Exam 5 Fundamentals II

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Questions and Answers

Which domain of learning primarily focuses on the skills needed for physical tasks?

Cognitive

Psychomotor (correct)

Effective

Kinesthetic

What is the primary focus of the effective domain in learning?

Developing technical skills

Memorizing facts

Applying knowledge in practice

Understanding feelings and motivations (correct)

Which method is most effective for teaching psychomotor skills?

Storytelling

Demonstration and return demonstration (correct)

Lectures

Group discussions

What is meant by 'the right context' in patient education?

The teaching environment is conducive to learning Signup and view all the answers

Which of the following tools can be effective in the cognitive domain of learning?

Audiovisual materials Signup and view all the answers

What is one of the five rights of teaching that involves ensuring the patient is engaged?

Right goal Signup and view all the answers

Which teaching method is most likely to encourage personal reflection in the effective domain?

Journaling Signup and view all the answers

What is a key indicator that the 'right time' for teaching has been met?

The patient is free of pain and motivated Signup and view all the answers

Which factor contributes to skin breakdown in elderly individuals?

Thinner, more permeable skin Signup and view all the answers

What is the primary purpose of the subcutaneous layer?

Insulate the body and cushion organs Signup and view all the answers

Clients with which condition are more likely to develop pressure injuries?

Diminished sensation Signup and view all the answers

How does impaired circulation affect skin integrity?

It delays wound healing and contributes to tissue damage Signup and view all the answers

Which nutrient is essential for maintaining skin health?

Protein Signup and view all the answers

What type of wound is formed without any break in the skin?

Closed wound Signup and view all the answers

What are clean/contaminated wounds?

Wounds from unsterile surgical incisions into sterile areas Signup and view all the answers

Which type of wound healing involves little to no tissue loss?

Primary intention Signup and view all the answers

What can excessive moisture on the skin lead to?

Maceration and skin breakdown Signup and view all the answers

Which of the following describes a chronic wound?

A wound that exceeds the expected length of recovery Signup and view all the answers

What type of injury is classified as a superficial wound?

Injuries involving only the epidermal layer Signup and view all the answers

Clients with impaired cognition are at higher risk for pressure injuries due to which reason?

Lack of awareness to reposition themselves Signup and view all the answers

What can frequently bathing and using drying soaps lead to?

Compromised skin barrier and function Signup and view all the answers

What problem can arise from medications that affect skin integrity?

Skin itching and rashes Signup and view all the answers

What is the primary characteristic of secondary intention healing?

Involves extensive tissue loss Signup and view all the answers

During which phase of wound healing does hemostasis occur?

Inflammatory phase Signup and view all the answers

What type of drainage is characterized by a pinkish color due to a mix of fluids?

Serosanguinous Signup and view all the answers

Which complication of wound healing occurs most likely during the inflammatory phase?

Dehiscence Signup and view all the answers

What is the main purpose of the proliferative phase in wound healing?

Depositing collagen for strength Signup and view all the answers

What condition indicates that evisceration has occurred?

Protrusion of internal organs through the incision Signup and view all the answers

What type of healing involves delayed primary closure?

Tertiary intention healing Signup and view all the answers

What is a common cause of dehiscence in wound healing?

Poor nutritional status Signup and view all the answers

Which phase of wound healing is characterized by the presence of macrophages clearing debris?

Inflammatory phase Signup and view all the answers

What type of wound drainage is indicative of an infection?

Purulent Signup and view all the answers

What must a plaintiff prove to win a malpractice lawsuit?

Existence of a duty, breach of duty, causation, and damages Signup and view all the answers

What factor does the Braden Scale NOT assess?

Pain Signup and view all the answers

Which of the following is a form of defamation of character?

Slander Signup and view all the answers

What complication is characterized by an abnormal passage connecting two body cavities?

Fistula formation Signup and view all the answers

What does false imprisonment in nursing refer to?

Restraining a patient without legal authorization Signup and view all the answers

How long does the inflammatory phase of wound healing typically last?

