Nursing Process and Critical Thinking Flashcards
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Questions and Answers

What condition does the patient have on his back?

Scabies

What is an example of an appropriate nursing diagnosis?

  • Patient has a duodenal ulcer
  • Need for laxatives
  • Patient complains of constipation
  • Constipation (correct)
  • What is an example of an appropriately written nursing diagnosis?

  • Risk for impaired skin integrity related to physical immobilization (correct)
  • Physical immobilization secondary to risk for impaired skin integrity
  • Physical immobilization secondary to decreased cognitive ability
  • Risk for impaired skin integrity related to diagnosis of decubitus ulcers
  • Which is an example of a nursing diagnosis?

    <p>Impaired skin integrity</p> Signup and view all the answers

    Which is an example of a medical diagnosis?

    <p>Diabetes mellitus</p> Signup and view all the answers

    Which is an example of a medical diagnosis?

    <p>Pneumonia</p> Signup and view all the answers

    Which are acceptable secondary sources for data? (Select all that apply)

    <p>Textbooks</p> Signup and view all the answers

    Which are official categories of nursing diagnoses? (Select all that apply)

    <p>Wellness</p> Signup and view all the answers

    Which are considered phases of the nursing process? (Select all that apply)

    <p>Implementation</p> Signup and view all the answers

    How often does NANDA International meet to reorganize diagnosis labels and language?

    <p>Every 2 years</p> Signup and view all the answers

    The standards that name and measure patient outcomes are referred to as __.

    <p>NOC (Nursing Outcome Classification)</p> Signup and view all the answers

    The document that outlines a multidisciplinary plan for care interventions over a specified time frame is a __.

    <p>clinical pathway</p> Signup and view all the answers

    A systematic method by which nurses plan and provide care for patients is known as the __.

    <p>nursing process</p> Signup and view all the answers

    A systematic, dynamic process by which the nurse collects and analyzes data about the patient is known as __.

    <p>assessment</p> Signup and view all the answers

    Any health care condition that requires diagnostic, therapeutic, or educational actions is known as a __.

    <p>problem</p> Signup and view all the answers

    A clinical judgment about individual, family, or community responses to health problems is known as a __.

    <p>nursing diagnosis</p> Signup and view all the answers

    The human responses to health conditions/life processes that exist in an individual, family, or community are known as a(n) __.

    <p>actual nursing diagnosis</p> Signup and view all the answers

    Human responses to health conditions that may develop in a vulnerable individual, family, or community are known as a(n) __.

    <p>risk nursing diagnosis</p> Signup and view all the answers

    Human responses to levels of wellness in an individual that have a readiness for enhancement are known as a __.

    <p>wellness nursing diagnosis</p> Signup and view all the answers

    The identification of a disease or condition by scientific evaluation is a __.

    <p>medical diagnosis</p> Signup and view all the answers

    A health care system that provides control over health care services for a specific group is known as __.

    <p>managed care</p> Signup and view all the answers

    A multidisciplinary plan that schedules clinical interventions is known as a __.

    <p>critical pathway</p> Signup and view all the answers

    Why is it important for the nurse to understand and accept each person as an individual?

    <p>To provide holistic care</p> Signup and view all the answers

    What is a fixed concept of how all members of an ethnic group act or think?

    <p>Ethnic stereotypes</p> Signup and view all the answers

    What is the integration of cultural knowledge into all aspects of care?

    <p>Transcultural nursing</p> Signup and view all the answers

    What is the term for when members of a particular ethnic group believe that their beliefs and practices are the best?

    <p>Ethnocentrism</p> Signup and view all the answers

    What is the term used to describe cultures in which women make decisions about health care?

    <p>Matriarchal</p> Signup and view all the answers

    What basic philosophy in the United States is relevant to health care?

    <p>Biomedical therapy</p> Signup and view all the answers

    What is a set of learned values, beliefs, customs, and practices shared by a group?

    <p>Culture</p> Signup and view all the answers

    What must a nurse develop to provide care to patients from different cultures?

    <p>Cultural competence</p> Signup and view all the answers

    What difference between a nurse from New York and a patient from Atlanta may cause communication difficulty?

    <p>Subculture</p> Signup and view all the answers

    What should a nurse do immediately after the death of an American Indian father?

