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What condition does the patient have on his back?
What condition does the patient have on his back?
Scabies
What is an example of an appropriate nursing diagnosis?
What is an example of an appropriate nursing diagnosis?
What is an example of an appropriately written nursing diagnosis?
What is an example of an appropriately written nursing diagnosis?
Which is an example of a nursing diagnosis?
Which is an example of a nursing diagnosis?
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Which is an example of a medical diagnosis?
Which is an example of a medical diagnosis?
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Which is an example of a medical diagnosis?
Which is an example of a medical diagnosis?
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Which are acceptable secondary sources for data? (Select all that apply)
Which are acceptable secondary sources for data? (Select all that apply)
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Which are official categories of nursing diagnoses? (Select all that apply)
Which are official categories of nursing diagnoses? (Select all that apply)
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Which are considered phases of the nursing process? (Select all that apply)
Which are considered phases of the nursing process? (Select all that apply)
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How often does NANDA International meet to reorganize diagnosis labels and language?
How often does NANDA International meet to reorganize diagnosis labels and language?
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The standards that name and measure patient outcomes are referred to as __.
The standards that name and measure patient outcomes are referred to as __.
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The document that outlines a multidisciplinary plan for care interventions over a specified time frame is a __.
The document that outlines a multidisciplinary plan for care interventions over a specified time frame is a __.
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A systematic method by which nurses plan and provide care for patients is known as the __.
A systematic method by which nurses plan and provide care for patients is known as the __.
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A systematic, dynamic process by which the nurse collects and analyzes data about the patient is known as __.
A systematic, dynamic process by which the nurse collects and analyzes data about the patient is known as __.
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Any health care condition that requires diagnostic, therapeutic, or educational actions is known as a __.
Any health care condition that requires diagnostic, therapeutic, or educational actions is known as a __.
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A clinical judgment about individual, family, or community responses to health problems is known as a __.
A clinical judgment about individual, family, or community responses to health problems is known as a __.
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The human responses to health conditions/life processes that exist in an individual, family, or community are known as a(n) __.
The human responses to health conditions/life processes that exist in an individual, family, or community are known as a(n) __.
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Human responses to health conditions that may develop in a vulnerable individual, family, or community are known as a(n) __.
Human responses to health conditions that may develop in a vulnerable individual, family, or community are known as a(n) __.
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Human responses to levels of wellness in an individual that have a readiness for enhancement are known as a __.
Human responses to levels of wellness in an individual that have a readiness for enhancement are known as a __.
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The identification of a disease or condition by scientific evaluation is a __.
The identification of a disease or condition by scientific evaluation is a __.
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A health care system that provides control over health care services for a specific group is known as __.
A health care system that provides control over health care services for a specific group is known as __.
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A multidisciplinary plan that schedules clinical interventions is known as a __.
A multidisciplinary plan that schedules clinical interventions is known as a __.
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Why is it important for the nurse to understand and accept each person as an individual?
Why is it important for the nurse to understand and accept each person as an individual?
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What is a fixed concept of how all members of an ethnic group act or think?
What is a fixed concept of how all members of an ethnic group act or think?
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What is the integration of cultural knowledge into all aspects of care?
What is the integration of cultural knowledge into all aspects of care?
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What is the term for when members of a particular ethnic group believe that their beliefs and practices are the best?
What is the term for when members of a particular ethnic group believe that their beliefs and practices are the best?
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What is the term used to describe cultures in which women make decisions about health care?
What is the term used to describe cultures in which women make decisions about health care?
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What basic philosophy in the United States is relevant to health care?
What basic philosophy in the United States is relevant to health care?
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What is a set of learned values, beliefs, customs, and practices shared by a group?
What is a set of learned values, beliefs, customs, and practices shared by a group?
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What must a nurse develop to provide care to patients from different cultures?
What must a nurse develop to provide care to patients from different cultures?
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What difference between a nurse from New York and a patient from Atlanta may cause communication difficulty?
What difference between a nurse from New York and a patient from Atlanta may cause communication difficulty?
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What should a nurse do immediately after the death of an American Indian father?
What should a nurse do immediately after the death of an American Indian father?
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What is the term for a generalization about a behavior or individual?
What is the term for a generalization about a behavior or individual?
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What is the term for a group of people sharing biologic characteristics?
What is the term for a group of people sharing biologic characteristics?
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What is the term for a group of people sharing social and cultural heritage?
What is the term for a group of people sharing social and cultural heritage?
