Nursing 155 Final Exam Study Guide: Key Concepts and Practice Questions, Exams of Nursing

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Checking accuracy and reliability - Correct Answers ✅✅realizing that something doesn't seem quite right and taking action to determine if it is accurate or not, sounds suspicious and looking further into it Nursing Process - Correct Answers ✅✅step by step approach directed at planning and providing pt care. Data collection(assessment), Planning, Implementation, Evaluation Nursing process D - Correct Answers ✅✅Data collection- gather and review info about the pt, assessment Nursing process P - Correct Answers ✅✅Planning- development of a nursing dx, goals, and interventions for a pt plan of care. Nursing process I - Correct Answers ✅✅implementation of planned interventions actually carrying out the orders Nursing process E - Correct Answers ✅✅Evaluation- comparing actual outcomes with expected outcomes

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Tanner's Model of Clinical Judgement - Correct Answers ✅✅A model based on how a nurse thinks, it explains the 4 steps in the critical thinking process that nurses use to solve any problem: Noticing Interpereting Responding Reflecting Step 1 Noticing - Correct Answers ✅✅-Identifying signs and symptoms -gathering complete and accurate data -assessing systematically and comprehensivly -predicting and (managing) potential complications -identifying assumptions Identifying signs and symptoms - Correct Answers ✅✅Indicates when a situation is normal, abnormal, or has changed, something is different than expected Gathering complete and accurate data - Correct Answers ✅✅Data collected from all available sources is used as the basis for identifying issues, problems, concerns. Must verify that data is complete and accurate

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-comparing and contrasting -(predicting) and managing potential complications -judging how much ambiguity is acceptable -using legal, ethical and professional HERE WE- PLANNING, PRIORITIZE, DESICIONS WHAT ARE YOU GOING DO WITH THE DATA YOU RECIEVE, MAKE SENCE OF THE DATA* Clustering related information - Correct Answers ✅✅Grouping together information with a common theme. A method of organizing data so that you put .things together in order to understand the situation, what is alike ex. headache-clustering orther related sx-sleepy, hit head, dizziness Recognizing inconsistencies - Correct Answers ✅✅does the objective data match the subjective data ex. pt says they aren't in pain but face is telling you diff. they are grimacing, clinching fists, tearful, holding their side Distinguishing relevant from irrelevant - Correct Answers ✅✅decidingco what information is pertinent or connects to the matter at hand, sort out what info relates to the current problem ex. pt tells cardiologist my back hurts

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may be important to pt overall care but not the current problem Comparing and contrasting - Correct Answers ✅✅looking at 2 similar cases, identifying the subtle differences, and acting on them ex. pts both have arthritis look at similarities and subtle differences (Predicting) and managing potential complications - Correct Answers ✅✅look at big picture figure our possible complications for and individual pt. must know common complications and consider individual differences. Interpreting- you are planning interventions to help manage or reduce the risk of complications ex. plan interventions to reduce atelectasis and pneumonia- encourage use of incentive spirometer, ambulation schedule. ex. pt fall risk. plan for bed down, toileting assisted, socks with grips Judging how much ambiguity is acceptable - Correct Answers ✅✅- unclear, uncertain, or vague situation. how much wiggle room do you have when applying a rule to a particular situation. look at pt situations and assessment data to determine if assessment measures are acceptable for that particular pt ex. pt flu and temp 100.2, although temp above norm, this temp is ok based on the specific situation

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Delegating - Correct Answers ✅✅asking someone to do part of your job that is not part of their expected job assignment. delegating to a competent UAP make sure willing and able to do the task 5 rights of delegation - Correct Answers ✅✅right task right circumstance ex. no rx for UAP right person ex. competent, experience right direction ex. exact directions right supervision ex check if task done an done correctly 1.Evaluating data (Step 4- Reflecting) - Correct Answers ✅✅after actions and interventions are preformed, assessment data is collected again to determine if the interventions were effective. helps determine what further actions are needed REFLECTION IN ACTION ex. pt 8/10 pain Demerol given at 3;30 IM 25mg, check back 45-1hr, check pain level again and maybe vitals Evaluating and correcting thinking - Correct Answers ✅✅reflecting on what just happened , how the situation was handled,, what lessons can be learned for use in similar situations in the future. how were the results, what could be done better. REFLECTION ON ACTION

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ex.code blue, came back to life, sent to icu, reflection on this what could have been done better, what was done good Brenners stages of clinical competance - Correct Answers ✅✅1. novice

2. advanced beginner
3. competent
4. proficient
5. the expert Novice - Correct Answers ✅✅beginner no experience in situation, lack confidence to demonstrate safe practice and requires continual verbal and physical cues Advanced beginner - Correct Answers ✅✅demonstrate marginally acceptable performance because nurse has had prior experience in actual situations, efficient and skillfull in parts of the practice with occasional supportive cues,, knowledge developing Competant - Correct Answers ✅✅nurse on the job who has been on the same or similar situations for 2-3 years, demonstrates efficiency and has confidence in her actions

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ex. what the pt is doing or can do that will assist them in earning a positive sense of self Self actualization - Correct Answers ✅✅highest level of needs, not everyone attains this level, maximum realization and fullfillmant SPICES - Correct Answers ✅✅Sleep disorder Problems with eating or feeding Incontinence confusion evidence of falls skin breakdown SPICES-S - Correct Answers ✅✅sleep disorders SPICES-P - Correct Answers ✅✅Problems with eating or feeding SPICES-I - Correct Answers ✅✅Incontinance SPICES-C - Correct Answers ✅✅Confusion

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SPICES-E - Correct Answers ✅✅Evidence of falls SPICES-S - Correct Answers ✅✅Skin breakdown Epworth sleepiness scale - Correct Answers ✅✅measures average daytime sleep, can lead to falls, declining quality of life , less chance of recovery. Can enable the nurse to intervene or refer to another Epworth sleepiness scale scoring - Correct Answers ✅✅0-3- never sleepy 3+ always sleepy above 10- above normal daytime sleepiness, need of futher eval Noticing def - Correct Answers ✅✅all about data, assessment Interpreting def - Correct Answers ✅✅make sense of the data, planning Responding def - Correct Answers ✅✅what a nurse does, hands on, implement your plan

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professional standards, use individual stregnths, constantly reevaluating, self correcting , and striving to improve Factors that influence critical thinking - Correct Answers ✅✅upbringing and culture, motivation, attidude influences thinking ethics def - Correct Answers ✅✅system of standards or morals that direct actiions as being right or wrong morals def - Correct Answers ✅✅dealing with right or wrong behavior, conduct and character NANDA-I - Correct Answers ✅✅a professional nursing organization that provides standardized language that would provide a common language for nurses to communicate with one another barrier in nursing data - Correct Answers ✅✅insufficient time, cultural differences, poor skills in data collection, communication failure, language barrier, comatose pt, distractions, too sick to speak well, pt bias-label the pt before interview is complete(make assumptions) instead of evidence or fact, respectful distance is nessesary