardized treatment procedures for efficiency

Focusing on the healthcare provider's preferences

Recognizing the client as the source of control and full partner (correct)

Providing care based solely on clinical expertise

In the context of clinical judgment, what is the first step in the model represented by 'Red Apples Provide Great Tasting Energy'?

Take Action

Evaluate Outcomes

Generate Solutions

Recognizing Cues (correct)

Which attitude is NOT considered a critical thinking attitude?

Indifference Signup and view all the answers

Which of the following aspects is part of the standards of professional performance?

Resource Stewardship Signup and view all the answers

What is the main goal of cultural competency in healthcare?

To recognize and effectively interact with diverse cultures Signup and view all the answers

Which of the following is included in the critical thinking and clinical judgment components?

Self-regulation Signup and view all the answers

What does the 'Analyze Cues' step in clinical judgment primarily involve?

Understanding the significance of gathered information Signup and view all the answers

What is the expected anterior-posterior to transverse diameter ratio in a healthy adult?

1:2 Signup and view all the answers

Which of the following findings in tactile fremitus would indicate an abnormality?

Increased vibrations on one side Signup and view all the answers

What sound is expected during percussion over healthy lung tissue?

Resonant Signup and view all the answers

Which adventitious lung sound is characterized by high-pitched musical squeaking on expiration?

Wheezing Signup and view all the answers

A patient with chronic bronchitis typically presents with which of the following features?

Prolonged expiration and wheezing Signup and view all the answers

What chest assessment finding indicates a barrel chest?

A/P = transverse diameter Signup and view all the answers

What is a common subjective finding in patients suffering from emphysema?

Dyspnea on exertion Signup and view all the answers

Which percussion sound indicates too much air in the thorax?

Hyperresonance Signup and view all the answers

In assessing lung sounds, which term describes crackles that are low-pitched and heard early in inspiration?

Course crackles Signup and view all the answers

Which of the following findings is NOT expected in a healthy thorax assessment?

Crackles during auscultation Signup and view all the answers

What is meant by health disparities?

Differences in healthcare access based on population groups Signup and view all the answers

Which of the following best describes health literacy?

The ability to understand and process healthcare information Signup and view all the answers

What is a key element of linguistic competence in healthcare?

Using certified medical interpreters when necessary Signup and view all the answers

Which of the following is NOT a mode of transmission of infections?

Forceful transmission Signup and view all the answers

What type of isolation precaution requires a private negative-pressure room?

Airborne precautions Signup and view all the answers

What is the correct method for cleaning an artificial eye?

Wash with warm water and mild, non-scented soap. Signup and view all the answers

Which heart sound is associated with the closure of the mitral and tricuspid valves?

S1 Signup and view all the answers

Which technique is used to conduct an oral temperature assessment?

Measure in the posterior sublingual pockets Signup and view all the answers

What skin color change is associated with increased bilirubin in the blood?

Jaundice Signup and view all the answers

What is an appropriate technique for auscultating heart sounds?

Inform the patient that listening may take some time. Signup and view all the answers

Which assessment technique is used to evaluate skin integrity?

Assessing color, texture, and lesions Signup and view all the answers

What is indicated by the term 'tachycardia' in pulse characteristics?

A fast pulse rate. Signup and view all the answers

In which situation would you use a tympanic membrane thermometer?

When oral measurement is not practical Signup and view all the answers

What does systolic pressure represent in blood pressure readings?

The maximum pressure in the arteries. Signup and view all the answers

Which of the following is a common symptom of peripheral artery disease (PAD)?

Cold, pale, or bluish skin on the legs. Signup and view all the answers

Which of the following statements about skin lesions is correct?

A vesicle is filled with clear serum. Signup and view all the answers

Which variable is NOT considered a normal variation that affects body temperature?

Acute illness Signup and view all the answers

What is the normal range for blood pressure in a healthy adult?

120/80 Signup and view all the answers

Which assessment technique involves tapping on the body to detect sounds?

