NUR 155 Exam 2 Study Guide 2023 With Complete Solution 100%Correct Answers.

NUR 155 Exam 2 Study Guide 2023 With Complete Solution 100%Correct Answers. Foundations of Nursing: Exam 2 Ch. 10 – Critical Thinking Critical thinking skills  Analyzing – separating/ breaking whole into parts  Applying standards – judging according to established personal  Discriminating - recognizing differences  Information seeking – search for evidence  Logical reasoning – drawing inferences  Predicting – envision a plan  Transforming knowledge – changing/converting the condition, nature, form/function of concepts Problem-solving Process  Trial & error  Intuition  Research process  Examples of problem solving situations: safety/infection o Everything we do as a nurse is backed up by research (evidence-based practice) Decision-making Process  Choosing the best actions to meet a desired goal o Make value decisions time management decisions o Scheduling decisions o Priority decisions Ch. 11-14 - Nursing Process *The nursing process is client centered  Assessment o Collect data  Database – contains all the information about the client  Subjective (symptoms/what client says)  Objective (signs/vital signs, chart – can be seen, heard, felt, smelled or observed by physical examination)  Sources of data  Observing/Interviewing  Closed ended questions  Open ended questions  Don’t ask, “Why?”  Instead say, “tell me about…” 1 o Organize data o Validate data o Document data  Nursing Diagnosis o Analyze data o Identify health problems, risks, and strengths o Formulate diagnostic statements  Types of diagnoses:  Actual diagnosis  Risk diagnosis  Health promotion diagnosis  Wellness diagnosis  NANDA-1 nursing diagnoses  Prioritization – Maslow’s Hierarchy of Needs  Planning o Prioritize problems/diagnoses o Formulate goals/desired outcomes o Select nursing interventions o Write nursing interventions  Implementation o Reassess the client o Determine the nurse’s need for assistance o Implement the nursing interventions o Supervise delegated care o Document nursing activities  Evaluation o Collect data related to outcomes o Compare data with outcomes o Related nursing actions to client goals/outcomes o Draw conclusions about problem status o Continue, modify or terminate the client’s care plan  Writing Nursing Diagnoses o Basic Two-Part Statement (at risk) 2 part  Problem (P)  Etiology (E) o Basic Three-Part Statement (actual) 3 part  Problem (P)  Etiology (E)  Signs and symptoms (S) **If the goal is not met, always go back and re-assess** 2 Ch. 49 - Fecal Elimination  Defecations is the process of elimination of waste from the digestive system o Feces or stool  Feces o Cases distention of rectum o Stimulates distention of receptors o The sitting position increases the downward pressure on the rectum, making it easier to pass stool Characteristics of Feces Normal Abnormal Possible Cause Color Adult: brown Infant: yellow Clay or white Black or tarry Red Pale Orange or green Absence bile pigment (bile obstruction); diagnostic study using barium Drug (e.g., iron); bleeding from upper gi track (e.g., stomach and small intestine); diet high in rich meat and dark green vegetables (e.g., spinach) Bleeding from lower gi tract (e.g., rectum); some foods (e.g., beets) *Other causes of red: Hemorrhoids Coumadin Cancer Malabsorption of fats; diet high in milk and milk products and low in meat Intestinal infection Consistency Formed, soft, semisolid, moist Hard, dry Dehydration; decreased intestinal motility resulting from lack of fiber in diet, lack of exercise, emotional upset, laxative abuse Shape Cylindrical (contour of rectum) about 2.5 cm (1 in.) in diameter in adults Narrow, pencilshaped, or string like stool Obstructive condition of the rectum Amount Varies with diet (about 100-400 g/day) Odor Aromatic; affected by ingested food and individual’s own bacterial flora Pungent Infection, blood Constituents Small amounts of undigested roughage, sloughed dead bacteria and epithelial cells, fat, protein, dried Pus Parasites Blood Mucus Bacterial infection Inflammatory condition 3 constituents of digestive juices (e.g., bile pigments, inorganic matter) Large quantities of fat Foreign objects GI bleeding Malabsorption Accidental ingestion  Factors Affecting Bowel Elimination o Developmental  Newborns & infants  Toddlers  School-age Children & Adolescents  Older adults o Diet  Fiber is necessary for fecal volume  Soluble Fiber  Dissolves in water to form a gel-like material  Oats, peas, beans, apples, citrus fruits, barley  Insoluble Fiber  Promotes movement of material through digestive system & increases stool bulk  Wheat flower, wheat bran, nuts and vegetables o Activity o Psychological o Defecation habits o Medications  Laxitives o Diagnostic procedures o Anesthesia and Surgery o Pathological conditions o Pain.