    <p>Ask about the death ceremony</p> Signup and view all the answers

    What is the term for a generalization about a behavior or individual?

    <p>Stereotype</p> Signup and view all the answers

    What is the term for a group of people sharing biologic characteristics?

    <p>Race</p> Signup and view all the answers

    What is the term for a group of people sharing social and cultural heritage?

    <p>Ethnicity</p> Signup and view all the answers

    Who can be expected to name a neonate born to Orthodox Jewish parents?

    <p>Father</p> Signup and view all the answers

    Who will perform the circumcision of a male neonate in observant Orthodox Jewish families?

    <p>A mohel</p> Signup and view all the answers

    What book is used when naming a female neonate in Orthodox Jewish culture?

    <p>Holy Torah</p> Signup and view all the answers

    What can the nurse expect regarding the spouse's participation in his wife's care after she has given birth?

    <p>He will avoid physical contact with the patient.</p> Signup and view all the answers

    What is the most appropriate dietary requirement for an Orthodox Jewish patient?

    <p>Use of separate cooking utensils for meat and milk products</p> Signup and view all the answers

    What intervention is appropriate for an Orthodox Jewish patient during Passover?

    <p>Encourage time for prayer</p> Signup and view all the answers

    What is the most appropriate method for discussing birth control options with a Roman Catholic patient?

    <p>Abstinence</p> Signup and view all the answers

    What beverage should the nurse prepare for a patient who is a Latter-Day Saint?

    <p>Fruit juice</p> Signup and view all the answers

    What intervention is appropriate for a Latter-Day Saint patient wearing sacred undergarments?

    <p>Remove the undergarments in emergency situations only</p> Signup and view all the answers

    Which statement about the biomedical health belief system is true?

    <p>Life processes can be manipulated by human beings by mechanical interventions.</p> Signup and view all the answers

    Which health belief system is commonly referred to as 'third-world' beliefs and practices?

    <p>Folk health belief system</p> Signup and view all the answers

    Which health belief system includes a belief of a supernatural force exerting influence to cause health or illness?

    <p>Folk</p> Signup and view all the answers

    Which health belief system focuses on restoring balance with physical, social, and metaphysical worlds?

    <p>Holistic health belief system</p> Signup and view all the answers

    The nurse is caring for a patient who fasts during daylight hours during Ramadan. Which culture does the nurse recognize this patient adheres to?

    <p>Muslims</p> Signup and view all the answers

    What dietary selection should the nurse serve to a Muslim patient?

    <p>Chicken and rice</p> Signup and view all the answers

    A patient requests a consultation between the physician and a religious leader known as an Imam. What is this patient's cultural belief?

    <p>Muslim</p> Signup and view all the answers

    What intervention is most appropriate for a female Muslim patient receiving care?

    <p>Providing her with a female nurse</p> Signup and view all the answers

    How should a nurse demonstrate cultural awareness when caring for a Chinese American patient?

    <p>Sit side-to-side when speaking with the patient</p> Signup and view all the answers

    What nursing intervention would best demonstrate cultural sensitivity to a Mexican American patient?

    <p>Encouraging consultation of male members of the family regarding health care decisions</p> Signup and view all the answers

    Who would the nurse expect to be the primary decision maker in an African American patient's family?

    <p>Women</p> Signup and view all the answers

    How can a nurse best demonstrate cultural sensitivity when caring for a Mexican American patient in labor?

    <p>Encouraging female family members to be present for the delivery</p> Signup and view all the answers

    Which cultural beliefs does a postpartum patient adhere to if she requests to dry and bury the umbilical cord?

    <p>American Indian</p> Signup and view all the answers

    What are some characteristics that cultures have in common?

    <p>Survival modes</p> Signup and view all the answers

    What should the culturally sensitive nurse do for a Muslim woman being treated in the hospital?

    <p>Allow privacy for prayer.</p> Signup and view all the answers

    What should a nurse take into consideration when admitting an 85-year-old resident of Hispanic descent diagnosed with Alzheimer disease?

    <p>Cultural background has an important role in determining the resident's status</p> Signup and view all the answers

    The nurse should not maintain eye contact with a Korean patient because many Asians believe prolonged eye contact is impolite.

    <p>True</p> Signup and view all the answers

    What is the cultural characteristic of unwillingness to leave a current activity, which may result in late or missed appointments?

