Nursing Quiz Questions and Answers

(1) Assessment

(2) Nursing Diagnosis

(3) Planning

(4) Implementation

(5) Evaluation

Define Assessment

Collects comprehensive data pertinent to the patient’s health and/or situation.

– info medical personnel can look at
– begins the moment you walk through the door

NO! Only the patient can give subjective info.

OBJECTIVE info is what the RN sees, hears, or smells

Analyze the assessment and make a clinical judgement related to an ACTUAL or POTENTIAL health problem.

** Nurses have to be aware of potential risks based on health problems.

** Also collaborate with other specialists to manage the problem(s)

First info → Related to → as evidence by

WHAT is the problem?
WHY is it a problem?
WHAT is the evidence of that problem?

Ex:
“Acute pain → related to surgical incision → as evidence by patient report (or as evidence by crying)”

This is the statement of how a patient’s status will change once interventions have been successfully instituted

Identify the expected outcomes when planning for the patient’s individual situation.

Interventions must be measurable criterion indicating that objectives have been met.

Develops a plan that prescribes strategies and alternatives to attain expected outcomes.

– Prioritize strategies

– Goals (statement that describes the aim if the nursing care) should be short term and long term

Expression through: Words, movements, voice inflection, facial expression, and use of space

• Pre-interaction
• Orientation
• Working
• Termination

– Review available data, history
– Talk to other caregivers who have info about patient
– Anticipate health concerns or issues that arise
– Identify a location or setting that fosters comfortable, private interaction
– Plan enough time for initial interaction

– Set the tone for the relationship by adopting a warm, empathetic, caring manner
– Recognize relationship is tentative
– Expect patient to test your competence and commitment
– Closely observe
– Begin to make inference and form judgements about messages and behaviors
– ASSESS PATIENT HEALTH STATUS

When nurse and patient work together to solve problems and accomplish goals. TEACHING occurs.

– Encourage pt. to express feelings about health
– encourage pt. w/ self exploration
– Provide information
– Help pt. set goals
– Take action to meet said goals
– Use therapeutic comm
– Use appropriate self-disclosure & confrontation

Describe the TERMINATION phase of the Helping Relationship. Ending of the relationship

– Remind pt. that termination is near
– Evaluate goal achievement with pt.
– Reminisce about relationship with pt.
– Separate from the pt. by relinquishing responsibility for care
– Achieve a smooth transition for pt. to other caregivers

• Professionalism – appearance, demeanor, behavior
• Courtesy – hello, good-bye, knock on doors, please, thank you…
• Use of Names – Always introduce yourself
• Confidentiality – HIPPA
• Trust – always honest!
• Acceptance & Respect – Non-judgmental attitudes
• Availability – “Anything else I can get you?
• Socializing – don’t socialize with pt. and don’t socialize with colleagues where pt’s can hear

** Use SOLER to facilitate attentive listening

S – Sit facing the patient

O – Open posture

L – Lean toward the patient

E – Establish & maintain eye contact

R – Relax

Define the therapeutic communication technique of:

Particularly useful when people are confronted with decisions that require thought.

Developmental -age, physiological status (pain, hunger, weakness)SociocultureLanguage

Gender

• Become sensitive to self & others
• Promote and accept expression of pos & neg feelings
• Develop helping trust relationships
• Instill faith & hope
• Promote interpersonal teaching & learning
• Provide supportive environment
• Assist with gratification of human needs
• Allow for spiritual expression

• Social zone
• Consent zone
• Vulnerable zone
• Intimate zone

1. Sitting at a patient’s bedside
2. Taking patient history
3. Teaching patient
4. Exchanging info at shift change

• Making rounds with physician
• Sitting at the head of a conference table
• Teaching a class for patients with diabetes
• Conducting family support

• Speaking at a community forum
• Testifying at a legislative hearing
• Lecturing to a class of students

Chronic or serious infections/diseases/disorders
– COPD → pneumonia
– heart failure → skin breakdown
– diabetes → venous stasis ulcers

• * diabetes patients at risk for chronic infections

⊗ Disturbed body image = look bad, smell bad, etc

⊗ Risk for fall

⊗ Risk for infection = lab results (WBC 5,000-10,000/mm³), review current meds

⊗ Identify potential sites of infection = IV, catheter

⊗ Imbalanced nutrition = protein needed for healing

⊗ Acute pain

⊗ Impaired skin integrity or tissue integrity

⊗ Social isolation

Goals & Outcomes

Setting priorities
→ Treatment is always a priority

Collaborative care

Health promotion – break chain of infection

Nutrition

Hygiene

Immunization

Adequate rest and regular exercise

Keloids – Hypertrophic scarring that extends beyond
the borders of the initial injury.Langerhans Cells – Attach themselves to antigens that invade damaged skin.Lichenification – Thickening and roughening of the skin with
increased visibility of skin furrows from
chronic rubbing.Precursor – A substance, cell, or cellular component from which another substance, cell, or cellular component is formed especially
by natural processes.Stratum germinativum – Inner cellular keratin layer of the epidermis, that contains melanocytes.Stratum corneum – Outer horny layer of dead keratinized cells

Grasping the skin on the sternum, forehead, or top of the hand and gently pulling up.

After letting go of the skin, the skin should “snap” back into place within three seconds.

Skin that remains elevated or “tented” may be due to age related
changes, dehydration, or a combination of both

The appearance of the patient’s nails may provide information about systemic illnesses and yield information about their self care abilities or behaviors:

•Clubbed nails may indicate chronic hypoxia. Bases are flat or rounded, not concave.

° Inadequate nutrition – lines (grooves) going across nails horizontally.

•Cyanosis: May be present in the nail bed, indicating poor
perfusion and possible underlying vascular insufficiency. Nicotine staining can be seen in the nails.

Observe for infections of the nails or nail bed

Feet – bear weight or ambulate

Hands – dexterity

Nails – infection

• Cleanses the skin
• Acts as skin conditioner
• Relax the patient
• Promotes circulation
• Encourages musculoskeletal exercises
• Stimulates rate & depth of respirations
• Promotes comfort through muscle relaxation and skin stimulation
• Improves self-image
• Helps build stronger nurse-patient relationship

Complete bed bath -nurse washes entire body. usually comatose or critical care patients Partial bath –
only areas that cause discomfort or odor if left unwashed Sponge bath at sink –
pt. sits in chair at sink and nurse helps with areas pt. can”t reach Bag bath – commercially prepared & disposableShower – full self-care