_Class participation 6- Practice Questions.pptx

Class Participation Activity Module 9 Nextgen nclex: Clinical judgement model Nextgen nclex: Clinical judgement model The 6 cognitive functions are: Function 1: Recognize cues (assessment). The filtering of information from different sources (i.e., signs, symptoms, health...

Class Participation Activity Module 9 Nextgen nclex: Clinical judgement model Nextgen nclex: Clinical judgement model The 6 cognitive functions are: Function 1: Recognize cues (assessment). The filtering of information from different sources (i.e., signs, symptoms, health history, environment). Function 2: Analyze cues (analysis). The linking of recognized cues to the client's clinical presentation and establishing probable client needs, concerns, and problems. Function 3: Prioritize hypotheses (analysis). Establishing priorities of care based on the client's health problems (i.e., environmental factors, risk assessment, urgency, signs/symptoms, diagnostic tests, lab values). Function 4: Generate solutions (planning). Identifying expected outcomes and related nursing interventions to ensure a client’s needs are met. Function 5: Take actions (implementation). To implement appropriate interventions based on nursing knowledge, priorities of care, and planned outcomes to promote, maintain, or restore a client's health. Function 6: Evaluate outcomes (evaluation). To evaluate a client's response to nursing interventions and reach a nursing judgment regarding the extent to which outcomes have been met. Establishing Assessment Priorities ABCs Vital Signs + Pain Temp, Pulse, BP, RR Pain rating and description Level of Consciousness Awake and alert Lethargic Stuporous Comatose A nurse is caring for older adults in a senior adult services center. Select whether the Appropriate Inappropriate following nursing findings are appropriate or inappropriate. related to the normal aging process A. Patients with wrinkles on the face and arms due to increased skin elasticity B. A patient with skin pigmentation caused by exposure to the sun over the years C. A patient with thinner toenails with a bluish tint to the nail beds D. A patient healing from a hip fracture that occurred due to porous and brittle bones E. Bruising on a patient’s forearms due to fragile blood vessels in the dermis F. Decreased patient voiding due to increased bladder capacity  For each patient need, click to specify appropriate A nurse on a medical-surgical nursing intervention(s). Each patient need may support unit is caring for a 54-year-old more than one nursing intervention. At least one male patient, who developed nursing intervention is correct in each patient need Clostridium difficile (C. diff) category. after treatment with antibiotics Patient Potential Nursing Interventions for a severe infection. Patient is Need experiencing explosive foul-  Offer bland, low-residue foods smelling diarrhea. Patient Nutritional  Avoid gas-producing foods reports orange juice makes it  Offer orange juice worse, Nurs even though he likes the  Obtain a bedside commode taste. e  Apply skin barrier ointment Elimination  Note Keep the head of the bed flat when on 0900 Patient bedpan s reports abdominal Fluid and  Request an intravenous (IV) infusion cramping with Electrolyte  Reduce fluid intake diarrhea s  Monitor for dehydration  Test stool for ova and parasites Infection  Wash hands with soap and water 1100 Patient Control  Place on contact isolation precautions states, “I feel so  “I’m sorry you feel that way” weak. What is the  “Don’t say that. Life is always worth Communic point of living if ation living.”  “Can you share with me more about how you feel like this?”. you are feeling?  For each patient need, click to specify appropriate A nurse on a medical-surgical nursing intervention(s). Each patient need may support unit is caring for a 54-year-old more than one nursing intervention. At least one male patient, who developed nursing intervention is correct in each patient need Clostridium difficile (C. diff) category. after treatment with antibiotics Patient Potential Nursing Interventions for a severe infection. Patient is Need experiencing explosive foul- Offer bland, low-residue foods  smelling diarrhea. Patient Nutritional  Avoid gas-producing foods reports orange juice makes it  Offer orange juice worse, Nurs even though he likes the  Obtain a bedside commode taste. e  Apply skin barrier ointment Elimination  Note Keep the head of the bed flat when on 0900 Patient bedpan s reports abdominal Fluid and  Request an intravenous (IV) infusion cramping with Electrolyte Reduce fluid intake  diarrhea s  Monitor for dehydration Test stool for ova and parasites  Infection Wash hands with soap and water  1100 Patient Control  Place on contact isolation precautions states, “I feel so  “I’m sorry you feel that way” weak. What is the “Don’t say that. Life is always worth  Communic point of living if ation living.”  “Can you share with me more about how you feel like this?”. you are feeling? The nurse is caring for a 60yo client who has an autoimmune condition exacerbated by stress. The client has a full-time job and 3 school-age children. The client shares that his mother just had a stroke and he is managing her new medications and appointments. Which nursing diagnosis fits best? A. Decisional conflict B. Self-care deficit C. Ineffective coping D. Caregiver role strain A nurse assisting an older adult with an unsteady gait in a skilled nursing facility with a tub bath. Which action is recommended in this procedure? A. Add bath oil to the water to prevent dry skin. B.Allow the patient to lock the door to guarantee privacy. C.Assist the patient in and out of the tub to prevent falling. D.Keep the water temperature very warm because older adults chill easily. A nurse is about to bathe a female patient who has an IV access in place in her forearm. The patient's gown, which does not have snaps on the sleeves, needs to be removed prior to bathing. What is the appropriate nursing action? A. Temporarily disconnect the IV tubing at a point close to the patient and thread it through the gown sleeve. B.Thread the bag and tubing through the gown sleeve, keeping the line intact. C.Cut the gown with scissors to allow arm movement. D.Temporarily disconnect the tubing from the IV bag, threading it through the gown. A nurse is caring for a patient who is hospitalized with pneumonia and is experiencing some difficulty breathing. The nurse most appropriately assists him into which position to promote maximal breathing in the thoracic cavity? A. Dorsal recumbent B.Lateral C.Sim's D.Fowler's After assisting a patient who is post op day 2 from a c-section to the side of the bed and to stand up, the patient's knees buckle and she says she feels faint. What is the appropriate nursing action? A. Wait a few minutes and then continue the move to the chair. B.Call for assistance and continue to move with the help of another nurse. C.Lower the patient back to the side of the bed and pivot her back into bed. D.Have the patient sit down on the bed and dangle her feet before moving. A nurse is caring for a patient who is on bedrest after a spinal cord injury. In which position would the nurse place the patient's feet to prevent footdrop? A. Dorsiflexion B.Supination C.Hyperextension D.Abduction