Nursing Process and Evidence-Based Practice

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Questions and Answers

Which aspect is NOT included in a cultural assessment for patient care?

Cultural or religious traditions

Patient's health beliefs and practices

Language and communication preferences

Patient's socioeconomic status (correct)

What should a nurse prioritize when taking notes during a patient interview?

Encouraging the patient to speak more slowly

Maintaining an active listening attitude (correct)

Asking more closed-ended questions

Documenting every detail verbatim

In the interview process, which phase is INACCURATELY described?

Closing: Plan next steps

Body: Summarize key points (correct)

Opening: Establish rapport

Summary: Document findings

Which verbal communication strategy entails offering perspectives on a patient's statements?

Interpretation Signup and view all the answers

What is a key difference between verbal and nonverbal communication in patient interviews?

Verbal communication includes tone, while nonverbal includes gestures Signup and view all the answers

When using an interpreter, how should the nurse conduct the conversation?

Directly address the patient while using the interpreter Signup and view all the answers

Which factor is NOT typically gathered in a patient’s health history?

Patient’s dietary preferences Signup and view all the answers

What should a nurse explore after a patient reports pain?

Characteristics of the pain experienced Signup and view all the answers

Which major illnesses should family health history questions focus on?

Chronic conditions like diabetes and heart disease Signup and view all the answers

What is the primary purpose of a genogram in healthcare?

To visually represent a family's health history Signup and view all the answers

Which technique is performed last when conducting a physical assessment?

Palpation Signup and view all the answers

In a physical assessment, which sound indicates the presence of a solid structure when percussion is performed?

Dull sound Signup and view all the answers

What should be assessed during functional ability assessments?

Patient's ability to perform activities of daily living Signup and view all the answers

What are the components of a stethoscope used for auscultation?

Diaphragm and bell Signup and view all the answers

What does a nurse assess for when observing crepitus during palpation?

Crackling or grating sensation Signup and view all the answers

What is the standard duration for assessing pulse and respirations for accuracy?

1 minute Signup and view all the answers

Which of the following is NOT considered one of the four vital signs?

Body mass index Signup and view all the answers

When performing an abdominal assessment, which technique is used first?

Inspection Signup and view all the answers

What adaptation should a nurse note when assessing a patient's use of assistive devices?

The patient's manual dexterity with the device Signup and view all the answers

Which statement accurately distinguishes between objective and subjective data?

Objective data includes measurable indicators, whereas subjective data relies on patient-reported symptoms. Signup and view all the answers

What is the primary purpose of evidence-based practice in nursing?

To integrate the best available evidence with clinical expertise and patient values. Signup and view all the answers

During which step of the nursing process is a patient's risk for falls identified?

Diagnosis Signup and view all the answers

What best describes how objective data should be documented during a physical exam?

In a factual and descriptive manner without personal bias. Signup and view all the answers

What is the main difference between a complete history and a focused/problem-centered history?

Complete history gathers comprehensive information while focused history deals with specific concerns. Signup and view all the answers

Cultural competence in nursing primarily involves which of the following behaviors?

Acknowledging personal biases and adapting care based on patient cultural needs. Signup and view all the answers

Which of the following best describes spirituality in a healthcare context?

It refers to a sense of connection and meaning, regardless of religious beliefs. Signup and view all the answers

What is an example of an effective nursing action during the planning phase of the nursing process?

Setting a collaborative goal with the patient. Signup and view all the answers

Which of the following statements about subjective data is true?

Subjective data is primarily based on the patient's self-reported experiences. Signup and view all the answers

Which action best represents implementation in the nursing process?

Providing patient education on disease management. Signup and view all the answers

What is the correct blood pressure range for a child?

90/60 to 120/80 mmHg Signup and view all the answers

Which factor is least likely to affect blood pressure measurement accuracy?

Room temperature Signup and view all the answers

What is the typical method for assessing respirations in an infant?

Observing the rise and fall of the chest and abdomen Signup and view all the answers

Which statement about acute pain is correct?

It is sudden in onset and time-limited. Signup and view all the answers

When using the PQRST mnemonic for pain assessment, what does the 'R' stand for?

Region/Radiation Signup and view all the answers

What is the appropriate blood pressure cuff size for an obese patient?

Large adult cuff Signup and view all the answers

Which of the following statements about rectal temperature measurement is accurate?

It is suitable for infants and patients unable to hold a thermometer under the tongue. Signup and view all the answers

Which is NOT a common indication of orthostatic hypotension?

Increase of 20 mmHg in systolic blood pressure Signup and view all the answers

What benefit does the use of open-ended questions provide in patient assessments?