Percussion Signup and view all the answers

What is the purpose of donning PPE?

To provide protection for healthcare workers from exposure Signup and view all the answers

What is a key indicator of peripheral venous insufficiency?

Brown discoloration of the skin. Signup and view all the answers

What indicates poor skin turgor during a hydration assessment?

Skin remains tented after being pinched Signup and view all the answers

Which of the following describes the ABCDE method for assessing skin lesions?

Asymmetry, Border, Color, Diameter, Evolution Signup and view all the answers

Which symptom is typically associated with oxygen deficit due to arterial insufficiency?

Deep muscle pain during activity. Signup and view all the answers

What is the recommended action to avoid false high blood pressure readings?

Wait 1-2 minutes between readings. Signup and view all the answers

Which breathing pattern is characterized by more than 24 breaths per minute and is often deep?

Tachypnea Signup and view all the answers

What common finding characterizes the skin of a person suffering from severe peripheral artery disease?

Shiny and hairless skin. Signup and view all the answers

What sound is characterized by the closure of the aortic and pulmonic valves?

S2 Signup and view all the answers

What is the expected angle of the nail when assessing for clubbing?

180 degrees Signup and view all the answers

Which practice is NOT recommended for diabetic foot care?

Soaking feet Signup and view all the answers

Which guideline is essential when giving a bath to a patient?

Provide privacy Signup and view all the answers

What should be assessed in the mouth during a hygiene evaluation?

Masses or lesions Signup and view all the answers

When performing an eye assessment, which condition refers to involuntary, rapid eye movement?

Nystagmus Signup and view all the answers

Which factor does NOT influence a person's hygiene practices?

Favorite color Signup and view all the answers

Which practice should be avoided when cleaning dentures?

Using abrasive cleaners Signup and view all the answers

What is the proper action for performing ear irrigation?

Ensure patient is upright Signup and view all the answers

During a scalp assessment, which condition is characterized by hair loss?

Alopecia Signup and view all the answers

How should you assess capillary refill in a patient?

Apply light pressure to the nail bed Signup and view all the answers

What is the best position for an unconscious client during oral hygiene?

Semi-fowlers with head turned to the side Signup and view all the answers

Which of the following describes the purpose of rinsing during oral hygiene?

To remove excess toothpaste Signup and view all the answers

What should the nurse do first when performing an ear irrigation?

Assess for any infection Signup and view all the answers

Study Notes

Quality and Safety Education for Nurses (QSEN)

QSEN is a framework for educating nurses in quality and safety.
Topics include Evidence-Based Practice, Quality Improvement, Safety, Informatics, Patient-Centered Care, and Teamwork & Collaboration.
Mnemonic: Every Quick Squirrel Investigate Potential Trees.

Patient-Centered Care

Patient-centered care prioritizes the patient as the central figure in their care.
It involves respecting patient preferences, values, and needs, and coordinating care accordingly.
Patients are active participants in decisions about their health.

Nursing Process (ADPIE)

Assessment: Gathering patient information.
Diagnosis: Identifying patient problems.
Planning: Setting care goals and actions.
Implementation: Performing planned nursing actions.
Evaluation: Determining if goals were met.

Clinical Judgement

Clinical judgment is a complex cognitive process.
Model: Red Apples Provide Great Tasting Energy. Concepts to remember: Recognize Cues, Analyze Cues, Prioritize Hypotheses, Generate Solutions, Take action, and Evaluate Outcomes.
Key Concepts: Every Kite Soars Really Quickly.

Critical Thinking Attitudes

Critical thinking involves attributes like confidence, independent thought, fairness, responsibility, risk assessment, and discipline.
Also includes perseverance, creativity, curiosity, integrity, and humility.

Critical Thinking and Clinical Judgement Skills

Interpretation
Analysis
Inference
Evaluation
Explanation
Self-Regulation

Standards of Professional Performance

Ethical conduct, advocating for patients, respecting others, effective communication, collaboration, effective leadership, professional learning, scholarly inquiry, quality of care, professional evaluation, resource management, environmental health.

