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Nursing Test 1 > Test 1 > Flashcards

Test 1 Flashcards

(72 cards)

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1
Q

What is nursing history?

A

it identifies the patients health status, strengths, health problems, health risks and need for nursing care

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2
Q

What is the first step in the nursing process?

A

assessment

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3
Q

What is an initial assessment?

A

performed shortly after the patient is admitted;its goal is to establish complete database for problem identification and care planning; collects data, establish priorities based on this data

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4
Q

What is a focused assessment?

A

the nurse gathers data about a specific problem that has already been identified

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5
Q

What is an emergency assessment?

A

when a psychological or physiological crises occurs; identify life threatening problems

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6
Q

What is a time lapsed assessment?

A

scheduled to compare a patients current status to data obtained earlier;reassessment

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7
Q

What are assessment priorities influenced by?

A

health orientation, development stage, culture and need for nursing

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8
Q

What is subjective data?

A

information perceived only by the affected person

ex: feeling chilly, nervous or nauseous

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9
Q

What is objective data?

A

observable and measurable data that can be seen, heard or felt by someone other than the person experiencing

ex: reddened skin

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10
Q

What are some sources of data?

A

Patient(primary), family and significant others, patient record, medical history, consultations, reports and lab work, report of therapies, other healthcare professionals,nursing and healthcare professionals

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11
Q

What are some methods of data collection?

A

observation and nursing history

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12
Q

What are the components of a nursing history?

A

profile (age,sex,race,etc.),reason for seeking healthcare, normal health habits and patterns, cultural considerations, current state of body systems,current medication and allergies to medication, coping status, patients and families expectations of care, patients personal resources, patients potential for injury

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13
Q

What are the four phases of a patient interview?

A

preparatory, introductory, working and termination

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14
Q

What is a physical assessment?

A

examination of the patient for objective data that may better define the patients condition

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15
Q

What is Review of Systems (ROS)?

A

examination of all body systems in a systematic manner commonly in the head to toe format

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16
Q

What is data validation?

A

act of confirming or verifying testing the data

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17
Q

What is a cue?

A

indicates that something may be wrong

ex: cannot hear

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18
Q

What is an inference?

A

judgment you reach because of a cue

ex: hearing impaired

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19
Q

What is the second step in the nursing process?

A

Diagnosis

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20
Q

What is a health problem/etiology?

A

condition that necessitates intervention to prevent or resolve disease or illness or to promote coping and wellness

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21
Q

What is a nursing diagnosis?

A

actual or potential health problems that can be prevented or resolved by independent nursing intervention; can change day to day

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22
Q

What is a medical diagnosis?

A

A medical diagnosis a often a disease or serious problem: a medical diagnosis stays as long as the disease is present

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23
Q

What is a collaborative problem?

A

certain physiologic complications that nurses monitor to detect onset or changes in status

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24
Q

What does PC stand for?

A

Potential complications

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25
What is a data cluster?
grouping of patient data or cues that points to the existence of a patient health problem
26
How does one interpret data?
recognizing significant data, patterns or clusters, and identifying strengths and problems
27
What is NANDA?
the nursing terminology abbreviations book
28
What is an actual nursing diagnosis?
problem that has been validated by the presence of major defining characteristics
29
What is a risk nursing diagnosis?
clinical judgements that an individual family or community is more vulnerable to develop the problem than others in the same sit
30
What is a possible nursing diagnosis?
statement describing a suspected problem
31
What is a wellness diagnosis?
clinical judgements about an individual or community in transition from a specific level of wellness to a higher level of wellness
32
What is a goal?
an aim or an end
33
What is a patient outcome?
an expected conclusion to a patient health problem, or in the event of a wellness diagnosis an expected conclusion yo a patients health expectation; refers to more measurable criteria that is used to evaluate the extent that the goal is met
34
What are standardized care plans?
prepared plans of care that identify the nursing diagnosis, outcomes and related interventions common to a problem
35
What is the Maslow Hierarchy of needs? and what are the levels?
Priorities in which a persons needs, need to be met 1. physiologically 2. safety needs 3. love and belonging 4. self esteem 5. self actualization
36
How long are long term outcomes?
greater than a week
37
How long are short term outcomes?
less than a week
38
What is a nursing intervention?
any treatment based on clinical judgement and knowledge, that a nurse performs to enhance a patient outcome
39
What is a plan of nursing care?
written guide that directs the efforts of the nursing team as nurses to work with patients to meet their health goals
40
What is a Kardex plan of care?
a plan of nursing care that is recorded on a folded card and placed in a central kardex file where it is easily accessible
41
What is a computerized plan of care?
electronically medical record, large knowledge base, improved record keeping
42
What is a case management plan of care?
healthcare delivery system intended to provide high quality cost effective care for individuals groups and families
43
What is a concept map?
diagram of a patient problem and interventions
44
What are clinical/critical pathways?
tools used in case management to communicate the standardized plan of care
45
What is the fourth step of the nursing process?
implementing
46
what is implementing in regards to the nursing process?
nursing actions planned in previous step are now carried out
47
What is direct care?
interaction with the patient
48
What is indirect care?
performed away from the patient but on there behalf
49
What is a physician initiated intervention?
dependent interventions, carrying out physician prescribed orders
50
What is a collaborative intervention?
interdependent nursing where multiple people on the healthcare team work together
51
What is an evidenced based practice?
nursing intervention that is supported by a sound scientific rationale
52
What is the last step in the nursing process?
Evaluation
53
What is the evaluation in terms of the nursing process?
The nurse and patient measure how well the patient has achieved the outcomes specified in the plan of care. The plan of care is either continued, modified or terminated.
54
What are cognitive outcomes?
increase in patient knowledge
55
What are psycho-motor outcomes?
achievement of new skills
56
What are affective outcomes?
changes in patient values/beliefs
57
What are physiologic outcomes?
physical changes
58
What are the options for deciding whether an outcome has been met?
met, partially met or not met
59
What does assessment mean?
collecting, organizing, validating and documenting client data
60
What does diagnosing mean?
analyzing and synthesizing data (strengths weaknesses etc.)
61
What does planning mean?
determining how to prevent, reduce or resolve identified client problems
62
What does implementing mean?
carrying out plan and interventions
63
What does evaluating mean?
measure degree to which outcomes have achieved or failed
64
What does the novice skill level in nursing mean?
uses rules to perform correctly in client care situation
65
What does the advanced beginner level in nursing mean?
recognizes common patterns and benefits from assistance in setting priorities
66
What does competent mean in the level of nursing?
recognizes own thinking and analyzes problems (2 to 3 years experience)
67
What does the proficient level of nursing mean?
increasingly intuitive thinking, clinical is seen as a whole, has speed and accuracy 3 to 5 years of experience
68
What does the expert level of nursing mean?
intuition prominent thinking, 5 or more years of experience, may or may not be achieved by all nurses
69
What is an open ended question?
express and clarify thoughts, specify broad area, longer answers
70
What is a close ended question?
factual shirt answers, often yes or no, useful with stressed clients
71
What is a leading question?
suggest an expected answer, direct the clients answer, inaccurate data can be given to please nurse
72
What are the parts of a nursing diagnosis?
Label- name of diagnosis, definition- description of diagnosis, related factors, and defining characteristics- signs and symptoms label - problem r/t related too AEB as evidenced by

Nursing Test 1 (1 decks)

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