301 chap 2, 3 , 4, and 21 Flashcards
1
Q
More than one health problem occurring at the same time
A
Comorbitidity
2
Q
A set of interrelated concepts that represents a certain way of thinking about something
A
Model
3
Q
Five steps of the nursing process
A
Assessment Diagnosis Planning Implementation Evaluation
4
Q
The nursing interview AND physical assessment become part of the
A
Patient database
5
Q
Nurse assistants are allowed to collect data such as
A
Temperature, height, weight
6
Q
Data gathered by a physical assessment or laboratory tests
A
Objective data
7
Q
Assessment tool for figuring out if someone can do the more sophisticated tasks like shopping
A
Lawton scale
8
Q
Assessment tool used mostly in palliative care
A
Karnofsky
9
Q
Form for data collection that is especially useful for identifying medical problems
A
Body systems (medical) framework
10
Q
Includes vital signs such as blood pressure, pulse so trends over time can be seen clearly
A
Graphic flow sheet
11
Q
primary vs secondary data: patient’s chart
A
secondary
12
Q
primary vs secondary data: another healthcare provider
A
secondary
13
Q
primary vs secondary data: something the patient says
A
primary
14
Q
primary vs secondary data: something you find on the patient
A
primary
15
Q
the first step in the process of analyzing and interpreting data?
A
Identify significant data
16
Q
the __ phase begins when you meet the client and introduce yourself and your role in the relationship
A
orientation phase
17
Q
The goal of this phase is to establish rapport and trust through the use of verbal and nonverbal communication
A
orientation phase
18
Q
kind of interviewing, which is used to obtain factual, easily categorized information
A
directive interviewing
19
Q
During a physical examination, you take a client’s pulse and blood pressure, auscultate his lungs, and palpate his neck. Which zone of the client’s personal space have you entered while performing these assessments?
A
intimate
20
Q
“Problem r/t ___ as manifested by (AMB) signs or symptoms.”
A
etiology
21
Q
“Problem r/t etiology ___ signs or symptoms.”
A
AMB
22
Q
“___ r/t etiology as manifested by (AMB) signs or symptoms.”
A
Problem
23
Q
To ___ the message, instead of just requesting further explanation from the client regarding a statement, go ahead and suggest your interpretation and ask whether it is correct
A
validate
24
Q
___ means using your own words to summarize the message you received from the client
A
Restating
25
___ messages helps ensure that you have accurately interpreted the information. It involves expressing a lack of understanding of the client's statement and requesting further explanation
Clarifying
26
Record cues, not ___
inferences
27
Performance scale is used primarily in palliative care settings to assess functional abilities at the end of life
Karnofsky
28
What are the two components of "caring" in the full-spectrum nursing concepts
Self-knowledge and ethical knowledge
29
what is typically left out of a collaborative problem
etiology
30
___ status would be assessed in a comprehensive assessment but not in an initial assessment
Emotional
31
A client's marital status would be recorded as part of the ___ assessment, which focuses on static data—data that are not likely to change often—such as demographic data (marital status, occupation)
initial
32
A normal resting heart rate for adults ranges from __ to 100 beats a minute
60
33
The Joint Commission requires that agencies designate when each patient is to be ____
reassessed
34
The component of care "___" is striving to understand what an event (e.g., an illness) means in the life of the patient
Knowing
35
The component of care "__ __" is doing what the patient would do for himself if he could (e.g., bathing)
Doing for
36
The component of care "___" is supporting the patient through coping with life changes and unfamiliar events, such as hospitalization
enabling
37
The component of care "___" is being emotionally present for the patient (e.g., making eye contact, actively listening)
being with
38
___ is a technique whereby you acknowledge that there may be some truth to a criticism but you remain the judge of your own action
Fogging
39
When you use ___ inquiry, you request clarification of one's criticism of you
negative
40
full spectrum nursing involves 3 things: t___, d___, and c___ and ___ situation
thinking doing caring and patient situation
41
cognitive processes used in complex thinking operations such as problem-solving are critical thinking ___
skills
42
different than critical thinking skills, ___s are more like feelings
attitudes
43
critical thinking attitude: dont believe everything you're told
independent thinking
44
critical thinking attitude: love to learn new things
intellectual curiosity
45
critical thinking attitude: are that you don't know everything
humility
46
critical thinking attitude: try to understand the feelings of others
empathy
47
critical thinking attitude: examine things even when it's uncomfortable
courage
48
critical thinking attitude: don't settle for quick easy answers
perseverance
49
critical thinking attitude: make impartial judgements
fair-mindedness
50
reflective, creative thinking about patient care
clinical reasoning
51
critical thinking model: awareness of the total situation
contextual awareness
52
critical thinking model: applying standards of good reasoning to your thinking
inquiry based on credible sources
53
critical thinking model: imagining alternatives
considering alternatives
54
critical thinking model: recognizing assumptions
analyzing assumptions
55
critical thinking model: questioning your rationale
reflecting skeptically
56
knowledge that enables you to apply your theoretical knowledge to patients
practical knowledge
57
component of caring: striving to understand what an event means in the life of the patient
knowing
58
component of caring: being EMOTIONALLY present for patient
being with
59
component of caring: do what the patient can't do for himself
doing for
60
component of caring: supporting the patient through coping with life changes and unfamiliar events (such as being hospitalized)
enabling
61
component of caring: having faith in the patients ability to get through the change
maintaining belief
62
The JC requires that agencies have assessments that are written, ___, and used to identify ___
comprehensive
| priorities
63
The JC requires that agency policy designates when patients are to be ___ and which disciplines can make which ___
released
| assessments
64
The JC requires that all patients are assessed for