Cultural Competency Model

Cultural awareness: Recognizing one's own biases.
Cultural knowledge: Learning about other cultures.
Cultural skills: Communicating effectively with diverse populations.
Cultural encounters: Directly engaging with diverse groups.
Cultural desire: The motivation to be culturally competent.

Health Disparities

Health disparities highlight differences in health outcomes among population groups based on factors like race, ethnicity, socioeconomic status, gender, or geography.

Health Literacy

Health literacy is the ability to process and understand health information to make informed decisions.

Linguistic Competence

Linguistic competence means effectively communicating with patients of different language backgrounds.
It includes using interpreters and translation services, and being mindful of non-verbal cues.

Interview Techniques

Observing verbal and nonverbal cues.
Open-ended questions: encourage detailed responses.
Leading questions: influence responses.
Back channeling: show active listening.
Direct closed-ended questions: precise answers.
Probing: asking for more detail.
4Cs for open-ended questions: What do you CALL your problems? Cause, concerns, cope.
Interview skills: Courtesy, comfort, connection, and confirmation.

Modes of Transmission

Contact transmission:
- Direct: Person-to-person (fecal-oral).
- Indirect: Object-to-person.
Droplet: Organisms ≥5 mcg.
Airborne: Organisms <5 mcg.
Vehicles: Contaminated items (needles, water, blood, food).
Vector-borne: Organisms carried by animals/insects.

Isolation Precautions

Contact: Private room/cohort, gown, gloves.
Droplet: Private room/cohort, surgical mask.
Airborne: Private negative-pressure room, N95 respirator.
Protective: Private positive-airflow room, mask, gown, gloves.

Standard Precautions

Treating all body fluids as potentially infectious.
Hand hygiene, Personal Protective Equipment (PPE).

Donning and Doffing PPE

Donning: Putting on PPE (gown, mask, goggles, gloves).
Doffing: Removing PPE (gloves, gown, goggles, mask).

Temperature Assessment

Oral: Posterior sublingual pockets.
Rectal: Used when other routes aren't possible. ≈0.7 – 1 degree F higher)
Tympanic: Infrared emissions.
Temporal artery: Infrared emission across forehead/behind ear. ≈1 degree F higher than oral.
Axillary: Used when other routes aren't possible. ≈1 degree F lower than oral.

Variables Affecting Temperature

Normal variations: Exercise, menstrual cycle, circadian rhythm, age, environment.
Abnormal variations: Fever, hyperthermia, heatstroke, heat exhaustion, hypothermia.

Skin Color Changes

General pigmentation.
Localized bruising, vascularity.
Pallor (white): Reduced oxyhemoglobin.
Erythema (red): Increased oxyhemoglobin.
Cyanosis (blue): Increased deoxyhemoglobin.
Jaundice (yellow): Increased bilirubin.

ABCDE of Skin Lesions

Asymmetry
Border
Color
Diameter
Evolution

Skin Lesions (Types)

Macule
Papule
Nodule
Tumor
Wheal
Vesicle
Pustule
Ulcer
Atrophy

Skin Turgor

Measuring skin hydration. Normal = 1-2 seconds for skin to return to normal.

Skin Integrity

Skin's health and ability to protect.

Hair Assessment

Expected: Symmetrical distribution.
Assess for cleanliness and uniformity.
Alopecia (hair loss).
Pediculosis Capitis: Head lice.

Nail Assessment

Shape, contour, consistency, color, capillary refill (2-3 seconds is brisk).

Factors Influencing Hygiene

Social practices.
Personal preferences.
Body image.
Socioeconomic status.
Health beliefs/motivation.
Cultural variables.
Developmental stage.
Physical condition.

Bathing Procedures

Collect supplies.
Explain procedure.
Apply gloves.
Maintain safety and warmth.
Promote independence.

