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NR 302 Exam 1 Study Guide Updated, Exams of Nursing

South University - SavannahNursing

NR 302 Exam 1 Study Guide/NR 302 Exam 1 Study Guide/NR 302 Exam 1 Study Guide/NR 302 Exam 1 Study Guide/NR 302 Exam 1 Study Guide/NR 302 Exam 1 Study Guide/NR 302 Exam 1 Study Guide/NR 302 Exam 1 Study Guide

Typology: Exams

2022/2023

Available from 10/20/2022

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EXAM #1STUDY
GUIDE
NURSING PROCESS (ADPIE)
Nursing Process : Systematic problem-solving method by which nurses individualize care for
each patient.
•Steps
a. Assessment : registered nurse collects pertinent data and information relative to
the healthcare consumer’s health or the situation.
b. Diagnosis : registered nurse analyzes the assessment data to determine
the actual or potential diagnoses, problems, and issues.
i. Choose appropriate nursing diagnosis for patient
c. Planning : registered nurse develops a plan that prescribes strategies to
attain expected, measurable outcomes.
i. Write care plans and interventions
d. Implementation : registered nurse implements the identified plan
i. Coordination of Care: The registered nurse coordinates care delivery.
ii. Health Teaching and Health Promotion: The registered nurse
employs strategies to promote health and a safe environment.
iii. Examples
1. Ordered medications
2. Measure vitals
3. Re-assess
4. educate
e. Evaluation : registered nurse evaluates progress toward attainment of outcomes.
i. Have patient teach-back
PRIORITY PROBLEM LEVELS
First level priority problem :emergent and life-threatening problems that are immediate
• Examples
oEstablish airway or support breathing
oUnresponsiveness
oStroke symptoms
oChanges in cognitive status
Second level priority problem : problems that are next in urgency and require prompt
intervention to forestall further deterioration
• Examples
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Download NR 302 Exam 1 Study Guide Updated and more Exams Nursing in PDF only on Docsity!

EXAM #1STUDY

GUIDE

NURSING PROCESS (ADPIE)

Nursing Process : Systematic problem-solving method by which nurses individualize care for

each patient.

  • Steps

a. Assessment : registered nurse collects pertinent data and information relative to

the healthcare consumer’s health or the situation.

b. Diagnosis : registered nurse analyzes the assessment data to determine

the actual or potential diagnoses, problems, and issues.

i. Choose appropriate nursing diagnosis for patient

c. Planning : registered nurse develops a plan that prescribes strategies to

attain expected, measurable outcomes.

i. Write care plans and interventions

d. Implementation : registered nurse implements the identified plan

i. Coordination of Care: The registered nurse coordinates care delivery.

ii. Health Teaching and Health Promotion: The registered nurse

employs strategies to promote health and a safe environment.

iii. Examples

1. Ordered medications

2. Measure vitals

3. Re-assess

4. educate

e. Evaluation : registered nurse evaluates progress toward attainment of outcomes.

i. Have patient teach-back

PRIORITY PROBLEM LEVELS

First level priority problem :emergent and life-threatening problems that are immediate

  • Examples o Establish airway or support breathing o Unresponsiveness o Stroke symptoms o Changes in cognitive status Second level priority problem : problems that are next in urgency and require prompt intervention to forestall further deterioration
  • Examples

o Mental status change o Acute pain

o Free of feelings, perceptions and prejudices o Obtained by 5 senses ▪ Hear it? ▪ See it? ▪ Smell it? ▪ Touch it? ▪ Taste it? o Examples ▪ Heart rate ▪ Respiratory rate ▪ Heart rhythm on cardiac monitor ▪ BP ▪ Bleedin g Types of Databases

