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203: Health Assessment > 221 Exam #2 > Flashcards

221 Exam #2 Flashcards

1
Q

What are the four pieces of the full-spectrum nursing process?

A

Thinking, doing, caring, patient situation

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2
Q

The following are a part of which aspect of full-spectrum nursing:
- Critical thinking
- Theoretical knowledge

A

Thinking

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3
Q

The following are a part of which aspect of full-spectrum nursing:
- Practical knowledge
- Nursing process

A

Doing

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4
Q

The following are a part of which aspect of full-spectrum nursing:
- Self-knowledge
- Ethical knowledge

A

Caring

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5
Q

The following are a part of which aspect of full-spectrum nursing:
- Patient data
- Patient preferences
- Context

A

Patient situation

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6
Q

What is critical thinking in simple terms?

A

Integration of knowledge, skills, & experiences

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7
Q

What are the three primary components of theoretical knowledge?

A

Principles, theories, & known facts

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8
Q

What is ethical knowledge?

A

Knowing your obligations, sense of right vs. wrong

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9
Q

What are the three primary components of patient data?

A

Physical, psychosocial, spiritual (holism)

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10
Q

What is the context component of patient situation in the full-spectrum nursing model?

A

Where & how care is happening

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11
Q

What is the difference between the medical assessment and the nursing assessment?

A

Medical assessment: focus on disease & pathology (ex. Patient has CHF)

Nursing assessment: focus on patient’s response to illness or health problem (ex. Patient has altered breathing pattern & fluid volume overload)

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12
Q

Which 3 aspects of assessment can be delegated by a professional work to nurse aid/unlicensed assistive personnel?

A

Vital signs
Pain reports
Fingerstick blood glucose

Tasks can’t involve assessment, interpretation, or independent decision making during implementation or at completion

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13
Q

Which aspects of assessment must be conducted by a professional nurse?

A
  • Interview
  • Physical assessment
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14
Q

What does a professional nurse have to do in order to be able to delegate to a nurse aid/unlicensed assistive personnel?

A
  • Assign the task
  • Validate the collected data
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15
Q

When an RN delegates a task to a UAP, who assumes responsibility accountability for said task?

A

The RN

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16
Q

Which three resources should a RN consult for clarification related to delegation?

A
  • State’s nurse practice act
  • American Nurses Association (ANA) scope & standards of practice
  • Accrediting agencies
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17
Q

What are the six steps of the nursing process in order?

A
  1. Assessment
  2. Diagnosis
  3. Planning outcomes
  4. Planning interventions
  5. Implementation
  6. Evaluation
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18
Q

What does the assessment (1) stage of the nursing process entail?

A

Gathering data

19
Q

What does the diagnosis (2) stage of the nursing process entail?

A

Identifying patient health needs

20
Q

What does the planning outcomes (3) stage of the nursing process entail?

A

Identifying goal you want to achieve through nursing actions (one short-term, one long-term)

21
Q

What does the planning interventions (4) stage of the nursing process entail?

A

Determine how to help patient achieve stated goal(s)

22
Q

What does the implementation (5) stage of the nursing process entail?

A

Putting plan into action

23
Q

What does the evaluation (6) stage of the nursing process entail?

A

Judging whether or not plan was successful- whether or not patient goal(s) were met

24
Q

What differentiates subjective and objective data?

A

Subjective: data reported by patient
Objective: measurable data

25
Q

What is theoretical nursing e /?
Give an ex

A

The “why” behind nursing practices

26
Q

What is theoretical nursing knowledge?

Give an example relating to oxygenation

A

The “why” behind nursing practice
Ex. Room air is 21% oxygen

27
Q

What is practical nursing knowledge?

Give an example relating to oxygenation

A

The “doing” portion of nursing practices
Ex. Placing a nasal cannula to increase a patient’s oxygen levels

28
Q

What is self nursing knowledge?

A

Awareness/reflection of personal beliefs, biases, etc.

29
Q

What is a comprehensive nursing assessment?

A

Head-to-toe assessment that evaluates patient’s overall health, admission history

30
Q

What is a focused nursing assessment?

What are the two types of focused assessment?

A

Assessing for data specific to an identified or suspected issue (usually body part/ability focused)

Initial focused, ongoing focused

31
Q

What differentiates an initial focused assessment and an ongoing focused assessment?

A

Initial focused: assessing a specific patient complaint for the first time

Ongoing focused: assessing the same specific patient complaint on multiple occasions

32
Q

What is the reason for writing & developing goals for a patient?

A

To identify the change we want to see in the patient’s condition

33
Q

What differentiates independent and dependent nursing interventions?

A

Independent nursing intervention may be done without a doctor order, but dependent nursing intervention requires a doctor order

34
Q

What is ongoing evaluation?

A

Evaluation that is done overtime until patient goal is met

35
Q

What is intermittent evaluation?

A

Evaluation done at specific times

36
Q

What is terminal evaluation?

A

Evaluating if patient goal has been met in order to remove them from the care plan pertaining to said goal

37
Q

What does the S.M.A.R.T. goal mnemonic stand for?

A

S- specific
M- measurable
A- attainable/achievable
R- relevant
T- timely

38
Q

What are the 5 components of the “specific” portion of S.M.A.R.T. goals?

A
  • Who is involved? (Usually patient)
  • What do you want to accomplish?
  • Where will it be done?
  • Why will it be done?
  • Constraints and/or requirements
39
Q

What are the 2 components of the “measurable” portion of S.M.A.R.T. goals?

A
  • Can progress be tracked & outcomes measured?
  • How will I know that the goal has been accomplished?
40
Q

What is the “attainable” portion of S.M.A.R.T. goals?

A

Is the goal reasonable enough to be accomplished? How?
(neither below standard practice or out of reach)

41
Q

What are the 2 components of the “relevant” portion of S.M.A.R.T. goals?

A
  • Is the goal worthwhile & will it meet patient needs?
  • Is each goal consistent w/ other established goals & does it fit w/ both immediate & long-term plans?
42
Q

What is the “timely” portion of S.M.A.R.T. goals?

A

Include a time limit for goal to establish urgency when needed & to promote good time management

43
Q

Put the following tiers of Maslow’s Hierarchy of Needs in order starting w/ the needs that must be addressed first:
- Aesthetic
- Love & belonging
- Transcendence
- Physiological
- Safety & security
- Self-esteem
- Cognitive
- Self-actualization

A
  1. Physiological
  2. Safety & security
  3. Love & belonging
  4. Self-esteem
  5. Cognitive
  6. Aesthetic
  7. Self-actualization
  8. Transcendence
44
Q
A

203: Health Assessment (7 decks)

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