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Health Assessment > Assessment chap 11 (177-95); Alfaro chap 2 (44-89) > Flashcards

Assessment chap 11 (177-95); Alfaro chap 2 (44-89) Flashcards

1
Q

What are the five phases of the nursing process?

A

The five phases of the nursing process is: ADPIE assessing, diagnosing, planning, implementing, and evaluating.

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2
Q

A systematic, continuos method of planning and providing care that’s pt focused and includes five phases is called?

A

The nursing process

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3
Q

This phase of the nsg process involves collecting data w/outcomes, relating nsg actions to pt goals/outcomes, drawing conclusions, and continue or modify or terminate pt care plan

A

evaluation which determines whether to continue, modify or terminate the plan of care

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4
Q

This phase of the nsg process involves reassessing the pt, implementing nsg interventions, supervising/delegating care, and documenting nsg activities.

A

implementing which assists the pt to meet desired goals/outcomes; promote wellness; prevent illness and disease; restore health; and facilitate coping w/altered functioning

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5
Q

This phase of the nsg process includes prioritizing problems/dx, formulating goals/desired outcomes, selecting nsg interventions, writing nsg interventions

A

planning which develops an individualize care plan that specifies pt goals/desired outcomes along w/related nsg interventions

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6
Q

This phase of the nsg process includes analyzing data, identifying health problems, risks, and strengths,, formulating dx statements

A

diagnosing which identifies pt strengths and health problems that can be prevented/resolved by collaborative and independent nsg interventions and to develop a list of nsg collaborative problems

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7
Q

This phase of the nsg process includes collecting, organizing, validating, and documenting data.

A

assessment which establishes a database about a pt’s response to health concerns or illness and their ability to manage health care needs

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8
Q

What are the four different types of assessments in the nsg process?

A

The four different types of assessments include: initial nsg assessment, problem-focused assessment, emergency assessment, and time-lapsed assessment

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9
Q

According to the Joint Commission, when is the pt to have his/her initial assessment?

A

the pt is to have an initial assessment within 24 hrs

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10
Q

Activities of this phase of the nsg process includes: establishing a database via obtaining a nsg health hx, conducting a physical assessment, reviewing pt records, reviewing nsg literature, updating/organizing/validating/documentation of data

A

assessment

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11
Q

These activities of this phase of the nsg phase includes interpreting/analyzing data via comparing data against standards; generate a hypothesis by clustering data; identify gaps and inconsistencies; determine pt’s strengths/risks/problems; formulate dx and collaborative problem statements; document nsg dx on the care plan

A

diagnosing

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12
Q

The activities of this phase of the nsg process includes: setting priorities and goals/outcomes in collaboration w/pt; writing goals/outcomes; selecting nsg interventions; consulting w/health professionals; writing nsg interventions/nsg care plan; communicating the nsg care plan to relevant health care providers

A

planning

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13
Q

The activities of this phase of the nsg process includes: reassessing the pt to update the database; performing planned nsg interventions; communicating what nsg actions were implemented; documenting care and pt’s response; and giving/delegating

A

implementation

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14
Q

The activities of this phase in the nsg process includes collaboration w/pt while collecting data r/t desired outcomes; judge whether goals/outcomes have been achieved; relate nsg actions to pt goals/outcomes; review/modify/terminate pt care plan; document achievements/modifications of pt care plan

A

evaluating

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15
Q

This type of assessment is performed within specified time after admission and establishes a complete database for problem identification, reference, and future comparison

A

initial assessment (e.g. nsg admission assessment)

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16
Q

This type of nsg assessment is an ongoing process integrated w/nsg care which determines the status of a specific problem identified in an earlier assessment

A

problem-focused assessment (e.g. pt’s fluid intake and urinary output)

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17
Q

This type of nsg assessment is done during any physiological or psychological crisis of the pt which identifies life-threatening problems or any problems that are new or overlooked

A

emergency assessment (e.g. rapid assessment of pt’s airway, cardiac arrest, suicidal tendencies)

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18
Q

This type of nsg assessment is done several months after initial assessment to compare the pt’s current status to baseline data

A

time-lapsed assessment (e.g. reassessment of pt’s functional health patterns in a home care setting, OH, shift change)

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19
Q

A _________ contains all info about pt including nsg health hx, P&H, labs and dx tests…

A

database

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20
Q

Data that’s referred to as symptoms/covert apparent only to the person affected such as pt’s sensations, feelings, beliefs, attitudes, and perceptions of personal health is what type of data collected by the nsg?

A

subjective data

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21
Q

Data that’s referred to as signs/overt detectable to the nsg that can be measured, seen, heard, felt, smelled during observation or physical examination is what type of data collected by the nsg?

