Fundamentals Exam #1 PDF - Nursing - Assessment

Spring 2025 Exam #1 50 questions Multiple choice, order, select all that apply You will have 1 hour and 15 minutes to take the exam You will be using Blackboard respondus/lockdown browser to take t...

Spring 2025 Exam #1 50 questions Multiple choice, order, select all that apply You will have 1 hour and 15 minutes to take the exam You will be using Blackboard respondus/lockdown browser to take the exam Please make sure your computer is updated and has been charged for the exam. Your score will be provided the following day at 5PM. boo Stressors and Making Clinical Decisions Stressors ​ Recognize signs of stress in patient’s through assessment and critical thinking to analyze cues related to stress. ○​ Aids in developing an individualized stress management plan ​ “Tell me about any major lifestyle change occurring, such as loss of employment or place of residence, divorce, or disability” to learn about the stressors that may have contributed to a patients infection. Clinical Decisions ​ When making clinical decisions about stress, consider the patient's perception, environmental factors, support systems, and usual coping mechanisms. ○​ Identify potential stressors and cluster assessment data to determine appropriate nursing diagnoses focused on coping abilities. ○​ Develop interventions tailored to the underlying "related to" factors for each nursing diagnosis. ○​ Continuously evaluate the patient's response and adjust the plan as needed. ​ Effective stress management requires synthesizing knowledge, patient data, and clinical judgment. Nursing standards and institutional practice guidelines Nursing standards - Standards of practice are the minimum level of performance accepted to ensure high-quality care. For example, you do not take shortcuts (work-arounds) when you give a patient a medication (e.g., skipping a step—failing to identify a patient, preparing medication doses for multiple patients at the same time). Professional nurses are responsible for competently performing nursing therapies and making clinical decisions about patients. As a nurse you are answerable or accountable for your decisions, the outcomes of your actions, and knowing the limits and scope of your practice. Code of Ethics The nursing code of ethics is a statement of philosophical ideals of right and wrong that define the principles you will use to provide care to your patients. ○​ Make sure to incorporate your own values and ethics into your practice 1.​ Autonomy: Initiation of independent nursing interventions w/o error 2.​ Accountability: Responsible for professionally & legal type/quality of nursing care provided 3.​ Caregiver: Helping patients’ maintain & regain health 4.​ Advocate: Protect patents’ human & legal rights 5.​ Educator: Effectively improve patients knowledge, skills, self-care activities & make informed decisions 6.​ Communicator: Crucial in providing high-quality care. Meets patients’ needs, preferences,strengths & weaknesses 7.​ Manager: Direct group of nurses by establishing an environment for collaborative patient-centered care and safe, evidence-based quality care w/ positive outcomes Intellectual Standards Guide the manner in which a nurse pursues an assessment 1.​ Precise: Exact and specific (e.g., focusing on one problem and possible solution) 2.​ Specific: To mention, describe, or define in detail 3.​ Accurate: True and free from error; getting to the facts (objective and subjective) 4.​ Relevant: Essential and crucial to a situation (e.g., a patient’s changing clinical status) 5.​ Plausible: Reasonable or probable 6.​ Consistent: Expressing consistent beliefs or values 7.​ Logical: Engaging in correct reasoning from what one believes in a given instance to the conclusions that follow 8.​ Deep: Containing complexities and multiple relationships 9.​ Broad: Covering multiple viewpoints (e.g., patient and family) 10.​Complete: Thoroughly thinking and evaluating 11.​Significant: Focusing on what is important and not trivial 12.​Adequate (for purpose): Satisfactory in quality or amount Professional Standards of Practice and Behavior -​ Apply standard criteria when assessing a patient. -​ Compare the patient’s actual assessment findings with what the standard sets as normal or abnormal. 1.​ Ethics: The registered nurse integrates ethics in all aspect of practice. 2.​ Advocacy: The registered nurse demonstrates advocacy in all roles and settings. 3.​ Respectful and Equitable Practice: The registered nurse practices with cultural humility and inclusiveness. 4.​ Communication: The registered nurse communicates effectively in all areas of professional practice,  5.