    <p>elasticity</p> Signup and view all the answers

    Following the death of a Presbyterian infant, what should the nurse help arrange for?

    <p>baptism</p> Signup and view all the answers

    While caring for a Mexican American family in the home, who may the family consult for health advice?

    <p>curandero, folk healer</p> Signup and view all the answers

    What is known as a nation, community, or broad group of people who establish particular aims, beliefs, or standards of living and conduct?

    <p>society</p> Signup and view all the answers

    What is a set of learned values, beliefs, customs, and practices that are shared by a group and passed from one generation to another known as?

    <p>culture</p> Signup and view all the answers

    What best defines the nursing process?

    <p>A framework for the organization of individualized nursing care.</p> Signup and view all the answers

    On admission, which patient should receive a focused assessment?

    <p>53-year-old admitted with a perforated ulcer</p> Signup and view all the answers

    What subjective data does the nurse record following a head-to-toe examination?

    <p>Prolonged nausea</p> Signup and view all the answers

    What objective data should the nurse include after a patient assessment?

    <p>Flatulence</p> Signup and view all the answers

    What is classified as information provided by the family when a patient is unable to provide data during assessment?

    <p>Secondary</p> Signup and view all the answers

    What are the two primary methods used to collect data?

    <p>Interview and physical examination</p> Signup and view all the answers

    What is the major difference between the two nursing diagnoses: (1) inadequate nutritional intake related to vomiting as manifested by a 3-lb weight loss and (2) risk for impaired skin integrity related to inadequate nutrition?

    <p>The second diagnosis reflects a problem that does not yet exist.</p> Signup and view all the answers

    What framework does the establishment of priorities of care during the planning phase of the nursing process often use?

    <p>Maslow's hierarchy of needs</p> Signup and view all the answers

    What is an appropriate outcome statement for a patient with a nursing diagnosis of ineffective airway clearance related to thick secretions?

    <p>The patient will increase intake to 1000 mL daily to liquefy secretions.</p> Signup and view all the answers

    What is the primary purpose of nursing orders?

    <p>To provide direction for all caregivers</p> Signup and view all the answers

    What documentation reflects implementation?

    <p>&quot;Patient was ambulated for 15 minutes after lunch.&quot;</p> Signup and view all the answers

    Which nursing order is complete and correct?

    <p>&quot;Day nurse will cleanse wound and change dressings every day. May 10, A. Nurse&quot;</p> Signup and view all the answers

    A patient with a urinary tract infection is assessed using a clinical pathway. When a projected outcome is not met by a predetermined date, it is determined that what has occurred?

    <p>Variance</p> Signup and view all the answers

    During a physical examination, the nurse discovers that the patient demonstrates signs of flushed, dry, hot skin; dry oral mucous membranes; and temperature elevation. What does this data represent?

    <p>Data clustering</p> Signup and view all the answers

    What type of assessment is performed continuously throughout nurse-patient contact?

    <p>Focused</p> Signup and view all the answers

    What assists the nurse in the identification of nursing diagnoses?

    <p>Data clustering</p> Signup and view all the answers

    What organized approach might the nurse use when performing a complete physical examination?

    <p>A head-to-toe assessment</p> Signup and view all the answers

    Who is the person responsible for analyzing and interpreting data to arrive at a nursing diagnosis?

    <p>RN</p> Signup and view all the answers

    What is the basis for designing and selecting nursing interventions to meet patient needs?

    <p>Nursing diagnosis</p> Signup and view all the answers

    The patient is confined to bed rest, which contributes to immobility. What is bed rest considered in this situation?

    <p>A risk factor</p> Signup and view all the answers

    What is a nursing diagnosis considered when a problem is suspected but data to support it are lacking?

    <p>A possible nursing diagnosis</p> Signup and view all the answers

    When a nurse selects interventions to assist the patient to meet the needs demonstrated, the nurse is in which phase of the nursing process?

    <p>Planning</p> Signup and view all the answers

    What is an important consideration when developing the care plan?

    <p>Ensure the patient is involved in the process</p> Signup and view all the answers

    From where are the 'risk for' nursing diagnoses identified?

    <p>The assessment</p> Signup and view all the answers

    What expected outcome exemplifies accepted criteria?

