| A | B |
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| What is the purpose of nursing classification systems? | provide a standardized language for recording & analysis of individualized nursing care delivery |
| What is nursing diagnosis? | is a problem-solving method used in nursing |
| What are the 5 steps in the nursing process? | assessment, nursging diagnosis, planning, implementation, evaluation |
| What is the purpose of the assessment phase of the nursing diagnosis? | is an ongoing data-gathering process used to identify existing (actual) patient problems and/or to identify patient problems that may be evolving. |
| What the the defining characteristics? | are existing signs and symptoms that help define the presence of a patient problem. They provide clinical evidence of an existing or developing patient problem. |
| How does a medical diagnosis differ from a nurisng diagnosis? | a medical diagnosis is a statement relating to a disease's or disorder's effect on the individual's physiological functioning. A nursing diagnosis defines a patient problem in which the nurse can intervene. |
| Wha tis a collaborative problem? | require both medical or dental prescriptive orders and nursing interventions to monitor and evaluate the existing condition. |
| Why is a focused assessment beneficial to the nurse? | after establishing that a patient problem may or does exist, a focused assessment allows the nurse to concentrate the data collection process on a specific area that would help to define, validate, or negate the existence of a specific nursing diagnosis. |
| What is an "actual" nursing diagnois? | this is supported by defining characteristics (manifestations or signs and symptoms) that cluster in patterns of related cues or inferences. |
| What is "risk" nursing diagnosis? | a clinical judgement that the pt is "more susceptible" to the problem than others. It is supported by risk factors that contribute to increased vulnerability. |
| What is "possible" nursing diagnosis? | suspected pt problems requiring additional data for confirmation |
| What is "wellness" nursing diagnosis? | clinical judgement about a pt in transition from a specific level of wellness to a higher level of wellness. |
| What is "syndrome" nursing diagnosis? | these cluster "actual" or "risk" signs and symptoms that are predictive of certain circumstances. The cause is contained in the diagnostic label. |
| What are the 5 "syndrome" nursing diagnoses? | 1. rape trauma syndrome 2. disuse syndrome 3. post-trauma 4. relocation stress syndrome 5. impaired environmental interpretation syndrome |
| What is the intent of using critical pathways? | they provide a sequential, detailed plan for clinical interventions within a specified time period for a particular disease or disorder. |
| What are the 4 phases of the planning process to prepare to provide patient care? | planning ecompasses a)setting priorities b)developing measurable goal statements, c)formulating nursing interventions, d)developing anticipated therapeutic outcomes as a basis for evaluating the patient's status |
| Independent actions | positioning pt for comfort, providing oral care (could be dependent if ordered by the doctor) |
| dependent actions | administering a tube feeding, administering meds |
| What is a short-term goal for a pt receiving Maalox? | The patient will be able to state the correct schedule for self-administration of Maalox on Tuesday... |
| Why a drug history may be beneficial? | a drug history can be used to identify current drugs, OTC, herbal products being taken or problems relating to drug therapy and to evaluate the need for medications. |
| What is "subjective data"? | meds make me dizzy, pain meds gave me good relief |
| What is "objective data"? | one hour after administration of chemotherapy the nurse charts, pt vomited 4 oz greenish-tinged, watery vomitus |
| How do "indications" and "side effects" differ? | indications are nursing diagnosis statements that exist as a result of pt problems being experienced due to disruption of normal functioning by a disease process or disorder, side effects are patient problems that have evolved as a result of drug therapy |
| What would be a statement for the therapeutic intent of a sedative for a pt having surgery tomorrow morning? | Therapeutic intent is to "provide rest and relaxation prior to surgery" |
| How do "side effects to expect" differ from "side effects to report"? | "side effects to expect" are those that can gennerally be anticipated when the drug therapy is prescribed. "side effects to report" also known as adverse drug effects are those that require notification of the dr regarding the drugs action |
| What are common lab studies to evaluate liver (hepatic) function and those used to evaluate kidney (renal) function? | liver (hepatic)function tests include: AST, ALT, alkaline phosphatase, LDH, and GGT. Kidney (renal) function tests include: serum creatinine, creatinine clearance, blood urea nitrogen (BUN), urinalysis (UA) |
| When are culture and sensitivity (C&S) tests taken? | C&S specimens (throat cultures) are usually obtained prior to initiation of antibiotic therapy for an infection. |
| What changes in the baseline CBC report should be reported to the doctor? | elevated WBC's, bands, "segs" and/or lymphocytes should be reported |
| Why are serum drug levels monitored? | are monitored to establish whether the serum blood level of the specific drug is too low or in the nontherapeutic range, within the normal range and therapeutic, or too high and toxic to the patient. |
| What patient education should be done prior to discharge for all persons with medications prescribed? | before discharge should include drug name, dose, route, specific time of administration, reason for taking, side effects to expect, & to report, what to do if you miss a dose, and how to have the medication prescription filled |
| List 5 drugs that can be monitored by a blood draw? | digoxin, theophylline, gentamicin, tobramycin, lithium, lidocaine, phenytoin, procainamide, wuinidine, vancomycin, cyclosporine, chloramphenicol can be monitored by a blood draw |