They help obtain detailed information from the patient. Signup and view all the answers

What is the normal pulse rate for an infant?

100-160 bpm Signup and view all the answers

Study Notes

Data Types

Objective data: Factual and measurable information, such as vital signs and lab results.
Subjective data: Patient-reported symptoms and feelings.

Evidence-Based Practice

Clinical decisions based on the best research evidence, clinical expertise, and patient preferences.

Nursing Process

Assessment: Gathering patient health data (e.g., health history).
Diagnosis: Identifying nursing diagnoses (e.g., risk for falls).
Planning: Developing patient-centered care plans (e.g., ambulate 50 feet).
Implementation: Executing care interventions (e.g., fall prevention education).
Evaluation: Monitoring patient progress and adjusting care plans.

Physical Exam Documentation

Use factual and descriptive language for objective data (e.g., "Skin warm, dry, intact").

Health Histories

Complete history: Comprehensive patient information.
Focused history: Specific concern-driven details.

Cultural Competence

Providing respectful, responsive care that acknowledges cultural diversity.
Awareness of biases and adapting communication for different cultures.

Spirituality

Refers to a sense of meaning beyond oneself, not necessarily tied to religion.

Cultural Assessment

Include patient health beliefs, communication preferences, support systems, and traditions affecting healthcare.

Patient Interview Techniques

Note-taking should not disrupt active listening during patient interviews.
Interview process: Opening (establish rapport), Body (gather info), Closing (summarize), Summary (document findings).

Questioning Styles

Open-ended questions elicit detailed responses.
Closed-ended questions yield yes/no or short answers.

Verbal Communication Strategies

Empathy: Express understanding of patient experiences.
Reflection: Restate patient statements for clarity.
Facilitation: Use prompts to encourage sharing.
Interpretation: Provide insights into patient statements.
Confrontation: Challenge beliefs non-judgmentally.

Communication Discrepancies

Explore differences between verbal and nonverbal communication to understand patient implications.

Working with Interpreters

Speak directly to the patient and maintain eye contact to ensure meaning is conveyed properly.

Health History Purpose

Collect information regarding patient's past and present health, including medical and family history.

Pain Assessment

Follow-up questions for pain should explore location, intensity, quality, and factors influencing pain.

Family Health History

Cover major illnesses with genetic links, like cancer, heart disease, and diabetes.

Self-Promotion in Healthcare

Inquiry into patient participation in screenings and self-care actions.

Genogram

A visual tool for mapping family health history, revealing illness patterns and relationships.

Functional Ability Assessment

Questions should address the patient’s ability to perform daily activities and use of assistive devices.

Physical Assessment Techniques

Techniques: Inspection (visual exam), Auscultation (listening), Percussion (tapping), Palpation (feeling).

Assessment Techniques Explained

Dull percussion sound suggests solid organs; resonant sound indicates air presence.
Diaphragm of stethoscope measures high-pitched sounds; bell measures low-pitched sounds.

Vital Signs Overview

Four vital signs: Temperature, blood pressure, pulse, respirations.
Normal ranges: Adult T: 97.6-99.6°F, BP: 120/80 mmHg, Pulse: 60-100 bpm, Resp: 12-20/min.
Variations for children and infants in vital sign norms.

Blood Pressure Measurement

Use a larger cuff for obese patients to ensure accuracy.
Inflate cuff 30 mmHg above where the pulse disappears.

Orthostatic Hypotension

Blood pressure drops upon standing, marked by decreases in systolic and diastolic readings.

Respirations in Infants

Assess by observing chest and abdomen rise and fall; count breaths accurately.

Pain Assessment Additional Methods

Observe nonverbal cues alongside patient self-reporting for pain evaluation.

Rectal Temperature Indication

Suitable for infants or patients unable to use oral thermometers.

Advantages of Open-Ended Questions

Encourage detailed patient responses and enhance understanding of their perspective.

PQRST Pain Assessment Tool

Provocation/Palliation: Determine factors affecting pain.
Quality: Describe pain characteristics (sharp, dull).
Region/Radiation: Identify pain location and radiation.
Severity: Rate pain on a scale of 0-10.
Timing: Establish pain onset and duration.

Blood Pressure Reading Accuracy

Factors: Patient position, cuff size, leg position during measurement.

Pain Types

Acute pain: Sudden, severe, and short-lived.
Chronic pain: Persistent, lasting for months or years.

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Description

Test your understanding of the nursing process, objective vs subjective data, and the principles of evidence-based practice. This quiz covers essential concepts that every nursing student should know. Dive into clinical decision-making and improve your healthcare knowledge.