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N1115 - Trans. to Associates > Exam 1 > Flashcards

Exam 1 Flashcards

(74 cards)

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1
Q

Systematic way of planning and providing care; involve decision making process, judgement and problem solving

A

The Nursing Process

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2
Q

ADPIE

A 
Assessment
Diagnosis
Planning
Implementation
Evaluation
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3
Q

Level of nursing that is task oriented, rule oriented, inflexible.

Slow, methodical

A

Novice nurse

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4
Q

Level of nursing that is intuition oriented, uses patterns

Fast, fluid.

A

Expert nurse

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5
Q

Part of the nursing process that is systemic, continuously gathering, organizing, and validating date

A

Assessment

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6
Q

TJC requires H&P to be completed with __ hours of admission

A

24

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7
Q

Types of assessment date

A

Objective

Subjective

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8
Q

Types of assessment sources

A

pt
pt significant other
pt records
HCPs

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9
Q

Methods of collecting assessment data

A

Observation
Interview
Examination

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10
Q

The 4 types of nursing diagnosis

A 
actual problem (present issue)
potential problem (risk for)
health promotion (ready to learn)
syndrome (several similar problems)
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11
Q

part of the nursing process that uses assessment data and nursing diagnosis to formulate a goal and design interventions to meet the goal

A

Planning

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12
Q

any treatment based upon clinical judgement and knowledge that a nurse performs to enhance pt/client outcomes

A

nursing intervention

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13
Q

independent interventions

A

license to implement based on our knowledge skills

emotional support, basic care

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14
Q

dependent interventions

A

require an order from a provider

medication administration

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15
Q

collaborative interventions

A

works with other members of healthcare team to carry out

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16
Q

things to keep in mind when choosing a nursing intervention

A 
safe and appropriate
achievable
congruent with client goals
congruent with other therapies
based on nursing knowledge
within scope of practice
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17
Q

Who is responsible for implementing interventions?

A

RN

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18
Q

What must be done after every intervention?

A

Reassess

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19
Q

Key points when implementing interventions

A 
assess before, after
determine need for assistance
base on nursing knowledge
know what you're doing
adapt to pt needs
be safe
teach, support, comfort
holistic
respect dignity
encourage pt participation
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20
Q

What are the 2 modes of communication

A

verbal

nonverbal

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21
Q

erect posture, purposeful steady gait shows ___

A

confidence

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22
Q

slouched posture, slow shuffling gait shows ___

A

depression, discomfort

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23
Q

tense posture, rapid determined gait shows ___

A

anxiety

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24
Q

avert eyes shows ___

A

embarrassment

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25
intimate spacing
0-1.5 feet touching, assessing we often need to violate the pts personal space for assessments
26
person spacing
1.5-4 feet more comfortable for conversation, often informal people tense when someone enters their personal space
27
social spacing
4-12 feet formal communication making rounds
28
public spacing
more than 12 feet | lose individuality
29
what are the phases of helping (healthy??) relationship
preinteraction introduction working phase resolution
30
preinteraction phase
gather information, plan
31
introductory phase
sets tone, develops trust | sets pt at ease
32
working phase
exploring and understanding | working
33
communication with older adults
``` assistive devices communication aids decrease distractions speak sport, simple sentences face the pt allow time to respond include family in convo ```
34
safety alert: faxing
let receiver know its coming cover sheet correct number remove pt identifiers if able
35
purpose of EHR
``` interdisciplinary communication data for planning care audits research education reimbursement legal/evidence analysis/quality improvement ```
36
types of nursing documentation
``` narrative SOAP ADPIE focus charting charting by exception (DBE) ```
37
narrative documentation
write it out
38
SOAP
subjective objective assessment plan
39
focus charting
action, response
40
CBE
flow sheets and defined norms
41
sums up care and instructions used when transferring to another facility or sending home
discharge summary
42
what should discharge instructions include
``` condition, procedures care of wounds/incisions/drains med list and education restrictions (driving, lifting) instructions (activity, exercise) appointments when to seek care (fever, pain) ```
43
charting guidelines
``` chart changes (show f/u) read prior nurse notes be timely (avoid late charting) objective, subjective factual correct errors chart teachings use pt "actual words" review sign eliminate blank spaces ```
44
latin verb meaning "to suffer"
patient
45
latin verb meaning "to lean"
client
46
Maslow Hierachy of Needs
``` physiologic safety and security sense of belonging and affection esteem and self-respect self-actualization ```
47
WHO defines ____ as a "state of complete physical, mental, and social well being an not merely the absence of disease and infirmity"
health
48
What are the 4 components of wellness
capacity of perform to the best of ones ability ability to adjust and adapt to varying situations reported feeling of well-being feeling that "everything is together" and harmonious
49
this focuses on the potential for wellness and targets appropriate alterations in personal habits, lifestyle, and environment in ways that reduce risks and enhance health and well-being
health promotion
50
cognitive process that utilizes thinking that is purposeful, insightful, reflective, and goal directed in order to develop conclusions, solutions, and alternatives that are appropriate for the given situation includes reasoning and judgement
critical thinking
51
___ ___ has been identified as an essential core competency for nurses
critical thinking
52
the examination of one's own reasoning or thought process involves reflective thinking as well as awareness of the nursing skill needed for pt-centered care
metacognition
53
critical components of clinical reasoning
communication and relationships educational level knowledge and ability to use critical thinking familiarity with the environment and context of care experience and exposure to a variety of situations professionalism
54
justification of actions or interventions used to address pt problems and help pts move towards desired outcomes
explanation
55
process of determining whether outcomes have been met
evaluation
56
examining the care provided and adjusting the intervention as needed
self-regulation
57
decision making skills include:
systematic and comprehensive assessment recognition of assumptions inconsistencies and biases verification of reliability and accuracy identification of missing info distinguishing relevant from irrelevant info support of the evidence with facts and conclusions priority setting with timely decision making determination of pt-specific outcomes reassessment of responses and outcomes
58
certain physiologic complications that nurses monitor to detect changes in the status or onset of complications
collaborative problems
59
when does the implementation phase of the nursing process end?
when the interventions have been completed
60
formal, systematic study of moral beliefs to understand, analyze, and evaluate matters of right and wrong
ethics often used interchangeably with morality
61
includes specific values, characteristics, or actions whose outcomes are often examined through systematic ethical analysis
morality often used interchangeably with ethics
62
when to obtain wound culture?
after wound care has been performed
63
care to be provided to NGT pts
oral care | assess nares
64
SQ locations
``` abdomen top of thighs upper buttock scapula back of arms ```
65
Deltoid can not receive more than __ mL. Must use a __ inch needle
1 mL | 1 inch needle
66
Needle size and mL amount for IM, besides deltoids
3mL | 1.5 ich
67
what to draw back in syringe before placing in vial
air
68
ID angle
15 degree, almost parallel to arm
69
___ before ___ insulin
clear before cloudy
70
Can you shake NPH insulin (cloudy)?
No, roll between hands
71
___ for SQ, hold ___ for IM
pinch - SQ | taut - IM
72
Subjective data
information gathered from pt statements pt feelings and perceptions
73
Objective data
information that can be observed by others
74
Primary source
obtained from the pt

N1115 - Trans. to Associates (21 decks)

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