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Who can be expected to name a neonate born to Orthodox Jewish parents?
Who can be expected to name a neonate born to Orthodox Jewish parents?
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Who will perform the circumcision of a male neonate in observant Orthodox Jewish families?
Who will perform the circumcision of a male neonate in observant Orthodox Jewish families?
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What book is used when naming a female neonate in Orthodox Jewish culture?
What book is used when naming a female neonate in Orthodox Jewish culture?
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What can the nurse expect regarding the spouse's participation in his wife's care after she has given birth?
What can the nurse expect regarding the spouse's participation in his wife's care after she has given birth?
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What is the most appropriate dietary requirement for an Orthodox Jewish patient?
What is the most appropriate dietary requirement for an Orthodox Jewish patient?
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What intervention is appropriate for an Orthodox Jewish patient during Passover?
What intervention is appropriate for an Orthodox Jewish patient during Passover?
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What is the most appropriate method for discussing birth control options with a Roman Catholic patient?
What is the most appropriate method for discussing birth control options with a Roman Catholic patient?
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What beverage should the nurse prepare for a patient who is a Latter-Day Saint?
What beverage should the nurse prepare for a patient who is a Latter-Day Saint?
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What intervention is appropriate for a Latter-Day Saint patient wearing sacred undergarments?
What intervention is appropriate for a Latter-Day Saint patient wearing sacred undergarments?
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Which statement about the biomedical health belief system is true?
Which statement about the biomedical health belief system is true?
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Which health belief system is commonly referred to as 'third-world' beliefs and practices?
Which health belief system is commonly referred to as 'third-world' beliefs and practices?
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Which health belief system includes a belief of a supernatural force exerting influence to cause health or illness?
Which health belief system includes a belief of a supernatural force exerting influence to cause health or illness?
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Which health belief system focuses on restoring balance with physical, social, and metaphysical worlds?
Which health belief system focuses on restoring balance with physical, social, and metaphysical worlds?
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The nurse is caring for a patient who fasts during daylight hours during Ramadan. Which culture does the nurse recognize this patient adheres to?
The nurse is caring for a patient who fasts during daylight hours during Ramadan. Which culture does the nurse recognize this patient adheres to?
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What dietary selection should the nurse serve to a Muslim patient?
What dietary selection should the nurse serve to a Muslim patient?
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A patient requests a consultation between the physician and a religious leader known as an Imam. What is this patient's cultural belief?
A patient requests a consultation between the physician and a religious leader known as an Imam. What is this patient's cultural belief?
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What intervention is most appropriate for a female Muslim patient receiving care?
What intervention is most appropriate for a female Muslim patient receiving care?
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How should a nurse demonstrate cultural awareness when caring for a Chinese American patient?
How should a nurse demonstrate cultural awareness when caring for a Chinese American patient?
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What nursing intervention would best demonstrate cultural sensitivity to a Mexican American patient?
What nursing intervention would best demonstrate cultural sensitivity to a Mexican American patient?
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Who would the nurse expect to be the primary decision maker in an African American patient's family?
Who would the nurse expect to be the primary decision maker in an African American patient's family?
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How can a nurse best demonstrate cultural sensitivity when caring for a Mexican American patient in labor?
How can a nurse best demonstrate cultural sensitivity when caring for a Mexican American patient in labor?
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Which cultural beliefs does a postpartum patient adhere to if she requests to dry and bury the umbilical cord?
Which cultural beliefs does a postpartum patient adhere to if she requests to dry and bury the umbilical cord?
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What are some characteristics that cultures have in common?
What are some characteristics that cultures have in common?
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What should the culturally sensitive nurse do for a Muslim woman being treated in the hospital?
What should the culturally sensitive nurse do for a Muslim woman being treated in the hospital?
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What should a nurse take into consideration when admitting an 85-year-old resident of Hispanic descent diagnosed with Alzheimer disease?
What should a nurse take into consideration when admitting an 85-year-old resident of Hispanic descent diagnosed with Alzheimer disease?
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The nurse should not maintain eye contact with a Korean patient because many Asians believe prolonged eye contact is impolite.
The nurse should not maintain eye contact with a Korean patient because many Asians believe prolonged eye contact is impolite.
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What is the cultural characteristic of unwillingness to leave a current activity, which may result in late or missed appointments?
What is the cultural characteristic of unwillingness to leave a current activity, which may result in late or missed appointments?
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Following the death of a Presbyterian infant, what should the nurse help arrange for?
Following the death of a Presbyterian infant, what should the nurse help arrange for?