  • Complete total health database :Describes current and past health state and forms baseline to measure all future changes. o Includes ▪ Complete health history ▪ Physical exam o Yields the first diagnoses o Often collected in these types of settings ▪ Pediatric/ Family care practice clinic ▪ Independent/ group private clinic ▪ College health services ▪ Women’s health care agency ▪ Visiting nurse’s agency ▪ Community health agency o Components: ▪ Describe person’s health state ▪ Perception of health ▪ Strengths/assets such as health maintenance behaviors ▪ Individual coping patterns ▪ Support system ▪ Current developmental tasks ▪ Risk factors/ lifestyle changes ▪ Screen for pathology o Episodic/ problem-centered database :Collect “mini” database, smaller scope and more focused than complete database. o used for a limited or short-term problem.

o smaller in scope and more targeted than the complete database. o Concerns mainly one problem/cue complex/body system o History follows direction of presenting concern

  • Follow-up database :Status of all identified problems should be evaluated at regular and appropriate intervals. o evaluates the status of any identified problem at regular intervals to follow up on short-term and chronic health problems.
  • Emergency database :Rapid collection of data often compiled concurrently with lifesaving measures. o calls for rapid collection of crucial data, which often occurs while performing lifesaving measures.
  • Diagnosis must be swift and sure
  • Maybe compiled by questioning patient/ if patient is unresponsive GUIDE TO CLINICAL PREVENTIVE SERVICES (?) Services include:
  1. Screening history a. Dietary intake b. Physical activity c. Tobacco/alcohol/drug use d. Sexual practices
  2. Physical exam a. Height & weight b. BP c. Screening for cervical cancer and HIV
  3. Counseling a. Physical activity b. Risk prevention i. Secondhand smoke ii. Seatbelt use
  4. Depression screening
  5. Healthy diet a. Lipid disorder screening b. Obesity screening
  6. Chemoprophylaxis a. Multivitamin with folic acid i. Females capable of/ planning pregnancy

Communication

  • Before entering room, read the notes by other healthcare providers regarding patient
  • Introduce yourself and state role
  • Indicate the reason for the interview
  • Ask open-ended questions to let patient notify SITUATION, BACKGROUND, ASSESSMENT, RECOMMENDATION (SBAR) Situation, Background, Assessment, Recommendation (SBAR ): standardized framework to transmit important in-the-moment information keep your message concise and focused on the immediate problem yet give your colleague enough information to grasp the current situation and decide
  1. Situation : a. State your name, your unit, patient's name, room number, patient's problem, when it happened or when it started, and the severity.
  2. Background : a. Do not recite the patient's full history since admission. Do state the data pertinent to this moment's problem: admitting diagnosis, when admitted, and appropriate immediate assessment data (e.g., vital signs, pulse oximetry, change in mental status, allergies, current medications, IV fluids, laboratory results)
  3. Assessment : a. State your assessment findings. This can include what you found and what you think may be wrong.
  4. Recommendation : a. State what you want/need to continue caring for the patient. SCREEN FOR ANXIETY DISORDERS Generalized anxiety disorder (GAD): pattern of excessive worrying and morbid fear about anticipated “disasters” in the job, personal relationships, health, or finances
  • Characterized o Restlessness o muscle tension o diarrhea o palpitations o tachypnea

o fatigue o sleep disturbance.

  • Person devotes much time to preparing for anticipated catastrophe, has difficulty making decisions, and practices avoidance. Generalized anxiety disorder scale (GAD-7 ): identifies probable GAD and is a severity measure in that increasing scores are associated with increasing impairment and disability.
  • Consists of 7 itemized scale
  • Scores range from 0- o 0= no anxiety o 3+= GAD o Higher the score, the greater the likelihood o scores of 5, 10, and 15 represent mild, moderate, and severe levels of anxiety
  • First 2 questions relate to core anxiety
  • Common anxiety disorders include: o GAD o Panic disorder o Social anxiety disorder o Posttraumatic stress disorder (PTSD) SCREEN FOR DEPRESSION DISORDER Patient Health Questionnaire-2 (PHQ-2 ):Asks 2 questions about depressed mood and anhedonia (lack of interest) that will detect majority of depressed patients
  • Serves as a screening tool to use full PHQ-9 tool if they answer for several days or higher
  • Examples include: o “Over the past 2 weeks have you felt down, depressed, or hopeless?” o “Over the past 2 weeks, have you felt little interest or pleasure in doing things?” PHQ-9 :Series of 9 questions requiring adding column totals that relate to frequency of occurrence of symptoms
  • Higher the score, the greater the likelihood of functional impairment or clinical diagnosis.
  • Scores o 5 to 9 = minimal symptoms. o 10 to 14 = minor depression. o 15 to 19 = major depression.

