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[3] NUR114 | FUNDAMENTALS > Assessing > Flashcards

Assessing Flashcards

1
Q

A systematic, rational method of planning and providing individualized nursing care

A

Nursing Process

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2
Q

PURPOSES OF NURSING PROCESS
- Identify a client’s (1) __________ and actual or potential healthcare problems
- Establish plans to meet identified (2) ___________
- Deliver specific (3) ____________

A

(1) health status
(2) needs
(3) nursing interventions

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3
Q

Collecting, organizing, validating, and documenting data

A

Assessing

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4
Q

Analyzing and synthesizing data

A

Diagnosing

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5
Q

Determining how to prevent, reduce, or resolved identified priority client problems; how to support client strengths; and how to implement nursing interventions in an organized, individualized, and goal-directed manner

A

Planning

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6
Q

Carrying out or delegating and documenting the planned nursing interventions

A

Implementing

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7
Q

Measuring the degree to which goals or outcomes have been achieved and identifying factors that postively or negatively influence goal achievement

A

Evaluating

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8
Q

To establish a database about the client’s responses to health concerns or illness and the ability to manage healthcare needs

A

Assessing

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9
Q

To identify client strengths and health problems that can be prevented or resolved by collaborative and independent nursing interventions

A

Diagnosing

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10
Q

To develop an individualized care plan that specifies client goals or desired outcomes and related nursing interventions

A

Planning

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11
Q

To assist the client to meet desired goals or outcomes; promote wellness; prevent illness and disease; restore health; and facilitate coping with altered functioning

A

Implementing

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12
Q

To determine whether to continue, modify, or terminate the plan of care

A

Evaluating

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13
Q

The nursing process is __________. The nurse organizes the plan of care according to client problems rather than nursing goals

A

client centered

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14
Q

The nursing process is an adaptation of __________ and __________ theory.

A

problem solving / systems

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15
Q

Is involved in every phase of the nursing process

A

Decision-making

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16
Q

The nursing process is __________ and __________. It requires the nurse to communicate directly and consistenly with clients and families to meet their needs.

A

interpersonal and collaborative

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17
Q

The _____________ characteristic of the nursing process means that it can be used as a framework for nursing care in all types of healthcare settings.

A

universally applicable

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18
Q

Nurses must utilize __________ throughout the delivery of nursing care. By reflecting, the nurse determines whether the outcome of care was appropriate

A

clinical reasoning

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19
Q

Assessing is the systematic and continuous:
C - __________
O - __________
V - __________
D - __________ of data

A

Collection
Organization
Validation
Documentation

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20
Q

Nursing assessments focus on a client’s ___________. It should include, the client’s perceived needs, health problems, related experience, health practices, values, and lifestyle.

A

responses to a health problem

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21
Q

Is the process of gathering information about a client’s health status

A

Data Collection

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22
Q

Contains all the information about a client

A

Database

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23
Q

TRUE OR FALSE:
The database of a patient includes the following:
- Nursing health history
- Physical assessment
- Primary care provider’s history and physical examination
- Results of laboratory and diagnostic tests
- Material contributed by relatives

A

FALSE
It should include MATERIAL CONTRIBUTED BY OTHER HEALTH PERSONNEL

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24
Q

Performed within specified time after admission to a healthcare agency

A

Initial assessment

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25
Q

Ongoing process integrated with nursing care

A

Problem-focused assessment

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26
Q

During any physiologic or psychologic crisis of the client

A

Emergency assessment

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27
Q

Several months after initial assessment

A

Time-lapsed reassessment

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28
Q

To establish a complete database for problem identification, reference, and future comparison

A

Initial assessment

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29
Q

To determine the status of a specific problem identified in an earlier assessment

A

Problem-focused assessment

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30
Q

To identify life-threatening problems and new or overlooked problems

A

Emergency assessment

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31
Q

To compare the client’s current status to baseline data previously obtained

A

Time-lapsed reassessment

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32
Q

Nursing admission assessment

A

Initial assessment

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33
Q

Hourly assessment of client’s fluid intake and urinary output in an intensive care unit (ICU)

A

Problem-focused assessment

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34
Q

Assessment of client’s ability to perform self-care while assissting a client to bathe

A

Problem-focused assessment

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35
Q

Rapid assessment of an individual’s ABCs during a cardiac arrest

A

Emergency assessment

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36
Q

Assessment of suicidal tendencies or potential or violence

A

Emergency assessment

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37
Q

Reassessment of a client’s functional health patterns in a home care or outpatient setting or, in a hospital, at shift change

A

Time-lapsed reassessment

38
Q

Client’s name, address, age, sex, marital status, occupation, religious preference, healthcare financing, and usual source of medical care

A

Biographic Data

39
Q

“What is troubling you?”
“Describe the reason you came to the hospital or clinic today.”

A

Chief Complaint

40
Q

Illness
Immunizations
Allergies
Accidents
Hospitalizations
Medications

A

Past History

41
Q

To ascertain risk factors for certain diseases, the ages of siblings, parents, and grandparents and their current state of health, or, if they are deceased, the cause of death, are obtained

A

Family History of Illness

42
Q

Personal Habits
Diet
Sleep patterns
Activities
Instrumental ADLs
Recreation

A

Lifestyle

43
Q

Family relationships and friendships
Ethnic affiliation
Educational history
Occupational history
Economic status
Home and neighborhood conditions

A

Social Data

44
Q

Major stressors
Usual coping pattern
Communication style

A

Psychologic Data

45
Q

All healthcare resources the client is currently using and has used in the past

A

Patterns of Healthcare

46
Q

Symptoms or covert data that are apparent only to the individual affected and can be described or verified only by that individual

A

Subjective Data

47
Q

Signs or overt data that are detectable by an observer or can be measured or tested against an accepted standard

A

Objective Data

48
Q

The best source of data is usually the __________, unless they are too ill, young, or confused to communicate clearly

A

client

49
Q

Family members, friends, and caregivers who know the client well often can supplement or verify information provided by the client

A

Support People

50
Q

Are especially important source of data for a client who is very young, unconscious, or confused.

