chapter 1

Question 1

types of assessment

Answer 1

comprehensive 
focus/problem based
follow-up
shift
screening

Question 2

steps of assessment

Answer 2

preperation
data collection
validation
documentation

Question 3

sources of data collection

Answer 3

Subjective and objective sources

Question 4

subjective data

Answer 4

how the patient feels

symptoms

Question 5

objective data

Answer 5

measurable

signs

Question 6

steps of data analysis

Answer 6

Use critical thinking and reasoning to form nursing diAgnosis

Question 7

What is nursing diagnosis?

Answer 7

Is what the nurse is treating the patient for

includes label, definition, risk factors, and related factors

Question 8

collaborative problems

Answer 8

physiological complications that nurses monitor to detect onset or change in status
collaborate with physician to use interventions to prevent harm

Question 9

OLD CARTS

Answer 9

onset
location
duration
characteristics
aggrevates
relieves
timing
severity

Question 10

comprehensive exam

Answer 10

detailed history

physical exam

Question 11

focus/problem based

Answer 11

history

physical limited to problem

Question 12

follow-up

Answer 12

follow-up visit on problem

Question 13

shift

Answer 13

nursing assessment conducted each shift

Question 14

screening

Answer 14

short exam

disease detection

Question 15

preperation

Answer 15

review records
talk to staff
review tests
obtain items needed

Question 16

data collection

Answer 16

subjective and objective data

Question 17

validation

Answer 17

ids areas where data is missing

prevents inaccurate data documentation

Question 18

documentation

Answer 18

provides data for health care team

chart accurately

Question 19

relationship of nursing assessment and nursing process

Answer 19

This is the step where data is collected for analysis so that the rest of the process can begin.

Question 20

evolution of health assessment

Answer 20

Florence nightingale mother of nursing
lydia hall introduced apie
nurse practioners emerged
expansion of specialties

Question 21

confidentiality

Answer 21

patient’s info is not public or available to others
patient has a right to privacy
will be more open with you if they know info is safe
do not want others to see patients private info

Question 22

informed consent

Answer 22

patient is informed about what is happening to them including the risks
must be signed and have wittness(written consent)

Question 23

critical thinking

Answer 23

the way a nurse processes info

good problem solving skills

Question 24

importance of critical thinking

Answer 24

What is; to recognize patterns of behavior, to anticipate clients needs, develop nursing care plans and promote health/healing as well making reasoned judgments of various different actions

Question 25

five components of nursing process

Answer 25

adpie

Question 26

HIPAA

Answer 26

``` Health Insurance Portability Accountability Act ```

Question 27

normal temp

Answer 27

37. 0 C 98.6f 35. 8-37.3 96. 4-99.1

Question 28

normal adult pulse

Answer 28

60-100 bpm

Question 29

normal child pulse

Answer 29

80-100 bpm

Question 30

infant pulse

Answer 30

100 bpm

Question 31

normal respirations

Answer 31

12-20 breaths/min

Question 32

2 types of client goals

Answer 32

client goals and nursing goals | must be specific, attainable, timed

Question 33

types of interventions

Answer 33

nurse-initiated-independent physician-initiated-delegated collaborative-interdependent

Question 34

purpose of evaluation

Answer 34

the nurse must evaulate to see if treatments are being affective and to see if goals are being met

Question 35

parts of the care plan

Answer 35

goals expected outcome interventions evaluation

Question 36

goals

Answer 36

the direction one must go to improve a problem positive statement of problem What patient will do as a big picture

Question 37

expected outcomes

Answer 37

what the patient will do | must be measurable, realistic, and have definite time frame

Question 38

interventions

Answer 38

What the nurse will do diagnostic(monitoring) and therapeutic(comfort) /

Question 39

Dyspraxia

Answer 39

Difficulty breathing or shortness of breath

Question 40

Apnea

Answer 40

No respiration

Question 41

Orthopnea

Answer 41

Breathe in upright position

Question 42

Systolic

Answer 42

First sound heard | Top number

Question 43

Diastolic

Answer 43

Last sound heard | Lower number

Question 44

Gordon's functional health problems

Answer 44

``` Health management Nutrition Elimination Exercise Sleep Cognitive Self-esteem Relationship Sex Coping Beliefs ```

Question 45

Vital sign order

Answer 45

Temp Pulse Resp BP

Question 46

Exam techniques

Answer 46

Inspection Palpitations Percussion Auscultation

Question 47

Abdominal assessment

Answer 47

I A P P

Question 48

Clinical diagnosis

Answer 48

Same as medical diagnosis | Doctor

Question 49

Palpitations

Answer 49

Take temp Strength of pulse Using hands to feel

Question 50

Percussion

Answer 50

Striking a surface

Question 51

Auscultation

Answer 51

Listening for sounds i the body

Question 52

Hand washing

Answer 52

Before and after direct contact After contact with waste After handling food After gloves removed

Question 53

Hypertension

Answer 53

Above 140/90

Question 54

Guidelines for charting

Answer 54

``` Blue black ink Legible Timely order Chart in timely manner Use punctuation ```

Question 55

Essential data for charting

Answer 55

Objective and subjective data

Question 56

Purpose of analyzing

Answer 56

Allows you to create your nursing diagnosis

Question 57

Purpose of evaluation

Answer 57

You can see if your treatment is affected

Question 58

Purpose of health assessment interview

Answer 58

Ghh

Question 59

Diagnostic reasoning process

Answer 59

How the nurse thinks through and creates diagnosis

Question 60

Assessment

Answer 60

A continuous process Sub and objective data Functions determined First step of nursing process

Question 61

Importance of interview

Answer 61

Learn health history | Collect data