​ Collaboration: The registered nurse collaborates with health care consumers and other key stakeholders. 6.​ Leadership: The registered nurse leads within the professional practice setting and the profession. 7.​ Education: The registered nurse seeks knowledge and competence that reflects current nursing practice and promotes futuristic thinking. 8.​ Scholarly Inquiry: The registered nurse integrates scholarship, evidence, and research findings into practice. 9.​ Quality of Practice: The registered nurse contributes to quality nursing practice. 10.​Professional Practice Evaluation: The registered nurse evaluates one’s own and others’ nursing practice. 11.​Resource Stewardship: The registered nurse utilizes appropriate resources to plan, provide, and sustain evidence-based nursing services that are safe, effective, and fiscally responsible and avoid waste. 12.​Environmental Health: The registered nurse practices in a manner that advances environmental safety and health. Critical thinking and patient assessment/revaluation Critical Thinking 1.​ Analyzing assessment data objectively and considering multiple perspectives 2.​ Questioning assumptions and exploring alternative explanations 3.​ Recognizing gaps in information and seeking clarification 4.​ Synthesizing knowledge from various sources to understand the clinical picture 5.​ Identifying pertinent changes in the patient's condition over time 6.​ Evaluating the effectiveness of interventions and modifying the plan as needed Patient Assessment A set of assessment facts (e.g., objective clinical findings, diagnostic test results) and observations about a patient leads you to begin making generalizations and to then perform inductive reasoning. ​ Spend enough time during initial and follow-up patient assessments to observe patient behavior and measure physical and psychosocial findings to improve knowledge of your patients ​ Determine what is important to them and make a positive emotional connection. Revaluation Helps you decide whether to continue, discontinue, or revise the plan of care! ​ When there are unmet or partially met outcomes, or if you determine that perhaps a new problem has developed, reassessment is necessary.  ​ A complete reassessment of patient factors relating to an existing nursing diagnosis and etiology is necessary when modifying a plan. If outcomes have not been met, it is helpful to consider the SMART. ○​ Specific ○​ Measurable ○​ Achievable ○​ Relevant ○​ Time frame ​ Modify or add nursing diagnoses or collaborative problems with appropriate goals and expected outcomes. ​ Then select interventions and redefine priorities of care. ​ Reassessment ensures that the database is accurate and current. It also reveals any missing links (i.e., a critical piece of new information that was overlooked and thus interfered with goal achievement). ​ You sort, validate, and cluster all new data to analyze and interpret differences from the original database. Critical thinking attitudes ​ Critical thinking attitudes are guidelines for how to approach a problem and make the correct decision. ​ Knowing when you need more information, knowing when information is misleading, and recognizing your own knowledge limits are examples of how critical thinking attitudes guide decision making Critical thinking evaluation - part of nursing process, 6th step, methodically determines if nursing care approaches successfully led to desired or expected patient outcomes - Indicators that reflect when nurse shows competence in performing evaluation: examine the results of care according to clinical data collected, compare achieved effects or outcomes with expected outcomes, recognize errors or omissions, understand patients situation & reflect and correct errors - Nurse practice Application of evaluation: look at all situations objectively. Use objective criteria (ex. Expected outcomes, pain characteristics, learning objectives) to determine results of nursing actions. Reflect on your behavior. - consider if judgements were accurate and whether the correct and appropriate decisions were made (self evaluation) Clinical decision-making process steps-what is done in each Clinical decision is investigating and analyzing ALL aspects of the clinical problem and then applying scientific and nursing knowledge to choose the best course of action. This process is initiated by the patients healthcare needs and requires Critical thinking, Evidenced based practice and problem solving It separates the nurse from technicians or other assistive personnel (AP). Ex. a nurse uses ADPIE and takes immediate action when