A

Support People

51
Q

To gather data by using the senses

A

Observing

52
Q

Planned communication, or a conversation with a purpose, for example, to get or give information, identify problems of mutual concern, evaluate change, teach, provide support, or provide counseling or therapy

A

Interview

53
Q

In a __________, the nurse asks the client specific questions to collect information related to the client’s problem. This allows for collection of information previously missed and yields more in-depth information

A

Focused Interview

54
Q
  • Is highly structured and elicits specific information
  • Nurse established and controls the interview
  • Clients have limited opportunity to ask questions or discuss concerns
  • Used when time is limited
A

Directive Interview

55
Q
  • Rapport-building interview
  • The nurse allows the client to control the purpose, subject matter, and pacing
A

Nondirective Interview

56
Q

Is an understanding between two or more people

A

Rapport

57
Q

A combination of __________ and __________ approaches is usually appropriate during the information-gathering interview

A

directive and nondirective

58
Q
  • Used in the directive interview
  • Restrictive and generally require only “yes” or “no” or short factual answers
A

Closed Questions

59
Q
  • Associated with the nondirective interview
  • Invites clients to discover and explore, elaborate, clarify, or illustrate their thoughts or feelings
  • Specifies only the broad topic to be discussed
A

Open-ended Questions

60
Q

“What medication did you take?”
“Are you having pain now?”
“How old are you?”
“When did you fall?”

A

Closed Questions

61
Q

“How have you been feeling lately?”
“What brought you to the hospital?”
“What would you like to talk about today?”

A

Open-ended questions

62
Q
  • A question the client can answer without direction or pressure from the nurse
  • Open-ended and used in nondirective interviews
  • “How do you feel about that?”; “What do you think led to the operation?”
A

Neutral Question

63
Q
  • Questions that are usually closed and directs the client’s answer
  • Directive interview
  • “You’re stressed about the surgery tomorrow, aren’t you?”
A

Leading Question

64
Q

Try to avoid asking __________ questions. These questions can be perceived as a form of interrogation by the client.

A

“why”

65
Q

Nurses need to plan interviews with clients when the client is physically comforable and free of pain, and when interruptions by friends, family, and other health professionals are minimal

A

Time

66
Q

A well-lit, well-ventilated room that is relatively free of noise, movements, and distractions encourages communication

A

Place

67
Q

By standing and looking down at a client who is in bed or in a chair, the nurse risks intimidating the client.

A

Seating Arrangement

68
Q

When a client is in bed, the nurse can sit at a __________ angle to the bed.

A

45-degree

69
Q

The __________ between the interviewer and interviewee should be neither too small nor too great.

A

distance

70
Q

Is the study of use of space

A

Proxemics

71
Q

Most people feel comfortable maintaining a distance of __________ during an interview.

A

2-3 feet

72
Q

Failure to communicate in _________ the client can understand is a form of discrimination.

A

language

73
Q

TRUE OR FALSE:
The nurse must convert complicated medical terminology into common English usage, and interpreters or translators are needed if the client and the nurse do not speak the same language or dialect.

A

TRUE

74
Q

Can be the most important part of the interview because what is said and done at that time sets the tone for the remainder of the interview

A

The Opening

75
Q

The purpose of the opening are to establish _________ and _________ the interviewee

A

rapport and orient

76
Q

Is a process of creating goodwill and trust

A

Establishing rapport

77
Q

Where the client communicates what he or she thinks, feels, knows, and perceives in response to questions from the nurse

A

The Body

78
Q

The nurse terminates the interview when the needed information has been obtained

A

The Closing

79
Q

TRUE OR FALSE:
In some cases, the client terminates the interview, for example, when deciding to not give any more information for some other reason

A

TRUE

80
Q

The ___________ or head-to-toe approach begins the examination at the head; progresses to the neck, thorax, abdomen, and extremities; and ends at the toes

A

cephalocaudal

81
Q
  • Is a brief review of essential functioning of various body parts or systems
  • Data is measured against norms or standards
  • Nursing admission assessment form
A

Screening Examination / Review of Systems

82
Q

Used to assist clients to identify health risks and to explore lifestyle habits and health behaviors, beliefs, values, and attitudes that influence the level of wellness

A

Wellness Model

83
Q

Frameworks and models form other disciplines that are narrower than the model required in nursing

A

Nonnursing Models

84
Q

Model focused on abnormalities of the following anatomic systems

A

Body Systems Model

85
Q

Model the clusters data pertaining to the following:
- Physiologic needs
- Safety and security needs
- Love and belonging needs
- Self-esteem needs
- Self-actualization needs

A

Maslow’s Hierarchy of Needs

86
Q

The act of “double-checking” or verifying data to confirm that it is accurate and factual

A

Validation

87
Q
  • Are subjective or objective data that can be directly observed by the nurse
  • What the client says or what the nurse can see, hear, feel, smell, or measure
A

Cues

88
Q
  • Are the nurse’s interpretation or conclusions made based on the cues
  • e.g. Nurse observes the cues that an incision is red, hot, and swollen; thus saying that the incision is infected
A

Inferences

89
Q
  • Completes the assessment phase
  • Is essential and should include all data collected about the client’s health status
A

Documentation

90
Q

TRUE OR FALSE:
Data are recorded in a factual manner and interpreted by the nurse

A

FALSE
The nurse must NOT INTERPRET THE DATA maintain accuracy of it

[3] NUR114 | FUNDAMENTALS (15 decks)

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