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Nur 103 > Exam 5 > Flashcards

Exam 5 Flashcards

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1
Q

what is the act of recording client assessments and care in written or electronic form?

A

Documentation

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2
Q

TRUE or FALSE
If you didn’t document it, it didn’t happen!!!

A

TRUE

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3
Q

why is communication important?

A

it provides safe & quality care

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4
Q

why do students use client data as a case study?

A

to better understand illness and symptoms

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5
Q

compared findings =

A

data

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6
Q

what has changed the nursing practice and is linked to improved outcomes?

A

Analyzing

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7
Q

what contributes to evidence based?

A

results

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8
Q

what charting gets audited?

A

care plan, interventions, discharge planning, client education

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9
Q

what might scattered data lead to?

A

fragmentation

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10
Q

what does the source-oriented system contain?

A

admission, H&P, diagnostic, graphs, progress notes, labs, rehab

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11
Q

what are the 4 components of a problem-oriented system

A

database, problem list, plan of care, and progress notes

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12
Q

what type of charting can you use with source- or problem- oriented system?
has a “story format”

A

narrative

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13
Q

when is PIE charting used
(problem, interventions, evaluation)

A

only in problem-oriented charting
establishes an ongoing plan of care

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14
Q

SOAPIER charting

A

subjective
objective
assessment
planning
interventions
evaluation
revision

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15
Q

what form of charting highlights the client’s main concerns?

A

focus charting

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16
Q

what is DAR charting and when is it used

A

Data, Action, Response
used during column 3 of focus charting

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17
Q

what form of charting only charts significant findings or exceptions to norms

A

Charting by Exception

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18
Q

FACT documentation pneumonic

A

Flow sheets individualize specific services
Assessment with baseline data
Concise progress notes
Timely entries

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19
Q

what form of charting improves the quality of care

A

computerized charting

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20
Q

what words are important to avoid when documenting client care

A

appears, seems, apparently

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21
Q

when is keep it CUBAN used?

A

during handoff reports

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22
Q

CUBAN pneumonic

A

confidential
uninterupted
brief
accurate
named nurse

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23
Q

after providing patient care, the nurse charts in the permanent record. Which is considered appropriate documentation?
A. Pt appears restless when sitting up for lunch
B. Apparently enjoyed breakfast with family
C. Drank adequate amounts of water
D. Skin pale and cool

A

D.

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24
Q

The nurse has just medicated a client for pain. Documentation of this intervention would be found on the:

A

Flowsheet and MAR

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25
sensory systems:
vision, hearing, taste, smell, touch
26
what environment do the senses provide?
internal and external
27
what triggers a stimulant receptor?
stimulus
28
examples of a stimulus
loud noise, bright light, sour taste
29
what is the process of receiving stimuli from nerve endings?
reception
30
what are some types of receptors
mechanoreceptors (vibration) proprioceptors (body in space) chemoreceptors (taste) hair cells (balance) thermoreceptors photoreceptors
31
what is the ability to interpret sensory impulses as well as give meaning?
perception
32
what is perception affected by?
location of receptor number of receptors
33
what is composed of consciousness and alertness?
Arousal
34
what is mediated by reticular activating system (RAS)
arousal
35
what is arousal affected by?
environment and some medications
36
what are factors that affect response?
intensity of stimuli (bright light) contrasting stimuli (cold outside) adaption to stimuli (noise)
37
what factors affect the sensory experience?
the developmental stages culture lifestyle medications
38
what is the lack of meaningful stimuli
sensory deprivation
39
overwhelmed by environmental and internal stimuli
sensory overload
40
the client who has had a stroke states to the nurse, "you know I can't even tell where my left leg is." this reflects a lack of response to stimuli by the
proprioceptors
41
is pain objective or subjective
subjective
42
what are classifications of pain
origin, cause, duration, quality
43
what is deep somatic pain
pain that originates in the ligaments, tendons, nerves, blood vessels, and bone
44
where is visceral pain located
abdomen, cranium or thorax
45
nociceptive pain
normal pain processing- result of actual or potential tissue damage
46
somatic pain
pain arising from the skin and musculoskeletal structures (well localized)
47
what pain is NOT well localized
visceral
48
what is most important when assessing a client's pain?
the client's own perception of the pain
49
what activates neurons existing throughout the body response
transduction
50
what is the first process of nociception
transduction
51
what is the conduction of pain that messages through the spinal cord via nerve fibers
transmission
52
what marks the end of nerve transmission and involves the conscious awareness of pain
perception
53
what requires activation of higher brain structures
perception
54
what changes pain receptors
modulation
55
what maintains perfusion to vital organs, minimizes blood loss, fights infection, and promotes healing. "fight or flight"
sympathetic nervous system
56
consumes thoughts and changes daily living patterns
parasympathetic nervous system
57
the storage and recall of information are?
cognitive domains of learing
58
PCA example (patient-controlled analgesia)
morphine pump
59
what form of a domain of learning changes feelings, beliefs, attitudes and values?
affective learning
60
five rights of teaching
time, context, goal, content, method
61
the client needs to be taught how to find and check his own pulse. the nurse will complete this teaching. A. only if the client asks her to do so, to avoid causing stress B. when the client recognizes the need to learn the skill C. before pain medications are administered and the patient is alert D. right before the client is discharged so he can remember the skill
B.
62
what is loss?
the undesired change or removal of a valued object, person, or situation
63
what is psychological loss
internal loss (trust, fairness, hope)
64
the student nurse has earned "A's" in all her gen-ed courses. For the first nurse's exam, she got a "D" and now feels that she is not smart enough for nursing school. What type of loss is the student experiencing?
perceived
65
what is grief?
physical, psychological, and spiritual responses to a loss
66
what is bereavement?
mourning and adjustment time following a loss
67
what is disenfranchised grief?
not socially supported (affair)
68
what is anticipatory grief?
negative (the survivors friend dying)
69
examples of facilitating grief
expressing feelings recalling memories finding meaning bibliotherapy
70
rigor algor livor
stiffing of body blood stops circulating (body temp. decreases 2 degrees per hr.) bluish body, no blood circulating
71
ethnicity race religion
share a common culture/heritage biological simularties system of beliefs
72
example of indigenous healthcare systems
self-healing, folk medicine
73
what is complementary medicine?
therapy chiro.
74
ethnocentrism
your group is better than the rest
75
what is religion
a "map" that outlines beliefs, values, and codes of conduct into a manner of living
76
what is spirituality
a "journey" that take place over time and involves the accumulation of life experiences and understandings
77
how many chains or linked to infection
6
78
what are infectious agents?
bacteria, fungi, viruses, protozoa
79
what is a reservoir
where pathogens live and multiply
80
what are examples of the portal of exit
all body fluids
81
what causes the mode of transmission
touching, kissing, coughing, air conditing
82
what are examples of the portal of entry
eye, nose, mouth, cuts, scrapes, vagina, IV/drainge tube, bites
83
when can breaking the chain of infection occur
at any point
84
***stages of infection***
incubation- time of infection (can infect others) prodromal- vague symptoms illness- s/s are present decline- pathogens decline convalescence- tissue repair (becoming healthy)
85
local infection
occur in limited region of the body
86
systemic infection
spread through the body, affecting many regions
87
latent infection:
infection with no S/S for a long time (STD)
88
medical asepsis
a state of cleanliness that decreases the potential for the spread of infection
89
how is the prevention of infection promoted
maintaining a clean environment, clean hands, following CDC guidelines

Nur 103 (4 decks)

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