Assessing (ch 12)

Question 0

Nursing process

Answer 0

Purpose of nursing process: To diagnose and treat human responses to actual or potential health problems

Question 1

Nursing history

Answer 1

Identifies the patients health status , strengths, health problems, health risk, need for nursing care

Question 2

Initial assessment

Answer 2

Preformed shortly after the patient is admitted to a healthcare agency or service

Question 3

Purpose if initial assessment

Answer 3

Establish complete database for problem identification and care planning

Question 4

Focused assessment

Answer 4

Gathers information about a specific problem that has already been identified also identify new or overlooked problems

Question 5

Emergency assessment

Answer 5

Identify life threatening problems

Question 6

Time-lapsed assessment

Answer 6

scheduled to compare a patients current status to baseline taken earlier

Question 7

Minimum data set

Answer 7

Specifies the information that must be collected from every patient and a structured assessment form to organize or cluster this data

Question 8

Subjective data

Answer 8

Information perceived only by affected person

Question 9

Objective data

Answer 9

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

Question 10

Observation

Answer 10

Conscious and deliberate use of the five senses to gather data

Question 11

Interview

Answer 11

Planned communication

Question 12

Physical assessment

Answer 12

Examination of the patient for objective data that may define the patients condition and help the nurse in planning care

Question 13

Review of systems (ROM)

Answer 13

Nursing physical assessment involves the examination of all body systems

Question 14

Validation

Answer 14

Act of confirming or verifying: purpose of validating is to keep data as free from error, bias, and misinterpretation as possible

Question 15

Diagnosis

Answer 15

1. Identify how an individual, group or community responds to actual or potential health and life processes
2. Identify factors that contribute to or cause health problems
3. Identify resources the individuals, group or community can draw to resolve problem

Question 16

Health problem

Answer 16

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

Question 17

Nursing diagnosis

Answer 17

Actual or potential health problems that can be prevented or resolved by independent nursing intervention

Question 18

Medical diagnosis

Answer 18

Identify diseases

Question 19

Collaborative problems

Answer 19

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

Question 20

Cue

Answer 20

Used to denote significant data or data that influence this analysis

Question 21

Models for organizing or clustering data

Answer 21

Human needs ( Maslow) 
Functional health patterns (Gordon) 
Human response patterns (unitary person)
Body system model

Question 22

Standard

Answer 22

Generally accepted rule

Question 23

Data cluster

Answer 23

Grouping of patient data or cues that points to the existence of a patient health problem

Question 24

Actual nursing diagnosis

Answer 24

Represents a problem that has been validated by the presence of major defining characteristics

Question 25

Risk nursing diagnosis

Answer 25

Clinical judgments that an individual, family, or community is more vulnerable to develop the problem than others in the same or similar situation

Question 26

Possible nursing diagnosis

Answer 26

Statements describing a suspected problem for which additional data are needed

Question 27

Wellness diagnosis

Answer 27

Clinical judgements about an individual, group, or community, in transition from a specific level of wellness to higher level of wellness

Question 28

Syndrome nursing diagnosis

Answer 28

Comprise a cluster of actual or risk nursing diagnosis that are predicted to be present because of a certain event or situation

Question 29

Goal

Answer 29

An aim or an end

Question 30

Patient outcome

Answer 30

An expected conclusion to a patient health problem

Question 31

Expected outcomes

Answer 31

Used to refer to the more specific, measurable criteria used to evaluate the extent to which a goal has been met

Question 32

Initial planning

Answer 32

Developed by the nurse who performs the admission nursing history and physical assessment

Question 33

Standardized care plans

Answer 33

Prepared plans of care that identify the nursing diagnosis, outcomes, and related nursing interventions common to specific population or health problem

Question 34

Formulation of nursing diagnosis

Answer 34

Problem: identifies what is unhealthy about patient
Etiology: identifies factors maintaining the unhealthy state
Symptom: patient reports

Question 35

Ongoing planning

Answer 35

Carried out by any nurse who interacts with the patient