N254 exam 1 review - N254 EXAM 1 REVIEW SHEET There will be...

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N254 EXAM 1 REVIEW SHEET There will be 40 multiple-choice questions that cover the following topics: Nursing Process 1. Know the purpose of the Nursing Process - Nursing process is a formula for collecting data and using it to form a plan (an organizing framework for professional nursing practice) - It involves using your senses to collect data or assess patients - It is multidimensional: spiritual, cultural, physical, emotional - Similar to critical thinking, scientific reasoning, problem solving - Uses nursing interventions for individual clients to attain individual client outcomes, as opposed to evidence based and quality control which focus on the care of large numbers of clients 2. Describe all steps of the Nursing Process and the purpose of each. 1. ASSESSMENT - The data collection step, involves a thorough nursing assessment, first step to making an appropriate nursing diagnosis - Regardless of the approach (Gordon’s, head to toe, review of systems) the nurse is alert for symptoms that will help formulate a diagnosis - Starts with a health and medical history - Ask open-ended questions - Types of data collection: 1. Subjective data – what the patient says, thinks and feels, use quotes 2. Objective data – obtained from performing a physical assessment, vital signs, test results, nurses sensory observations 3. Client strengths – literate, cooperative, use of upper body – help them function to optimal physical ability 4. Client education – level of education, use of medical terminology - Pieces of data you want to focus on: current health problems, history, physical assessment data, treatments, medications, IV therapy, diagnostic tests, laboratory values, growth and development (Age appropriate), emotional state, cognition, pain, diet, activity, educational level - Review the assessment. Look for commonalities to see if the data forms any categories. 2. DIAGNOSIS - A clinical judgment about individual, a family or community response to actual or potential health processes. - Provide the basis for the selection of nursing interventions to achieve outcomes for which the nurse in accountable - Geared towards the symptoms a patient is experiencing as a result of the medical diagnosis - Example – impaired skin integrity r/t paraplegia aeb stage 2 decubitus ulcer that measures 2 by 1.5 inches
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- Listed from highest to lowest priority, actual first, then high risk - Part one – nursing diagnosis label – defining characteristics and symptoms should lead to and support the diagnosis - Part two – related to phrase or etiology – not the medical diagnosis, something the nurse can treat (not COPD, but what happens when someone has COPD that a nurse can help with) - Part three – defining characteristics – signs and symptoms that associate with the nursing diagnosis - Prioritizing by Airway, Breathing, Circulation, then Maslow’s hierarchy, real before risk 3. PLANNING - Writing measurable expected client outcomes and nursing interventions to accomplish the outcomes, using the prioritized nursing diagnoses
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N254 exam 1 review - N254 EXAM 1 REVIEW SHEET There will be...

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