A

objective data

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22
Q

What are the definitions of primary and secondary sources of data?

A

Primary data is the pt whereas secondary data are family members, support persons, other health professionals, records or reports and so on.

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23
Q

Biographical data, chief complaint, hx of present illness, past hx, family hx, lifestyle, social data, psychological data, and patterns of health care are all components of what?

A

Nsg health history

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24
Q

A interview that’s highly structured and elicits specific info where the nsg controls the interview so that the pt will respond to questions but has limited opportunity to ask/discuss questions/concern (e.g. initiated when there’s limited amount of time or in an emergency)

A

directive interview

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25
Q

This type of interview is where the pt has control of the purpose, subject matter, and pacing of the interview (e.g., where rapport, an understanding between two or more people, is built)

A

nondirective interview

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26
Q

A type of questioning used in a directive interview generally requiring “yes” or “no” or factual answers (e.g., used when info is needed quickly, “do you have any allergies to medication?”)

A

closed questioning

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27
Q

A type of questioning used during a nondirective interview to invite the pt to elaborate, explore, clarify their thoughts or feelings (e.g., invites answers longer than one or two words like: How have you been feeling lately?)

A

open-ended questions

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28
Q

A type of questioning where the pt can answer the nsg w/o added pressure; used in nondirective interviews and are open-ended (e.g., How do you feel about that?)

A

neutral question

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29
Q

A type of questioning that directs the pt’s answer; used in directive interview with close-ended questions (e.g., you’re stressed about the surgery tomorrow, aren’t you?)

A

leading question

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30
Q

The opening. the body, and the closing are three stages of what and which stage is can be the most important?

A

The opening, body, and the closing are all stages of an interview. The opening can be the most important part of the interview as it sets the tone for the remainder of the interview.

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31
Q

What stage of the interview is where rapport is established and orientation of the interview purpose is explained?

A

opening stage of the interview

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32
Q

What stage of the interview is where the pt communicates what he or she thinks, feels, knows, and perceives in response to the questions from the nsg?

A

Body stage of the interview

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33
Q

What stage of the interview is where the nurse terminates the interview when info is obtained, and for maintaing rapport and trust for facilitating future interactions?

A

closing stage of the interview

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34
Q

Subjective or objective data that can be directly observed by the nsg fall under _______ that can be validated.

A

cues

35
Q

The nsg’s interpretation or conclusions made on what can be validated based on cues are ________.

A

inferences

36
Q

In order to collect data accurately, what do nsg need to be aware of?

A

Nsg need to be aware of their own biases, values, beliefs, and separate fact from inference/interpretation/assumption in order to accurately collect data.

37
Q

Which of the following behaviors is most representative of the nsg diagnosis phase of the nsg process? 1: Identifying major problems or needs 2: Organizing data in the pt’s history 3: establishing short/long-term goals 4: administrating an antibiotic

A

1: identifying prob/needs is part of nsg dx

38
Q

Which of the following behaviors would indicate that the nsg was utilizing the assessment phase of the nsg process? 1: Proposes hypothesis 2: Generate desired outcomes 3: Reviews results of laboratory tests 4: Documents care

A

3: during assessment, data is collected/organized/validated/ and documented. Hypothesis are generated during dx, outcomes during planning, documentation occurs throughout the nsg process

39
Q

Which of the following elements is best categorized as secondary subjective data? 1: The nsg measures a weight loss of ten lbs since the last clinic visit 2: Spouse states the pt has lost all appetite 3: Nsg palpates edema in LE 4: Pt states severe pain when walking up stairs

A

2: Primary data comes form the pt, whereas secondary data comes from everywhere else

40
Q

The nsg wishes to determine the pt’s feelings about a recent dx. Which interview question is most likely to elicit this info? 1: “what did your doctor tell you about your dx?” 2: “Are you worried about how the dx will affect you in the future?” 3: “Tell me about your reactions to the dx?” 4: “How’s your family responding to the dx?”

A

3: Eliciting feelings requires open-ended question that does more than seek factual info

41
Q

The use of a conceptual or theoretical framework for collecting and organizing assessment data ensures which of the following? 1: Correlation of the data with other members of the health team 2: Demonstration of cost-effective care 3: Utilization of creativity and intuition in creating a care plan 4: Collection of all necessary info for a thorough apprasial

A

4: Frameworks help the nsg be systemic in data collection.