the patients clinical decision worses, while APs do not have that same ability to analyze why or when the patient's clinical conditions change. Objective and subjective data Objective Data ​ Findings resulting from observation of patient behavior and clinical signs as well as direct measurement ○​ Ex; what you see, hear, and touch Subjective Data ​ Patients’ verbal descriptions of their health problems gathered during interviews ○​ Ex; patients’ feelings, perceptions, and self-reported symptoms Data collection and the patient database ​ Data collection involves gathering subjective and objective information about the patient from various sources ○​ Ex; interviews, observations, physical assessments, diagnostic tests, and medical records  ​ Patient database: Electronic health record (EHR), which is a centralized digital repository that stores this comprehensive patient data ○​ Document assessment findings, nursing diagnoses, interventions, and evaluations in the EHR ○​ Allows the interprofessional team to access up-to-date patient information to guide clinical decision-making and coordinate care across settings ○​ EHR facilitates communication, promotes patient safety through features like medication reconciliation, and provides data for quality improvement efforts Types of approaches for patient assessment ​ Patient-centered interview (conducted during a nursing history) ​ Periodic assessments (conducted during ongoing contact with patients) Validation of patient data during assessment - Validation of assessment data is the comparison of data with another source to determine data accuracy. (Ex. Tonya observed an open inflamed area of the patients surgical incision and then VALIDATED by measuring the patient’s body temp) - Other nurses, healthcare team members, or family & friends may also validate your assessment information - It opens the door for gathering more assessment data because it involves clarifying vague or unclear data. Obtaining patient data and history-who and where do you get information - Patient (subjective) is a nurse’s PRIMARY and BEST source of info. Patient who is conscious, alert, and able to answer questions appropriately provide the most accurate info. Less reliable: easily distracted, dementia, anxiety/fear. - If patient is not reliable source → refer to caregiver / family (objective) - Offer tools for assessment of health literacy, spanish/english, short form Parts of the different types of nursing diagnosis- what are the types of diagnosis, what makes up the different types, how are they different - Medical diagnosis) identification of a disease condition based on a specific assessment of physical signs and symptoms, a patient’s medical history, and the results of diagnostic tests and procedures ; language of healthcare providers (physicians, advanced practice nurses) - Nursing diagnosis) clinical judgement made by RN to describe patient's response or vulnerability to health conditions or life events that the nurse is licensed and competent to treat ; classifies an individual’s family’s, or community response to illness so that all nurses, those in regular practice and advanced practices understand - Collaborative problems) requires both medical and nursing interventions to treat - there are 3 types of nursing diagnoses 1. Problem-focused nursing diagnoses- identify an undesirable human response or existing health problem that the patient is experiencing. Examples include Acute Pain, Impaired Mobility, or Disturbed Sleep Pattern. These diagnoses describe an actual patient problem that requires nursing interventions. 2. Risk nursing diagnoses - indicate an increased vulnerability or potential for developing a problem or complication. Examples are Risk for Falls, Risk for Impaired Skin Integrity, or Risk for Unstable Blood Glucose Level. These diagnoses identify patients at high risk so preventive nursing measures can be implemented. 3. Health promotion nursing diagnoses- recognize the patient's desire or motivation to enhance their well-being through positive behavioral changes. Examples are Readiness for Enhanced Nutrition, Readiness for Enhanced Sleep, or Readiness for Enhanced Family Coping. These diagnoses focus on the patient's willingness to improve their health status. Steps in the nursing process and what happens in each one American Nurses Association (ANA) Standards of Nursing: Nursing Process Assessment: The registered nurse collects pertinent data and information relative to the healthcare consumer’s health or the situation. Diagnosis: The registered nurse analyzes the assessment data to determine the actual or potential diagnoses, problems, and issues. Outcomes Identification: The registered nurse identifies expected outcomes for a plan individualized to the healthcare consumer or the situation. Planning: The registered nurse develops a plan encompassing strategies to achieve expected outcomes. Implementation: The registered nurse implements the identified plan. a.