1 to 5 days Signup and view all the answers

What is the role of fibroblasts during the proliferative phase?

They form collagen Signup and view all the answers

What is the primary purpose of Good Samaritan laws?

To protect those providing emergency care from liability Signup and view all the answers

Which element is NOT necessary to establish negligence in nursing?

Proof of intent to harm Signup and view all the answers

How should a nurse respond if a patient refuses care?

Document the patient's refusal and ensure they understand the consequences Signup and view all the answers

What does the failure to assess and diagnose imply in the context of nursing malpractice?

Failing to conduct an adequate assessment Signup and view all the answers

Which situation exemplifies invasion of privacy?

A nurse discussing a patient's condition with another patient Signup and view all the answers

What is required for a nurse to act in accordance with legal accountability?

Knowledge of state nursing practice acts Signup and view all the answers

What constitutes an intentional tort in nursing?

Restraining a patient without consent Signup and view all the answers

What is defined as fraud in nursing practice?

Providing misleading information to patients Signup and view all the answers

What does the term 'malpractice' primarily refer to in nursing?

Legal failures in the nursing profession Signup and view all the answers

Which of the following actions is crucial to minimize malpractice risk in nursing?

Keep detailed and accurate documentation of care provided Signup and view all the answers

What is the main purpose of standardized nursing terminology?

To make nursing care and its outcomes visible Signup and view all the answers

Which of the following is an advantage of source-oriented documentation systems?

Allows for easy identification of care by discipline Signup and view all the answers

What is one disadvantage of charting by exception?

Potential omissions of important information Signup and view all the answers

What does the minimum data set (MDS) process entail?

Comprehensive assessments of functional capabilities and health needs Signup and view all the answers

In the S-bar format of reporting, what does 'B' stand for?

Background Signup and view all the answers

What should be included when writing a prescription based on a verbal order?

Provider's name and your signature Signup and view all the answers

Which layer of the skin is responsible for producing new cells?

Stratum germinativum Signup and view all the answers

What is one of the main issues with problem-oriented documentation systems?

They centralize too much information Signup and view all the answers

Why is standardized terminology particularly important in EHR systems?

It allows for conversion into numerical codes Signup and view all the answers

Which statement correctly describes charting by exception?

Only significant findings are documented Signup and view all the answers

What document is critical for long-term care facilities to ensure compliance?

Minimum data set assessments Signup and view all the answers

In the context of nursing documentation, which is a benefit of problem-oriented systems?

Ease of monitoring the client’s progress Signup and view all the answers

Which of the following statements is true about the epidermis?

It lacks blood vessels Signup and view all the answers

What is a key characteristic of verbal orders during emergencies?

They must be confirmed for accuracy Signup and view all the answers

What is indicated by a Norton scale score of 18 or less for hospitalized patients?

High risk of pressure injuries Signup and view all the answers

Which stage of a pressure ulcer involves non-blanchable erythema of intact skin?

Stage 1 Signup and view all the answers

What is a key characteristic of Stage 3 pressure ulcers?

Loss of the epidermis and dermis Signup and view all the answers

Which of the following accurately describes a deep tissue injury?

It is characterized by purple or maroon discoloration Signup and view all the answers

What type of errors occur when the wrong action is taken, such as administering the incorrect medication?

Errors of commission Signup and view all the answers

Which of the following is NOT a nursing intervention for preventing pressure injuries?

Limiting nutritional intake Signup and view all the answers

What defines wisdom in the context of nursing informatics?

Applying knowledge appropriately to solve complex problems Signup and view all the answers

Which component of nursing informatics aids in reducing errors related to handwriting in prescriptions?

Electronic health records (EHRs) Signup and view all the answers

Which of the following categories was suggested to be added to the Norton scale?

Skin appearance Signup and view all the answers

What does inadequate nutrition negatively impact in relation to pressure injuries?

Skin integrity and wound healing Signup and view all the answers

What is a defining feature of unstageable pressure ulcers?

