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NUCM 103 Fundamentals in Nursing > ASSESSMENT > Flashcards

ASSESSMENT Flashcards

1
Q

data collection to establish

A

database

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2
Q

is the systematic and continuous collection, validation, and documentation of data (information)

A

assessing

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3
Q

What are the activities of assessment?

A

Establish database
obtain a nursing health history
conduct physical assessment
review of patient records
review of nursing literature
consultation of support persons
consultation of health professionals

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4
Q

What are the components of assessment?

A

Data Collection
Data Validation
Data Organization
Communication of Data (Kozier)
Documentation of Data (Taylor)

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5
Q

What are the two types of data?

A

subjective and objective data

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6
Q

information perceived only by the client or by the affected person

A

subjective data

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7
Q

cannot be perceived or verified by another person

A

subjective data

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8
Q

Subjective data is also called as ?

A

symptoms or covert data

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9
Q

consist of information given verbally by the patient

A

subjective data

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10
Q

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

A

objective data

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11
Q

can be observed by one person and can be verified by another person observing the same patient

A

objective data

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12
Q

obtained through observation or physical examination (IPPA)

what is IPPA?

A

Objective data
Inspection
Palpation
Percussion
Auscultation

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13
Q

Objective data is also called as

A

Signs or Overt Data

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14
Q

What are the sources of data or information

A

client or patient
support people like family members, SO
Client or patient record like
- medical history
- consultations
- reports or laboratory
- reports of therapies by other health care professional
- nursing and other health care literature

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15
Q

What are the characteristics of data?

A

complete
factual and accurate
relevant

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16
Q

What are the types of assessment?

A

Initial assessment
Problem focused assessment
Emergency assessment
Time-lapsed Assessment

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17
Q

Nursing assessments focus on a ________ to a health problem.

A

client’s response

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18
Q

process of gathering information about client’s health status

systematic and continuous

A

Data collection

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19
Q

all information about the client

A

database

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20
Q

To gather data using senses

A

observation

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21
Q

What are the senses involved in observation of the patient?

A

vision
touch
hearing
smell

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22
Q

What should the nurse observe of the patient?

A

clinical signs of client distress
threats to clients safety, real or anticipated
presence and functioning of associated equipment
the immediate environment, including the people

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23
Q

it is a planned communication or a conversation with a purpose

A

interview

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24
Q

What are the three types of interview?

A

Focused interview
Directive interview
Nondirective interview

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25
Q

nurses ask specific questions to the client’s problem

A

focused interview

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26
Q

it is highly structured
elicits specific information
emergency situation

A

directive interview

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27
Q

rapport building interview

A

non-directive interview

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28
Q

an understanding between two people

A

rapport

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29
Q

What are the four types of interview question?

A

Closed
Open
Neutral
leading

30
Q

In planning for the interview and setting, one must consider the following factors?

A

Time
place
seating arrangement
distance
language

31
Q

The place where the interview is conducted must be

A

well-lighted
well-ventilated
free from noise, movement, distractions

32
Q

What should be the appropriate distance of the patient from the nurse?

A

at least 3-4 feet

33
Q

the study of use of space

A

proxemics

34
Q

What are the stages of interview

A

Opening or introduction
body or development
closing

35
Q

In closing the interview, what should a nurse do?

A
  1. offer to ask questions
  2. use “well_____ end”
  3. thank the client
  4. express concern for the person’s welfare and future
  5. plan for the next meeting
  6. summary to verify accuracy and agreement
36
Q

Upon examining a patient, what should you do first?

A

first- observe the overall appearance and health status
second - vital signs
third - cephalocaudal or head to toe approach

37
Q

brief review of essential functioning of various body parts or systems

A

screening examination or review of systems

38
Q

Organizing data is also called as

A

nursing health history
nursing assessment
nursing database form

39
Q

What are the conceptual models and Frameworks in organizing data?

A

Gordon’s 11 functional health
Orem’s Self Care Model
Roy’s Adaptation Model

40
Q

What are the four observable categories according to Orem’s Self Care Model?

A

physiological
self-concept
role function
interdependence

41
Q

Used to identify health risks and explore lifestyle

A

wellness models

42
Q

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

A

validation

43
Q

subjective and objective data that can be directly observed by the nurse

A

cues

44
Q

These are nurse’s interpretation or conclusions made on the cues

A

inferences

45
Q

records client data

A

documenting data

46
Q

Diagnosis is

A

analyzing and synthesizing

47
Q

In this phase, nurses use critical thinking skills to interpret or analyze assessment data and identify client strength and health problems

A

diagnosis

48
Q

is used to interpret or analyze assessment data and identify client strength and health problems

A

Diagnosis

49
Q

The standard NANDA name for the diagnosis are called

A

Diagnostic Labels

50
Q

causal relationship between a problem and its related or risk factors

A

etiology

51
Q

a clinical judgment concerning a human response to health con- ditions/life processes, or a vulnerability for that response, by an indi- vidual, family, group, or community”

A

nursing diagnosis

52
Q

are responsible for mak- ing nursing diagnoses

A

Registered nurse

53
Q

is a judgment made only after thorough, sys- tematic data collection.

A

nursing diagnosis

54
Q

is a client problem that is present at the time of the nursing assessment

A

actual diagnosis

55
Q

relates to clients’ preparedness to implement behaviors to improve their health condition.

A

health promotion diagnosis

56
Q

is a clinical judgment that a prob- lem does not exist, but the presence of risk factors indicates that a problem is likely to develop unless nurses intervene.

A

risk nursing diagnosis

57
Q

is assigned by a nurse’s clinical judg- ment to describe a cluster of nursing diagnoses that have similar interventions

A

syndrome diagnosis

58
Q

What are the three components of nursing diagnosis

A

Problem and its definition
the etiology
the defining characteristics

59
Q

is to direct the formation of client goals and desired outcome

A

diagnostic labels

60
Q

are words that have been added to some NANDA labels to give additional meaning to the diagnostic statement

A

qualifiers

61
Q

What are the qualifiers used in nursing diagnosis?

A

deficient
impaired
decreased
ineffective
compromised

62
Q

identifies one or more probable causes of the health problem, gives direction to the required nursing therapy, and enables the nurse to individualize the client’s care.

A

etiology

63
Q

are the cluster of signs and symptoms that indicate the presence of a particular diagnostic label.

A

defining characteristics

64
Q

Nursing diagnosis describes a

A

client’s physical
socio-cultural
psychological
spiritual responses

65
Q

CUC

A

Chronic Ulcerative Colitis

66
Q

CA

A

Cancer

67
Q

CVA

A

Cerebral Vascular Accident

68
Q

What is the Diagnostic Process?

A

Analyzing data
Identifying health problem and risks and strength (focus area)
Formulating diagnostic statements

69
Q

R/t

A

Related to

70
Q

PIH

A

Pregnancy Induced Hypertension

NUCM 103 Fundamentals in Nursing (20 decks)

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