​ Coordination of Care: The registered nurse coordinates care delivery. b.​ Health Teaching and Health Promotion: The registered nurse employs strategies to teach and promote health and wellness. Evaluation: The registered nurse evaluates progress toward attainment of goals and outcomes. - This cycle is a continuous process that keeps going. Once you reach the evaluation step, you may need to go back and reassess. - Remember that planning begins at assessment. How to write the correct information in each of the parts of the nursing process/clinical judgment process ​ Assessment: Record all relevant subjective (patient-reported) and objective (observed) data in an organized manner. ○​ Include pertinent medical history, physical assessment findings, lab results, etc. ​ Nursing Diagnosis: State the identified actual or potential health problems/needs using approved nursing terminology. Support diagnoses with clustered assessment data. ​ Planning: Develop patient-centered, measurable goals. Outline evidence-based nursing interventions that address each diagnosis, considering patient preferences and circumstances. ​ Implementation: Describe nursing actions taken, patient's response, and any modifications made to the plan. Document according to principles like accuracy, completeness, and timeliness. ​ Evaluation: Objectively state if goals were met, partially met, or not met based on patient outcomes. Identify any areas requiring revision or continued care. Using prioritization for diagnosis, for interventions, for outcomes, for patient assessments - Based on urgency, patient’s current condition and desired outcomes - Priority setting) ordering of nursing diagnosis or patient problems to establish the preferred order in which you will implement nursing interventions - Prioritize nursing diagnosis first by considering patients immediate needs based on ABC (airway, breathing, and circulation) ​ Highest priority) risk for violence, impaired gas exchange, impaired cardiac function ​ Intermediate priority) nonemergent & not life-threatening - RISK for infection ​ Low priority) not always directly related to specific illness or prognosis but still affect the future or long-term health care needs - Prioritization of nursing diagnoses occurs when you use nursing and scientific knowledge to recognize patterns of data from a patient assessment and allow certain knowledge triggers to guide you to understand which diagnoses require more immediate intervention and when you need to take action When and how is evaluation of goal/outcome done and how is it written The evaluation of outcome is done by the patient and sometimes family member telling you if the interventions helped or did not help The results of an evaluation help you to decide whether you want to continue, discontinue, or revise the plan of care. When the outcomes are unmet or partially met, reassessment is necessary. Consider the SMART acronym when writing the goal What makes a complete nursing database ​ Patient history (medical, surgical, family, social) ​ Review of systems ​ Physical assessment findings (inspection, palpation, percussion, auscultation) ​ Results from diagnostic tests (labs, imaging, etc.) ​ Vital signs and other physiological measurements ​ Psychological, cultural, and spiritual assessments ​ Environmental and economic factors ​ Current medications, treatments, and therapies The infectious process, cycle, prevention, risk for, local and systemic responses The infectious process: ​ Incubation period ​ Prodromal stage ​ Illness stage ​ Convalescence Defenses against infection ​ Normal floras ○​ Secrete antibacterial substances, and protect, and kill organisms. Prevent infection. ○​ Using a broad-spectrum of antibiotics for treatment can lean to supra infection which eliminates not only organisms that cause infection but also  normal flora organisms. This causes body defenses to reduce which allows disease-producing microorganisms to multiply and cause illness ​ Body system defences ○​ Each organ system has defense mechanisms physiologically suited to its specific structure and function ○​ ​ Inflammation ○​ The cellular response of the body to injury, infection, or irritation is termed inflammation. Inflammation is a protective vascular reaction that delivers fluid, blood