Subjective Data Flashcards

1
Q

3 stages of nursing interview

A

Introductory Stage, Working Stage, Termination Stage

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2
Q

Non-Verbal Communication

A

Appearance, Demeanor, Facial Expression, Attitude, Silence, Listening

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3
Q

Verbal Communication

A

Open-ended questions, Closed-ended questions, Laundry List, Rephrasing, Well placed phrases, Providing Information, Inferring

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4
Q

Communication To Avoid

A

Excessive or Insufficient Eye Contact, Distraction and Distance, Standing, Biased or Leading Questions, Rushing through the interview, Reading the Questions

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5
Q

Variations of Communication

A

Gerontologic, Cultural, Emotional

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6
Q

8 Sections of Health History

A

Biographical Data, Reasons for seeking health care, History of present illness/health concern, Past Health History, Family Health History, ROS (Review of systems), Lifestyle & Health Practices Profile, Developmental level

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7
Q

Role of The Nurse in Introductory Stage

A

Introduction of the nurse to the client , Explain the reason for taking notes, Ensure that the client is comfortable and has privacy, Develop trust and rapport

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8
Q

Role of the Nurse in Working Stage

A

Elicit the client’s comments about major biographic data, reasons for seeking care, history of present health concern, past health history, ROS, lifestyle and health practices and developmental level

Listens observes cues and uses critical nursing skills to interpret and validate information received

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9
Q

Role of the Nurse in Termination Stage

A

Summarizes and validates the information
Identifies and discussed possible plans to resolve the problem of the client
Makes sure to ask if anything else concerns the client and if there are further questions

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10
Q

Appearance

A

Professional in appearance
Wear comfortable, neat clothes
Wear your name tag
Neat hair and not in extreme style
Fingernails are short and neat
Jewelry minimal

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11
Q

Demeanor

A

No laughing out loud
Do not yell at your co-worker
Greet the client calmly and focus your full attention on her
Do not be overwhelmingly friendly or touchy
Maintain a professional distance

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12
Q

Facial Expression

A

Expression should be neutral and friendly
Appear understanding and concern

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13
Q

Attitude

A

Develop a non judgemental attitude
Do not act superior to the client or appear shocked, disgusted or surprised at what you are told
Do not try preaching to the client or imposing your own sense of ethics or morality
Avoid telling the patient that he or she is foolish or force guilt

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14
Q

Silence

A

Periods of silence allow the nurse and the client to reflect and organize thoughts

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15
Q

Listening

A

Most important skill learn and develop
Maintain good eye contact
Smile or display an open appropriate facial expression
Maintain an open arms and hands and lean forward
Avoid preconceived ideas or biases
Avoid crossing your arms, sitting back, tilting your head away from the client, thinking about other things or looking blank and inattentive
Keep an open mind

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16
Q

Use to elicit the client’s feelings and perceptions
Questions begin with HOW and WHAT

A

Open ended questions

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17
Q

Closed ended questions

A

Used to obtain facts and to focus on specific information
Questions begin with a WHEN and DID
Used to clarify or obtain more accurate information about issues

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18
Q

Rephrasing

A

An effective way to communicate during the interview
Helps to clarify information the client has stated
Enables the client reflect on what was said

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19
Q

Well-placed phrases

A

Properly used phrase will encourage the client to continue

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20
Q

Inferring

A

Will elicit more data or verify existing data
Be careful not to lead the client to answers that are not true

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21
Q

Assess hearing acuity

A

Gerontologic

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22
Q

Reluctance to reveal personal information

A

Cultural

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23
Q

Show respect to the client

A

Gerontologic

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24
Q

Seek help from experts if there is misunderstanding or difficulty in communicating with the client

A

Cultural

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25
Variations in willingness to openly express emotional distress or pain
Cultural
26
Variation in ability to receive information
Cultural
27
Variation in meaning conveyed by language
Cultural
28
Variation in use and meaning of non verbal communication: eye contact, gestures
Cultural
29
Variation in disease/illness perception
Cultural
30
Variation in past,present and future orientation
Cultural
31
Variation in the family's role in the decision making process
Cultural
32
Assure your elderly client that you are concern
Gerontologic
33
Speak clearly and use straightforward language during the interview
Gerontologic
34
Ask questions in simple terms
Gerontologic
35
Avoid medical jargon and modern slang
Gerontologic
36
Do not talk down to the client
Gerontologic
37
Emotions vary for several reasons
Emotional
38
Include information that identifies the client
Biographical Data
39
This takes into account several aspects of the health problem: CHARACTER, ONSET, LOCATION, DURATION, SEVERITY,PATTERN, ASSOCIATED FACTORS
History of Present Illness/ Health Concern
40
Questions related to the client's past, from the earliest beginnings to the present
Past Health History
41
This elicit data to the client's strengths and weaknesses
Past Health History
42
Discover genetically based problems
Family Health History
43
Provide client with a choice of words to choose from in describing symptoms
Laundry List
44
Providing Information
Answer every question well Explain well to the client what is being observed
45
Encourage the client to discuss fears or other feelings about having to see a health care provider
Reasons for seeking health care (chief complaints)
46
Helps the nurse to obtain specific answers and reduces the likelihood of the client's perceiving or providing an expected answer
Laundry List
47
This will cause the patient to provide answers that may or may not be true
Biased or leading questions
48
Take time with the client to show that you are concern about their health and helps them to open up
Rushing through the interview
49
A____ will help to organize and illustrate the client's family history
Genogram
50
The body systems is addressed and the client is asked specific questions to draw out current health problems or problems from recent past that may still affect the client or that are recurring
ROS (REVIEW OF SYSTEMS)
51
Documents the client's description of her health status for each body system and note the client's denial of signs, symptoms, diseases or problems the nurse asked but not experienced by the client
Review of Systems (ROS)
52
Deals with the client's human responses that include: nutritional habits, activity & exercise patterns, sleep and rest, self-concept & self- care activities, social community activity, relationship values and beliefs system, education and work, stress level and coping style, environment, developmental level
Lifestyle and Health Practices Profile
53
Is designed to teach people what types and amount of food to eat to ensure a balanced diet, to promote health and prevent disease
Food pyramid
54
Assess how active is the patient either at work or at home
Activity & Exercise patterns
55
Distinguish between activity done at work which is stressful, and exercise which is designed to reduce stress and strengthen the individual
Activity & Exercise Patterns
56
Explain to the client that regular exercise reduces the risk of heart disease, strengthens heart and lungs, reduces stress and manages weight
Activity & Exercise Patterns
57
Ask patient on the specific sleep pattern; problem in sleeping, rituals the patient use to promote sleep
Sleep & Rest
58
Remember that sleep requirements vary depending on age, health and stress levels
Sleep & Rest
59
Includes assessment of how the client view herself and investigation of all behaviors that a person does to promote her health
Self concept & Self care Activities
60
Questions on this area helps the nurse to discover what outlets the client has for support and relaxation
Social and Community Activity
61
Ask client to describe the composition of the family into which they were born and the current and past relationship with these family members
Relationship Values and Beliefs System
62
This will help to identify areas of stress and satisfaction in the client's life
EDUCATION AND WORK
63
Ask what events caused stress and how the patient respond
Stress level and Coping style
64
To assess health hazards unique to the client's living situation and lifestyle
ENVIRONMENT
65
Helps in determining developmental impairments
Developmental level