Covered with eschar preventing depth determination Signup and view all the answers

What role does computer technology play in nursing informatics?

Facilitates data processing and enhances information accessibility Signup and view all the answers

What is the primary purpose of frequent repositioning for patients at risk of pressure injuries?

To reduce prolonged pressure on bony prominences Signup and view all the answers

What is the primary function of the underlying data in nursing informatics?

To provide context to isolated numbers Signup and view all the answers

What does the process of 'Information Processing' include regarding computers?

Input, process, output, and storage Signup and view all the answers

What is the role of nurses in ensuring proper patient care through delegation?

Nurses must understand delegation and the scope of practice of those they delegate to. Signup and view all the answers

Which ethical principle emphasizes the duty to do no harm?

Non-maleficence Signup and view all the answers

What is the primary focus of the code of ethics in nursing?

To inform the public about minimum standards and ethical considerations. Signup and view all the answers

What should a nurse do if there is an immediate threat to health or safety?

Report it immediately. Signup and view all the answers

Which ethical principle is concerned with fairness and equal treatment?

Justice Signup and view all the answers

What does the THINK mnemonic help with in ethical decision-making processes?

It assists with evaluating potential harm to patients. Signup and view all the answers

In which model does the nurse assess the patient's capability to make decisions?

Autonomy model Signup and view all the answers

What is an ethical dilemma?

A scenario where two ethical principles conflict. Signup and view all the answers

What is a nursing responsibility regarding continuing education?

Nurses must remain current in practice through ongoing education and training. Signup and view all the answers

What is the role of a whistleblower in healthcare?

To reveal information about corrupt practices. Signup and view all the answers

Which element is NOT part of the THINK mnemonic?

Knowledge of ethical guidelines. Signup and view all the answers

What does the Patient Care Partnership emphasize?

Patient expectations and responsibilities in ethical treatment. Signup and view all the answers

What is the duty of fidelity in nursing?

Being faithful and keeping promises made to patients. Signup and view all the answers

How are ethical principles often described in nursing practice?

In a continuum of obligations. Signup and view all the answers

Study Notes

Patient Education

Patient education is crucial for nursing care, equipping patients with health management skills.
Three learning domains exist: cognitive, affective, and psychomotor.
Cognitive: Focuses on intellectual skills (recall, application). Includes thinking, problem-solving, and remembering. Taught via lectures, readings, discussions, and visuals.
Psychomotor: Involves physical skills and procedures (e.g., taking vitals, administering medications, ADLs). Learned through hands-on practice, demonstrations, return demonstrations, simulation, journaling, and reflection.
Affective: Deals with feelings, motivation, and engagement with new information. Influenced by student values, beliefs, and attitudes. Encourages personal reflection, empathy, and growth. Supported by role modeling, group discussions, storytelling, one-on-one teaching, and visuals.
Five rights of teaching:
- Right time: Patient readiness, motivation, pain-free, trust established, sufficient time.
- Right context: Quiet, distraction-free environment.
- Right goal: Patient actively involved in planning, realistic and valued goals.
- Right content: Appropriate to patient needs, new information or reinforcement, patient level, relevance.
- Right method: Teaching strategy matches patient learning style and ability, varied methods.

Documenting and Reporting

Standardized language enhances nursing visibility and demonstrable value, making outcomes more transparent.
Standardized terminology supports nursing research, EHR systems (numerical codes), and evidence-based practices.
Standardized nursing languages (NIC, NOC, NANDA) are used in documentation.
Source-oriented systems: Disciplines document in separate sections (history, labs, notes). Advantages: easy access to each discipline's care. Disadvantages: fragmented data, scattered throughout record; requires review of multiple sections for full understanding.
Problem-oriented systems: Database, problems, plan of care, progress notes. Advantages: common problem list, centralized information, easier progress monitoring, and enhanced team collaboration.
Charting by exception: Documents significant findings and exceptions to norms. Advantages: reduced time spent documenting routine care, highlights variations, easily read and understood. Disadvantages: potential omissions of important information.
Home Healthcare Documentation: Includes assessments, interventions, client responses, caregiver/provider interactions.
Long-Term Care Documentation: Comprehensive assessments, minimum data set (MDS) required for Medicare/Medicaid facilities. Updates necessary with condition changes. Includes SBAR (situation, background, assessment, recommendation).
Verbal/telephone orders: Less common due to CPOE. Require confirmation, repetition, spelling out terms, separate digit pronouncements. Must be countersigned within 24 hours.

