Prioritizes Show Identifies human responses to actual or potential health problems Determines effectiveness of plan of care Venous inflammation and clot formation impedes blood flow Client w/ sleep distrubance normal sleep aids - pillows, back rubs, snack - simplest interventions physiological - breathing, food, water, sex, sleep, homeostasis, elimination/excretion Safety - security of body, employment, resources of the - morality, family, healthy, property Love/belonging - friendship, family, sexual intimacy Esteem - confidence, achievement, respect Self Actualization - morality, creativity, problem solving When two nursing diagnoses appear closely related, what should the nurse do first to determine which diagnosis most accurately reflects the needs of a patient? Review the defining characteristics: The nurse performs an assessment of a newly admitted patient. The nurse understands that this admission assessment is conducted primarily to: Identify important data The guidelines for writing an appropriate nursing diagnosis include all of the following except: Answer- D Rationale- A nursing diagnosis is a statement about a patient's actual or potential health problem that is within the scope of independent nursing intervention. Medical terminology is never part of the nursing diagnosis. Independent nursing interventions commonly used for immobilized patients include all of the following except: Answer: D Rationale- A, B, & C are incorrect. These are not independent nursing interventions because they require a physician's order. The nurse would do which of the following activities during the diagnosing phase of the nursing process? Select all that apply. A. Collect
and organize client information B. Analyze data Rationale: The diagnosing phase of the nursing process involves data analysis, which leads to identification of problems, risks, and strengths and the development of nursing diagnoses. Collecting and organizing client data is done in the assessment phase of the nursing process. Goal setting occurs during the planning phase. First Step Making an educated judgment about a potential or actual health problem with a patient Making an educated judgment/inference about a potential or actual health problem
with a patient (they are hypertensive) 1. Plan is developed Follow through/coordinating the decided plan of action Outcome statements must be written in behavioral terms and identify specific, measurable client behaviors. They are stated in terms of the client with an action verb that, under identified conditions, will achieve the
desired behavior. They should also be realistic and achievable. A desired outcome for a client immobilized in a long leg cast reads; Client will state three signs of impaired circulation prior to discharge. When the nurse evaluates the client's progress, the client is able to state that numbness and tingling are signs of impaired circulation. What would be an appropriate evaluation statement for the nurse to write? A. Client understands the signs of impaired circulation C. Goal not met: Client able to name only two signs of impaired circulation Rationale: The goal has not been met because the client states only two out of three signs of impaired circulation. By comparing the data with the expected outcomes, the nurse judges that while there has been progress toward the goal, it has not been completely met. The care plan may need to be revised or more effective teaching strategies may need to be implemented to achieve the goal. A client centered goal is a specific and measurable behavior or response that reflects a client's: Highest possible level of wellness and independence in function. The nurse is most likely to collect timely, specific information by asking which of the following questions? "Would you describe what you are feeling?" he nurse needs to validate which of the following statements pertaining to an assigned client? A. The client has a hard, raised, red lesion on his right hand. The client reported an infected tow Rationale: Validation is the process of confirming that data are actual and factual. Data that can be measured can be accepted as factual, as in options 1, 3 and 4. The nurse should assess the client's toe to validate the statement. What are some examples of independent nursing interventions?Independent nursing interventions are the tasks that a nurse can perform without input from another discipline, particularly without a physician's order. These interventions include many basic comfort care actions such as providing water, repositioning a patient, providing toileting assistance, and bathing.
What is a nursing intervention for pressure ulcers?Nursing care for clients experiencing pressure ulcer (bedsores) includes assessing the contributing factors leading to a lack of tissue perfusion, assessing the extent of the injury, promoting compliance to the medication regimen, preventing further injury.
Which intervention would be classified as an independent nursing care function?Independent: A nurse can carry out these interventions on their own, without input or assistance from others. An example of an independent intervention includes educating a patient on the importance of their medication so they can administer it as prescribed.
What are the 5 nursing interventions?These are assessment, diagnosis, planning, implementation, and evaluation.
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Independent nursing interventions commonly used for patients with pressure ulcers include:
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