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While caring for a Mexican American family in the home, who may the family consult for health advice?
While caring for a Mexican American family in the home, who may the family consult for health advice?
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What is known as a nation, community, or broad group of people who establish particular aims, beliefs, or standards of living and conduct?
What is known as a nation, community, or broad group of people who establish particular aims, beliefs, or standards of living and conduct?
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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?
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?
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What best defines the nursing process?
What best defines the nursing process?
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On admission, which patient should receive a focused assessment?
On admission, which patient should receive a focused assessment?
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What subjective data does the nurse record following a head-to-toe examination?
What subjective data does the nurse record following a head-to-toe examination?
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What objective data should the nurse include after a patient assessment?
What objective data should the nurse include after a patient assessment?
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What is classified as information provided by the family when a patient is unable to provide data during assessment?
What is classified as information provided by the family when a patient is unable to provide data during assessment?
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What are the two primary methods used to collect data?
What are the two primary methods used to collect data?
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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?
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?
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What framework does the establishment of priorities of care during the planning phase of the nursing process often use?
What framework does the establishment of priorities of care during the planning phase of the nursing process often use?
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What is an appropriate outcome statement for a patient with a nursing diagnosis of ineffective airway clearance related to thick secretions?
What is an appropriate outcome statement for a patient with a nursing diagnosis of ineffective airway clearance related to thick secretions?
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What is the primary purpose of nursing orders?
What is the primary purpose of nursing orders?
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What documentation reflects implementation?
What documentation reflects implementation?
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Which nursing order is complete and correct?
Which nursing order is complete and correct?
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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?
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?
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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?
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?
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What type of assessment is performed continuously throughout nurse-patient contact?
What type of assessment is performed continuously throughout nurse-patient contact?
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What assists the nurse in the identification of nursing diagnoses?
What assists the nurse in the identification of nursing diagnoses?
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What organized approach might the nurse use when performing a complete physical examination?
What organized approach might the nurse use when performing a complete physical examination?
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Who is the person responsible for analyzing and interpreting data to arrive at a nursing diagnosis?
Who is the person responsible for analyzing and interpreting data to arrive at a nursing diagnosis?
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What is the basis for designing and selecting nursing interventions to meet patient needs?
What is the basis for designing and selecting nursing interventions to meet patient needs?
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The patient is confined to bed rest, which contributes to immobility. What is bed rest considered in this situation?
The patient is confined to bed rest, which contributes to immobility. What is bed rest considered in this situation?
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What is a nursing diagnosis considered when a problem is suspected but data to support it are lacking?
What is a nursing diagnosis considered when a problem is suspected but data to support it are lacking?
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When a nurse selects interventions to assist the patient to meet the needs demonstrated, the nurse is in which phase of the nursing process?
When a nurse selects interventions to assist the patient to meet the needs demonstrated, the nurse is in which phase of the nursing process?
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What is an important consideration when developing the care plan?
What is an important consideration when developing the care plan?
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From where are the 'risk for' nursing diagnoses identified?
From where are the 'risk for' nursing diagnoses identified?
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What expected outcome exemplifies accepted criteria?
What expected outcome exemplifies accepted criteria?
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During an admission assessment, the nurse collects objective and subjective data. What is an example of subjective data?
During an admission assessment, the nurse collects objective and subjective data. What is an example of subjective data?
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During an admission assessment, the nurse collects objective and subjective data. What is an example of subjective data?
During an admission assessment, the nurse collects objective and subjective data. What is an example of subjective data?
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During an admission assessment, the nurse collects objective and subjective data. What is an example of subjective data?
During an admission assessment, the nurse collects objective and subjective data. What is an example of subjective data?
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During an admission assessment, the nurse collects objective and subjective data. What is an example of objective data?
During an admission assessment, the nurse collects objective and subjective data. What is an example of objective data?
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During an admission assessment, the nurse collects objective and subjective data. What is an example of objective data?
During an admission assessment, the nurse collects objective and subjective data. What is an example of objective data?
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During an admission assessment, the nurse collects objective and subjective data. What is an example of objective data?
During an admission assessment, the nurse collects objective and subjective data. What is an example of objective data?
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What is an example of an appropriate nursing diagnosis?
What is an example of an appropriate nursing diagnosis?
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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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Test your understanding of the nursing process and critical thinking in nursing with these flashcards. This quiz covers key definitions and concepts that are essential for effective nursing care. Challenge your knowledge and reinforce your learning.