products, and nutrients to an area of injury. ○​ Signs of localized inflammation include swelling, redness, heat, pain or tenderness, and loss of function in the affected body part. ○​ When inflammation becomes systemic, other signs and symptoms develop, including fever, increased white blood cells (WBCs), malaise, anorexia, nausea, vomiting, lymph node enlargement, or organ failure. Cycle -​ infection can occur if this cycle remains uninterrupted. -​ Patient self-care activities or nurses actions can break the chain Prevention -​ Portals of exit include sites such as blood, skin and mucous membranes, respiratory tract, genitourinary (GU) tract, gastrointestinal (GI) tract, and transplacental (mother to fetus) -​ Infection prevention to reduce reservoirs of infection -​ Bathing -​ Dressing changes -​ Disposal of contaminated articles -​ Disposal of contaminated sharps -​ Keep table surfaces clean and dry in bedside unit  -​ Keep bottled solutions tightly capped and date the booths when open and discard in 24 hours -​ Wear gloves and protective eyewear -​ Empty and dispose of all drainage bottles -​ Never raise a drainage system above the level of the site being drained -​ Private room when needed Risk for Organisms enter the body through the same route they use for exiting. Factors that play in the susceptibility to infection: ​ Age (infants and older adults) ​ Sex ○​ Estrogens promote immune responses but have an increase risk of autoimmune diseases ○​ Androgens (more found in males) suppress immune response ​ Nutritional Status ○​ Protein intake is important ​ Stress ○​ If stress continues or becomes intense, elevated cortisone levels result in decreased resistance to infection ​ Disease process ○​ Patients with diseases of the immune system are at particular risk for infection. Leukemia, AIDS, lymphoma, and aplastic anemia are conditions that compromise a host by weakening defenses against infectious organisms Older adults are less capable of producing lymphocytes to combat challenges to the immune system. When antibodies are produced, the duration of their response is shorter, and fewer cells are produced Patients who develop HAIs often have multiple illnesses, are older adults, or are poorly nourished and may have a compromised immune system; thus, they are more susceptible to infections. An exogenous infection comes from microorganisms found outside the individual, such as Salmonella, Clostridium tetani, and Aspergillus. These microorganisms do not exist as normal floras. An endogenous infection occurs when part of the patient’s flora becomes altered and an overgrowth occurs (e.g., staphylococci, enterococci, yeasts, and streptococci). Iatrogenic infections are a type of HAI caused by an invasive diagnostic or therapeutic procedure. For example, procedures such as a bronchoscopy and treatment with broad-spectrum antibiotics increase the risk for certain infections. Local and systemic responses The body has natural defenses that protect against infection (normal floras, body system defenses, inflammation). If any of these fail, an infection usually occurs, triggering local and systemic responses Localized is when a patient experiences localized symptoms such as pain, tenderness, warmth, and redness at the wound site Systemic responses- occur when inflammation spreads throughout the body, leading to symptoms such as fever, increased white blood cells (WBCs), malaise, anorexia, nausea, vomiting, lymph node enlargement, or organ failure. Cleaning different surfaces, PPE-type for when needed Cleaning different surfaces *Cleaning occurs before disinfection and sterilization procedures.* -​ The two types of aseptic technique are medical and surgical asepsis. Basic medical aseptic techniques break the chain of infection. To ensure object is clean: -​ Rinse the contaminated object or article with cold running water to remove organic material. Hot water causes the protein in organic material to coagulate and stick to objects, making removal difficult. -​ 2. After rinsing, wash the object with soap and warm water. Soap or detergent reduces the surface tension of water and emulsifies dirt or remaining material. Rinse the object thoroughly.  -​ 3. Use a brush to remove dirt or material in grooves or seams. Friction dislodges contaminated material for easy removal. Open hinged items for cleaning. -​ 4. Rinse the object in warm water. -​ 5. Dry the object and prepare it for disinfection or sterilization if indicated by classification of the item (i.e., critical, semicritical, or noncritical). -​ 6. The brush, gloves, and sink used to clean the equipment are considered contaminated and are cleaned and dried according to policy. Disinfection describes a process that eliminates many or all microorganisms, with the exception of bacterial spores, from inanimate objects Hand hygiene, use of personal protective equipment, and routine environmental cleaning are examples of medical asepsis There are two types of disinfection: (1) the disinfection of surfaces, and (2) high-level disinfection. Sterilization eliminates or destroys all forms of microbial life, including spores. Sterilization methods include processing items using steam, dry heat, hydrogen peroxide plasma, or ethylene oxide (ETO). ​ Critical items must be sterile ○​ Items that enter sterile tissue or vascular system ○​ ex) surgical instruments, implants, or urinary catheters ​ Semi Critical items must be high-level disinfected or sterile ○​ Items that come in contact with mucus membranes or non-intact skin ○​ Ex) endoscope ​ Noncritical items must be disinfected ○​ Items that come in contact with intact skin ○​ ex) bed pans, stethoscope Hand hygiene is a general term that applies to four techniques: handwashing, antiseptic hand wash, antiseptic hand rub, or surgical hand antisepsis. Handwashing does not kill microorganisms PPE- type for when needed ​ Disinfection describes a process that eliminates many or all microorganisms, with the exception of bacterial spores, from inanimate object ​ When changing a dressing, wear a mask and goggles or a mask with a face shield if splashing or spraying with blood or body fluids is anticipated. Apply gloves to reduce the transmission of microorganisms into the wound. Apply special dressings to facilitate removal of drainage and promote healing of wound margins. ​ ​ Contact precautions ​ Used for direct and indirect contact with patients and their enviroments ​ PPE: gown and gloves Droplet precautions ​ Focus on disease that are transmitted by large droplets expelled into the air and being within 3 feet of a patient. ​ PPE: surgical mask when within 3 feet of the patient, proper hand hygiene, and some dedicated-care equipment ​ Ex) influenza Airborn precautions ​ Focus on diseases that are transmitted by smaller droplets, which remain in the air for longer periods of time. ​ PPE:. Airborne Precautions require a specially equipped room with a negative airflow referred to as an airborne infection isolation room. Air is not returned to the inside ventilation system but is filtered through a high-efficiency particulate air (HEPA) filter and exhausted directly to the outside. For example, all health care personnel wear an N95 respirator every time they enter the room of a patient with TB. ​ Protective environment ○​ Focuses on a very limited patient population, all of whom are highly susceptible to infection because of an underlying condition or treatment. ○​ PPE: This form of isolation requires a specialized room with positive airflow. The airflow rate is set at greater than 12 air exchanges per hour, and all air is filtered through a HEPA filter ○​ ex) kidney transplant PPE equipment: ​ Gowns ○​ prevent soiling clothes during contact with a patient ​ Mask ○​ Masks provide respiratory protection. ​ Eye protection ○​ Use either special glasses or goggles when performing procedures that generate splash or splatter. ​ Gloves ○​ Gloves help to prevent the transmission of pathogens by direct and indirect contact Vital signs-measuring, normal values, what to do if not normal, Vital signs- measuring When to measure: Normal values What to do if not normal Fever ​What to do with fever -​ The objective of therapy is to increase heat loss, reduce heat production, and prevent complication -​ Determine the cause of elevated temperature, a antibiotic may be ordered to destroy pyogenic bacteria and eliminates body stimulus for the elevated temperature -​ Give antipyretics- medication that reduces fever. *Fever is an important defense mechanism. It enhances the immune system. A prolonged fever weakens a patient by exhausting energy stores, cellular hypoxia (inadequate oxygen) occurs. Dehydration is a serious problem for those with low body weight. Maintaining optimum fluid volume status is an important nursing action* Heat stroke What to do with heat stroke- moving patient to cooler environment. Also admister IV fluids , irrigating stomach and lower bowel with cool solutions, and applying hypothermia blankets. What to do with hypothermia- prevent further decrease in body temperature Remove wet clothes and replace them and wrap patient sin blankets. In emergencies- patient lie under blankets next to warm person. Conscious patient- drinking hot liquids and avoiding alcohol and caffeine