    <p>Resident will take part in one activity daily for the next 90 days</p> Signup and view all the answers

    During an admission assessment, the nurse collects objective and subjective data. What is an example of subjective data?

    <p>The patient complains of nausea.</p> Signup and view all the answers

    During an admission assessment, the nurse collects objective and subjective data. What is an example of subjective data?

    <p>The patient states, 'I hurt all over.'</p> Signup and view all the answers

    During an admission assessment, the nurse collects objective and subjective data. What is an example of subjective data?

    <p>The patient complains of generalized discomfort.</p> Signup and view all the answers

    During an admission assessment, the nurse collects objective and subjective data. What is an example of objective data?

    <p>The patient is short of breath on exertion.</p> Signup and view all the answers

    During an admission assessment, the nurse collects objective and subjective data. What is an example of objective data?

    <p>The patient is jaundiced.</p> Signup and view all the answers

    During an admission assessment, the nurse collects objective and subjective data. What is an example of objective data?

    <p>The patient is pacing back and forth while chanting.</p> Signup and view all the answers

    What is an example of an appropriate nursing diagnosis?

    <p>Impaired skin integrity</p> Signup and view all the answers

    Study Notes

    Nursing Process Overview

    • The nursing process is a framework for organizing individualized nursing care, consisting of assessment, diagnosis, planning, implementation, and evaluation.

    Focused and Comprehensive Assessments

    • Focused assessments are critical and performed continuously; patients with severe conditions (e.g., perforated ulcer) should receive these assessments.
    • Objective data are measurable by others, while subjective data is sourced from patient statements about feelings or conditions.

    Data Collection Methods

    • Primary data collection methods include interviews and physical examinations.
    • Secondary data can be obtained from family members when the patient cannot provide information.

    Nursing Diagnoses

    • Actual nursing diagnoses represent current conditions, while “risk for” diagnoses indicate potential issues not yet manifested.
    • Possible nursing diagnoses require further data to confirm suspicions.

    Prioritization in Planning

    • Maslow's hierarchy of needs serves as a key framework for establishing care priorities, ensuring basic needs are addressed before higher-level needs.

    Implementing Nursing Care

    • Nursing orders must provide clear instructions for caregivers, detailing tasks, expected timeframes, and the responsible individual.
    • Implementation reflects the execution of nursing orders to achieve set outcomes.

    Variances and Evaluation

    • A variance occurs when a patient's progress does not meet established outcomes within expected timelines.
    • Documentation of outcomes should be specific, measurable, and time-bound.

    Objective vs. Subjective Data

    • Subjective data examples include patient complaints of nausea; objective data includes observable signs like jaundice.
    • A head-to-toe assessment format aids in systematically gathering both subjective and objective data.

    Care Plan Development

    • Involvement of the patient in care planning enhances effectiveness and compliance.
    • Nursing interventions are directly linked to nursing diagnoses for tailored care.

    Importance of Nursing Diagnoses

    • Nursing diagnoses guide the assessment and planning phases, informing interventions and expected outcomes.
    • Properly formulated nursing diagnoses should be NANDA-I approved for clarity and standardization.

    Summary of Key Terms

    • Nursing Diagnosis: Describes a patient’s health problem.
    • Objective Data: Observable and measurable signs (e.g., vital signs).
    • Subjective Data: Patient-reported symptoms (e.g., pain, anxiety).
    • Variance: A deviation from expected patient outcomes.
    • Care Plan: A structured approach outlining nursing actions based on diagnoses.### Medical Diagnosis vs. Nursing Diagnosis
    • Medical Diagnosis: Identifies disease or condition through evaluation (e.g., Diabetes mellitus, Pneumonia).
    • Nursing Diagnosis: Clinical judgment on individual, family, or community responses to health issues (e.g., Impaired skin integrity, Altered nutrition).

    Data Sources for Nursing Assessment

    • Primary Data: Collected directly from the patient.
    • Secondary Sources: Include family members, healthcare professionals, diagnostic reports, and textbooks for comprehensive information.

    Categories of Nursing Diagnoses

    • Four main types:
      • Actual Nursing Diagnosis: Present health condition.
      • Risk Nursing Diagnosis: Potential health issues that may develop.
      • Wellness Nursing Diagnosis: Readiness for health improvement.
      • Syndrome Nursing Diagnosis: Complex health issues that require a collaborative approach.