Skin Integrity and Wound Healing

Skin is the body's largest organ, composed of epidermis, dermis, and subcutaneous layers.
Epidermis: Protective barrier; stratum germinativum (basal layer) continuously produces new cells.
Dermis: Connective tissue, blood vessels, glands, nerves, hair follicles.
Subcutaneous: Insulation and cushioning.
Factors affecting skin integrity include:
- Age: Thin, permeable skin in infants/children and older adults.
- Nutrition: Adequate protein, vitamins (C, zinc, copper) for collagen formation.
- Sensation Level: Impaired sensation increases risk of injury.
- LOC (Level of Consciousness): Impaired cognition causes repositioning issues.
- Impaired Circulation: Delays healing.
- Medications: Skin reactions (itching, rashes).
- Moisture: Maceration (softening) increases breakdown risk.
- Fever: Sweating leading to maceration.
- Infection: Impairs healing.
- Lifestyle: Tanning, drying soaps, infrequent cleansing.
Wound Classification:
- Closed: No skin break (e.g., contusion).
- Open: Skin or mucous membrane break (e.g., abrasion, laceration).
- Acute: Short-duration healing.
- Chronic: Delayed healing.
- Clean, Clean/contaminated, Contaminated, Infected, Superficial, Partial-thickness, Full-thickness.
Wound Healing Processes (Primary, Secondary, Tertiary).
Phases of Wound Healing (Inflammatory, Proliferative, Maturation).
Types of wound drainage (serosanguinous, purulent, sanguinous, puro-sanguinous)
Wound Healing Complications (Hemorrhage, Infection, Dehiscence, Evisceration, Fistula formation).
Nursing Assessments: Focused skin assessments, Braden Scale, Norton scale.
Pressure Injuries: Types (Stage 1-4, deep tissue, unstageable) Nursing Interventions.

Nursing Informatics

Data: Unprocessed numbers, symbols, or words.
Information: Groups of data with context.
Knowledge: Meaningful information from groups of data.
Wisdom: Appropriate use of knowledge to solve complex problems.
Computer Functions: Input, process, output, storage.
Error Types: Commission (incorrect action), omission (missed action), planning, execution.
Benefits of EHRs: Efficiency, productivity, continuity, accessibility, reduced errors, privacy.
Informatics enhancing nursing: Evidence-based practice, literature databases, evidence-based practice databases (e.g., journals, organizations).

Legal Accountability/Leading & Managing

State laws guiding nursing: Mandatory reporting, good Samaritan, nurse practice acts.
Torts in nursing practice:
- Intentional torts: Assault, battery, false imprisonment, invasion of privacy, fraud, defamation.
- Negligence, malpractice (duty, breach of duty, causation, damages).
- Strategies to Minimize Malpractice Risk: Documentation, use of the nursing process, guidelines, delegation, continuing education, adherence to the legal and ethical framework.

Ethics and Values

Ethical dilemmas arise when ethical principles conflict.
Whistleblower actions (THINK pneumatic).
Ethical Principles (Autonomy, Non-maleficence, Beneficence, Fidelity, Veracity, Justice).
Code of ethics (ANA, guidelines for professional behavior).
Patient care partnerships (focus on patient expectations), The Joint Commission Standards.
Ethics models (autonomy, patient benefit, social justice).

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Description

This quiz explores the essential aspects of patient education within nursing, emphasizing the three learning domains: cognitive, psychomotor, and affective. Learn how these domains impact health management and patient engagement. Additionally, discover the five rights of teaching to enhance patient readiness and motivation.