Nursing Process
What are the 5 steps involved in the nursing process
Assess, Diagnose, Plan, Implementation, Evaluation
An American nurse tries to speak with a Korean client who cannot understand the English language. To effectively communicate to a client with a different language, what should the nurse implement?
Have an interpreter to translate
Feedback:Having an interpreter would be would be the best practice when communicating with a client who speaks a different language.
The code of ethics for nurses is composed and published by:
American Nursing Association (ANA
A nonspecific response of the body to a demand is:
Stress
What are the QSEN 6 major competencies?
Pt. centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics
ANA defines it as a"systematic dynamic process by which the nurse, through interaction with the client, significant others and health care providers collect and analyzes data about the client"
Assessment
The nurse is providing instructions to a Chinese-American client about the frequency and dosages of the take home medicines. When conducting the teaching, the client continuously turns away from the nurse. What should nurse do to take appropriate action?
Continue with the instructions, then confirm the client's understanding
Feedback:Most Chinese maintains a formal personal space with others, which is a form of respect. Most Chinese are uncomfortable with face-to-face communications, especially when eye contact is direct. If the client turns away from the nurse during a conversation, the most appropriate action is to continue with the instructions
Nurses agree to be advocated for their patients. The practice of advocacy calls for the nurse to:
Assess the client's point of view and prepare to articulate this point of view
Feedback:Nurses strengthen their ability to advocate for a client when they are able to identify personal values and then accurately identify the values of the client and articulate the client’s point of view.
A child and his mother have gone to the playroom on the pediatric unit. His mother tells him he cannot have a toy another child is playing with. The child cries, throws a block, and runs over to kick the door. This child is using a mechanism known as:
Displacement
A nurse observes some involuntary muscle jerking in a sleeping patient. The nurse determines that the patient is most likely in which stage of sleep?
Stage 1 NREM sleep
Feedback:Involuntary muscle jerking occurs in stage I NREM sleep. In the other stages, the muscles proceed from a relaxed state to large muscle immobility.
What three skills are required in the implementation phase of the nursing process ?
Cognitive (intellectual)
Psychomotor (technical)
Interpersonal
A nurse is preparing a plan of care for a client who is a Jehovah's Witness. The client has been told that the surgery is necessary. The nurse considers the client's religious preferences in developing the plan of care and notes that:
Blood products can not be administered
Feedback:Among Jehovah’s Witnesses, the administration of blood and blood products is prohibited.
The nurse is obligated to follow a physician's order unless:
The order is an error, violates hospital policy, or would be detrimental to the client.
When physiologic mechanisms within the body respond to internal changes to maintain an essential balance what processes has occurred?
Homeostasis
__________ is a national prevention initiative that focuses on improving the health of Americans.
Healthy people 2020
A common framework that helps guide the prioritization of nursing tasks during the process of planning
Maslow's hierarchy
process of learning norms, beliefs, and behavioral expectations of a group is called:
Acculturation
True or False with the reason behind the answer
Nurses who follow orders that are incomplete or incorrect are the leading cause of litigation in the hospital
True
Reason: The nurse is responsible for clarifying all orders that are illegible, unreasonable, unsafe, or incorrect. The failure of the nurse to question the physician about an order creates an area of liability on the nurse’s part because this is perceived as a medical action and not the role of the nurse to write orders.
The nurse goes in to check on a client before scheduled surgery. The client states that she is nervous, and her respiratory and pulse rates are elevated. The client is experiencing which type of anxiety?
Moderate anxiety
The World Health Organization's definition of health is:
a state of complete physical, mental, and social well-being; not just the absence of disease
When does a nurse need to verify data?
When there is a discrepancy between what the patient is saying and the nurse is observing OR when data lacks objectivity
What do you need to achieve cultural competence?
Understand your own cultural beliefs and practices
Perceive the health care setting from a patients point of view
Be open and sensitive to a patient's cultural values
When the nurse described the client as "that nasty old man in 354", the nurse is exhibiting which ethical dilemma?
Gender bias and ageism
Feedback: Stereotyping an “old man” as “nasty”is a gender bias and an ageism issue. The nurse is verbalizing a negative descriptor about the client.
A 23-year-old client who recently had a head injury from a motor vehicle accident is in a state of unconsciousness. Which of the following physiological adaptations is primarily responsible for his level of consciousness?
Reticular formation
Gender identity can best be described as:
An individual's personal or private sense of identity as male or female.