    Phases of the Nursing Process

    • Six key phases:
      • Diagnosis
      • Assessment
      • Outcome identification
      • Planning
      • Implementation
      • Evaluation
    • Note: No prediction phase exists in this process.

    Nursing Outcome Classification (NOC)

    • NOC: A framework for setting outcome criteria based on patient problems. Assists in measuring and naming patient outcomes.

    Clinical Pathways

    • Multidisciplinary plans guiding patient care over time for specific high-risk conditions, also known as critical paths or care maps.

    Cultural and Ethnic Considerations in Nursing

    • Cultural Competence: Essential for providing individualized, holistic care that respects patient diversity.
    • Stereotypes: Fixed ideas about behaviors of ethnic groups, leading to misinterpretation of individuality.

    Key Concepts in Culture

    • Ethnocentrism: Belief that one’s own ethnic group is superior.
    • Matriarchal Culture: Women hold primary decision-making roles in health care.
    • Biomedical Therapy: Predominant belief in U.S. healthcare for treating diseases.

    Importance of Culturally Appropriate Care

    • The integration of cultural knowledge is fundamental for effective nursing practice.
    • Awareness of cultural practices (e.g., dietary restrictions, family roles) enhances patient care.

    Case Considerations for Specific Cultures

    • American Indian Practices: Avoid touching the deceased; name avoidance after death.
    • Orthodox Jewish Practices: Dietary laws (e.g., Kosher), naming customs by the father, and circumcision by a mohel.
    • Latter-Day Saints (Mormons): Avoidance of caffeine and alcohol; preference for juice.

    Communication and Interaction

    • Understanding cultural subcultures promotes effective communication between healthcare providers and patients.

    Dietary Restrictions by Culture

    • Acknowledge and implement dietary laws specific to cultural practices, such as Kosher rules for Jewish patients.

    Ethical Considerations

    • Adapt to individualized care plans, especially concerning sensitive issues like maternity and dietary needs in religious contexts.### Nursing Interventions and Cultural Sensitivity
    • Sacred undergarments of Latter-Day Saints should only be removed in emergency situations.
    • Biomedical health belief system supports the idea that life processes can be manipulated by mechanical interventions.
    • Folk health belief system is often referred to as "third-world" practices and is viewed as strange by healthcare professionals unfamiliar with it.
    • The folk health belief system acknowledges supernatural forces affecting health and illness.
    • Holistic health belief system emphasizes restoring balance among physical, social, and metaphysical aspects of health.
    • Muslims observe fasting during daylight hours during Ramadan, highlighting cultural dietary practices.
    • Dietary restrictions for Muslims include avoidance of pork products; appropriate meals should comply with these restrictions.
    • A patient's request for an Imam consultation signifies cultural adherence by Muslim patients.
    • Same-sex healthcare providers are preferred for Muslim patients to respect cultural norms.
    • Comfort during interactions with Chinese American patients may require side-to-side seating to respect their cultural preferences.
    • Decision-making in Mexican American families often involves male consultation, emphasizing family dynamics in care decisions.
    • African American culture typically sees women as primary decision-makers within families.
    • In labor practices, encouraging female family members to be present is culturally sensitive for Mexican American patients.
    • In American Indian culture, the umbilical cord is dried and buried symbolically representing parents' wishes for the child.
    • Common characteristics among cultures include economic practices, survival modes, transportation systems, and family systems.
    • Culturally sensitive care for Muslim women includes assigning female staff, maintaining modesty, and allowing prayer privacy.
    • Understanding differences in communication styles is crucial, as some groups, like Korean patients, find prolonged eye contact impolite.
    • Elasticity is a cultural characteristic where individuals may miss appointments due to being preoccupied with current activities.
    • Infant baptism is significant in Presbyterian beliefs, highlighting the importance of cultural practices in healthcare.
    • Mexican Americans may seek health advice from curanderos (folk healers), indicating the value of traditional healing practices.
    • Society is defined as a group with established aims, beliefs, and standards influencing behavior and lifestyle.
    • Culture encompasses learned values and customs shared among a group, passed through generations.
    • Stereotypes represent generalizations about behaviors and groups, which can influence healthcare perceptions.

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