Diabetic Foot Care

Don't soak feet, clip nails with physician's order.
Cut nails straight across, file edges.
Avoid heat unless prescribed.

Avoiding Abbreviations

Avoid abbreviations that can be easily mistaken.

Eye Assessment

Visual Acuity (Snellen chart, handheld).
Myopia (nearsightedness), Presbyopia (age-related near vision).
Extraocular Movements (Inspect for nystagmus).
Visual Fields (Confrontation test).
External ocular structures: General, eyebrows, eyelids, eyeballs, conjunctiva, sclera, lacrimal apparatus.
External anterior eyeball: Cornea, lens, iris, pupils (PERRLA).
Pupillary light reflex (direct & consensual), Accommodation

Mouth, Head, and Neck Assessment

Mouth: Teeth, gums, tongue, mucous membranes.
Head: Normocephalic.
Neck: Supple ROM, no masses, or lymphadenopathy.

Oral Hygiene

Brushing, flossing, and rinsing are important.
Interventions for unconscious clients include suction and care to avoid accidental insertion of fingers into the mouth.

Denture Care

Encourage denture cleaning, removal nightly.
Store dentures covered in water and protected.

Eye Irrigation

Positioning, sterile saline, direction of irrigation.

Ear Irrigation

Assess for infection.
Positioning, warm water/solution, gentle irrigation.

Artificial Eye Care

Hygiene, gentle handling/washing.

Heart Auscultation Techniques

Begin at apex/base.
Diaphragm (high frequency), bell (low frequency)
Positions.
Eliminate external noise.

Heart Sounds

S1 (Lub): AV valve closure, loudest at apex.
S2 (Dub): Semilunar valve closure, loudest at base.
S3: Early rapid filling (ventricular resistance).
S4: Pre-systole (ventricular resistance).

Heart Auscultation Locations

Aortic, Pulmonic, Tricuspid, Mitral.

Pulse Characteristics

Rate: Tachycardia, Bradycardia.
Rhythm: Regular, Irregular.
Strength: Bounding, Strong, Normal, Thread, Absent.
Equality: Bilateral.

Blood Pressure

Systolic/Diastolic pressures.
Method: Brachial pulse, cuff placement, inflation, auscultation and note sounds.
Causes of false readings (high and low).

Peripheral Vascular Insufficiency (PVI)

Inadequate blood flow to extremities.
Causes: Arterial (atherosclerosis, blood clots, spasms) or Venous (valve damage, DVT, varicose veins).
Symptoms differ for arterial vs. venous insufficiency.

Peripheral Artery Disease (PAD)

Oxygen Deficit.
Symptoms: Leg pain (claudication), weak/absent pulses, cold/pale skin, non-healing wounds. Peripheral arterial issues: pain with activity, pallor, hair loss, coolness.

Peripheral Venous Insufficiency

Venous issues: redness, warmth, edema, pain, brownish skin, pitting, bleeding sores- skin is warm, pitting edema. Risk factors: immobility.

Lung & Thorax Assessment

Inspection, Palpation, Percussion, Auscultation

Lung/Thorax Inspection

General body posture, shape, and respiratory rate.
Observe Skin color, use accessory muscles.
Observe respirations.
Shape, configuration, and placement of trachea.

Lung/Thorax Palpation

Assess for tenderness, skin temperature, moisture, and tactile fremitus.

Lung/Thorax Percussion

Assessing for resonance/hyperresonance/dullness/flatness.

Lung/Thorax Auscultation

Listening for normal vesicular breath sounds, absence of adventitious sounds.
Auscultation steps and locations, expected findings are listed

Adventitious Lung Sounds

Crackles (fine & course), wheezes, and stridor.

Chronic Bronchitis and Emphysema (Expected findings)

Subjective, objective findings, and auscultation.

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Description

Test your knowledge on the nursing process and the critical thinking involved in clinical judgment. This quiz covers essential concepts such as patient-centered care, goal setting, and cultural competency in healthcare. Perfect for nursing students and professionals looking to reinforce their understanding.