pain
65
Nurses can delegate someone getting height, weight, etc but the nurse must __ the data, conduct the ___, and complete the assessment
data, interview
66
assessment completed when the client first comes to the agency
initial
67
assessment performed as needed, at any time after the initial database is completed
ongoing
68
performed to get data about an actual, potential, or possible problem
focused assessment
69
assessment that provides in depth info about an area of client functioning
special needs
70
Katz is an assessment tool that gives you 1 point for these 6 areas
```
bathing
continence
dressing
feeding
toileting
transfer
```
71
nursing health history covers some of the same topics as the medical history, but for different
reasons
72
conceptual term: something that indicates which info is significant
framework
73
Maslow's list
```
Physiological
Safety
Love/belonging
Esteem
Cognitive
Aesthetic
Self actualize
```
74
Maslow, need for affection
Love and Belonging
75
Maslow, need to feel good about yourself
esteem
76
Maslow, need for knowledge
cognitive
77
Maslow, need for order and beauty
aesthetic
78
Maslow, need grow and change, reach potential
self-actualize
79
in documentation, should be used sparingly and only if agency approved
acronyms
80
When recording patient's words, only use the most
important part
81
Record __s not ____s
cues not inferences
82
diagnostic reasoning is aka Diagnostic ___
process
83
the basis for planning client-centered goals and interventions
Dx
84
Dx is the reasoning process used in ___ing assessment data
interpreting
85
Dx contains both __ and __
problem and etiology
86
___ ___ in a sense forms the body of knowledge that is unique to nursing
diagnostic labels
87
nursing Dx is stated in terms of human responses to
disease and other stressors
88
nursing Dx can be a problem or
strength
89
you can't predict a patient's nursing Dx just by knowing the
medical Dx
90
a medical Dx can have __ nursing Dx
multiple
91
All patients who have a certain disease are at risk for the ___ complications
same
92
a collaborative problem is always a ___ problem
potential
93
If you can prevent the complication with independent ___ interventions alone, then it is not a collaborative problem
nursing
94
the thinking process that enables you to make sense of assessment data.
diagnostic reasoning
95
diagnostic reasoning is aka a____
analysis
96
In nursing, an etiology is always an ___ because you can never actually observe the link between etiology and problem
inference
97
NANDA categorizes diagnoses into 13 __ and 47 __
domains, classes
98
a word or phrase that represents a pattern of related cues and describes a problem or wellness response
diagnostic label
99
Explains the meaning of the label and distinguishes it from other similar labels
definition
100
the cues (signs and symptoms) that allow you to identify a problem or wellness diagnosis are called
defining characteristics
101
cues, conditions that are in some way associated with the problem
related factors
102
An individual's etiology will ___ include all the related factors that NANDA lists for the Dx
not
103
things that increase the vulnerability: ___ factors
risk factors
104
during the diagnostic process, the first step is to identify a ___ that fits the cue cluster
domain
105
during the diagnostic process, the second step is to choose the
class
106
the etiology will help you individualize nursing care because etiologies are __ to the individual
unique
107
a label that represents a collection of several nursing Dxs
syndrome Dx
108
you may need to add a second part of the etiology using the words "secondary to." This part is usually the
disease
109
in actual practice, you would not write an etiology for a ___ problem
collaborative
110
as a general rule, the problem suggests goals and the etiology suggests __
interventions
111
the __ is the opposite of the unhealthy response
goal
112
the aim of nursing ____s is to remove the factors contributing to the problem
interventions
113
as a rule, avoid using the word "___" in a problem statement
need
114
The ___ of the communication describes the actual subject matter, words, substance of the message
content
115
__ refers to the act of sending, receiving, interpreting, and reacting to a message.
process
116
process of selecting words, symbols, etc to transmit the message
encoding
117
the verbal and or nonverbal information the sender communicates
message
118
the medium used to send the message
channel
119
interpretation is aka
decoding
120
once message is rec'd, he may be stimulated to send
feedback
121
literal meaning of the word
denotation
122
tone of voice
intonation
123
older adults may be affected by sensory ___ such as hearing loss
alterations
124
the area immediately surrounding people (within 18 inches)
intimate distance
125
18 inches to 4 ft. appropriate when communicating caring or concern
personal distance
126
4 to 12 ft. Used in more formal interactions
Social distance
127
Over 12 ft
public distance
128
communication style that forces others to lose
aggressive approach
129
the expression of a wide range of positive and negative thoughts and feelings
assertive communication
130
in assertive communication, the expressions are direct, honest, and
nonjudgemental
131
good communication uses "_" statements
"I"
132
Use "____" to help you accept criticism without becoming defensive
fogging
133
in communicating it can help to use __ inquiry
negative inquiry
134
A therapeutic relationship focuses on
improving the health of the client
135
Therapeutic communication is client centered communication directed at achieving
client goals
136
the goal of the orientation phase is to establish ___ and ___
rapport and trust
137
Orientation phase ends when the relationship has been
defined
138
the bulk of the therapeutic communication occurs in the __ phase
working phase
139
empathy, respect, genuineness, concreteness, confrontation are the 5 characteristics of
therapeutic communication
140
valuing your client and being flexible for them
respect
141
difficulty expressing or interpreting messages
aphasia
142
means using your own words to summarize the message you received from the client
restating
143
asking the client whether you are making the correct interpretation
validating
144
Helps the patient explore a topic of importance. The nurse selects one topic for further discussion from among several topics presents by the patient
focusing
145
Let the patient know that a message was unclear and seeks specific info to make it clearer
clarification