o Disorientation o disordered thinking and perceptions (illusions and hallucinations)

September 21, 2021 Exam #1 Health Assessment I o defective memory o agitation o inattention. Dementia : chronic gradual, progressive process, causing decreased cognitive function even though the person is fully conscious and awake

  • loss of cognitive and intellectual functions
  • Characteristics: o Disorientation o impaired judgment o memory loss.
  • Examples o Alzheimer’s disease o Not part of normal aging
  • Risk Factors: o racial and ethnic groups other than Caucasians o advanced age o women o singles o living alone o lower educational attainment o lower income.

September 21, 2021 Exam #1 Health Assessment I inappropriate, rambling, repetitious Prognosis Reversible with proper and timely treatment Not reversible; progressive Reversible with proper and timely treatment

September 21, 2021 Exam #1 Health Assessment I PHYSICAL EXAM Requires use of technical skills through senses (sight/smell/touch/hearing) to obtain data Skills include: o Inspection :Close, scrutiny, first of individual as a whole and then of each body system ▪ First step of the assessment phase ▪ begins the moment you first meet the person and develop a “general survey.” ▪ initial impression of the person can be helpful as you proceed through your assessment ▪ requirements:

  • good lighting.
  • adequate exposure.
  • occasional use of instruments to enlarge view o otoscope o ophthalmoscope o penlight o nasal and vaginal specula o Palpitation : ▪ Applies sense of touch to assess:
  • Texture, temperature and moisture
  • Organ location and size
  • Swelling, vibration, pulsation or crepitation
  • Rigidity or spasticity
  • Presence of lumps or masses
  • Presence of tenderness or pain ▪ Should be slowly & systematically performed ▪ Start with light palpation to detect surface characteristics and to accustom the person to being touched. ▪ Then perform deeper palpation. ▪ Keep in mind that the person needs to be relaxed to allow adequate palpation.
  • encourage the person to use relaxation techniques such as imagery or deep breathing.
  • With deep palpation (as for abdominal contents), intermittent pressure is better than one long, continuous palpation. ▪ Avoid any situation in which deep palpation could cause internal injury or pain

September 21, 2021 Exam #1 Health Assessment I

  • Be prepared to have all necessary equipment in place before starting examination.
  • Perform hand hygiene.

September 21, 2021 Exam #1 Health Assessment I

  • Protective equipment including but not limited to gloves
  • Measurement of vital signs requires platform scale (with height attachment), stethoscope, sphygmomanometer, and thermometer. o Pulse oximetry reading can be included. PRECAUTIONS Standard precaution :based on a risk assessment and make use of common-sense practices and personal protective equipment use that protect healthcare providers from infection and prevent the spread of infection from patient to patient
  • Used for all patients regardless of diagnosis
  • Prevention of transmission of disease include components such as: o Hand hygiene o Use of personal protective equipment (PPE ) ▪ Gloves= use when anticipating contact with blood or other potentially infectious materials, mucous membranes, nonintact skin, or potentially contaminated intact skin could occur
  • Example= patient incontinent of stool or urine ▪ Gown= protect skin and clothing when you anticipate contact with blood, body fluids, secretions, or excretions ▪ Mouth/nose/eye protection= protect the mucous membranes during procedures that are likely to generate splashes or sprays of blood, body fluids, secretions, and excretions
  • e.g., suctioning a patient o Respiratory hygiene/cough etiquette GENERAL SURVEY General survey : study of the whole person, covering the general health state and any obvious physical characteristics.
  • covers four areas: o physical appearance o body structure o mobility o behavior