42
Q

Which of the following is the purpose of assessing? 1: Establish a database of pt responses to health status 2: Identify pt strengths and problems 3: Develop an individualized plan of care 4: Implement care, prevent illness, and promote wellness

A

1: assessing provides the database of the pt’s physiological/psychological responses to health status

43
Q

In the validating activity of the assessing phase of the nsg process, the nsg preforms which of the following? 1: collects subjective data 2: applies a framework to the collected data 3: confirms data is complete and accurate 4: records data in the pt’s record

A

3: In validating, the nsg confirms that the data is complete and accurate. Subjective data is collected in the collecting activity, a framework is applied to data in the organizing activity, and data is recorded in the documentation activity

44
Q

A major characteristic of the nsg process is which of the following? 1: A focus on pt needs 2: its static nature 3: an emphasis on physiology and illness 4: it’s exclusive use with nsg

A

1: The nsg process focuses on pt needs. It is dynamic rather than static.

45
Q

Which of the following is true regarding use of the observing method of data collection? 1: When observing, the nsg uses only visual sense 2: Observing is done only when no other nsg interventions are being preformed at the same time 3: Data should be gathered as it occurs, rather than in any particular order 4: Observed data should be interpreted in relation to other sources of collected data

A

4: Interpreting collected data is necessary to help validate its accuracy.

46
Q

Which of the following represent effective planning of the interview setting? Select all that apply: 1: keep the lighting deemed so as to not stressed the pt’s eyes 2: ensure that no one can overhear the interview 3: Stand near the pt’s head while the pt’s in bed/chair 4: Keep approx 3 ft away from the pt during the interview 5: Use a standard form to be sure all relevant data are covered in the interview

A

2, 4, 5: The nsg plans the interview so privacy is observed. A comfortable distance between nsg and pt to respect pt’s personal space of about 3 ft. Using a standard form wil ensure all data is collected. Lightning shold be normal level, nsg should be at dame height with pt, usually sitting at 45 degree angle facing the pt.

47
Q

The first step to determining health status is what of the nsg process?

A

assessment

48
Q

The accuracy, efficiency, effectiveness, and safety of all other steps of the nsg process depends on what?

A

the accurate collection of relevant and comprehensive assessment data

49
Q

How many phases are there in the assessment part of the nsg process?

A

1) Collecting data; 2) Cues & inferences; 3) validating data; 3) Clustering-data; 4) identifying patterns and testing impressions; 6) Reporting and recording data

50
Q

The things that you should find out first in all pt encounters during an assessment is categorized/defined as:

A

QPA (quick priority assessment)

51
Q

What are some Assessment priorities of QPA

A

Risks for problems/injuries; allergies; current meds; PMH

52
Q

This type of assessment is the comprehensive info gathered on initial contact:

A

data base assessment (easily found as in put in a computer)

53
Q

This type of assessment is info that’s gathered to determine the specific type of condition:

A

focused assessment

54
Q

A type of assessment that’s short, focused, prioritized that’s done to gain the most important of info needed in the planning of care for a pt:

A

quick priority assessment (QPA)

55
Q

An SBAR is an example of what type of assessment?

A

QPA

56
Q

S in the SBAR stands for:

A

situation

57
Q

B in SBAR stands for:

A

background

58
Q

A in SBAR stands for:

A

assessment

59
Q

R in SBAR stands for:

A

recommendation

60
Q

How are you feeling today, what did you have for dinner, what type of pain do you have are all examples of what type of questioning?

A

open-ended

61
Q

How do you clarify communication with a pt?

A

Use reflective statements by restating what I hear and use open-ended questions

62
Q

What term is a statement or conclusion regarding the nature of a phenomenon:

A

diagnosis

63
Q

The standardized NANDA names for the diagnosis are called:

A

diagnostic labels

64
Q

What term is the casual relationship between a problem and its related or risk factors:

A

etiology

65
Q

Combined, the diagnostic label and etiology is known as the:

A

nursing diagnosis

66
Q

A clinical judgement about individual, family, or community responses to actual and potential health problems/life processes that provides a basis of selecting interventions to achieve outcomes is known as the:

A

The nursing dx

67
Q

What are the status of nsg dx:

A

1) actual dx, 2) health promotion dx, 3)risk nsg dx, 4) wellness dx

68
Q

Which status of nsg dx describes pt responses to levels of wellness in an individual, family, or community is:

A

Wellness dx (e.g., readiness for enhanced family coping)

69
Q

Which status of nsg dx is a clinical judgment that a problem does not exist, but the presence of risk factors indicates that a problem is likely to develop unless nsg intervenes:

A

Risk-nsg dx (e.g., a pt w/DM has a higher risk of infection in a hospital than a pt w/o DM)

70
Q

Which status of nsg dx relates to the pts’ preparedness to implement behaviors to improve their health condition:

A

health promotion dx (e.g., dx labels that begin w/readiness for enhanced nutrition)

71
Q

Which status of nsg dx focuses on a pt’s actual problem that is present at the time of the nsg assessment:

A

actual dx (e.g., ineffective breathing pattern and anxiety)

72
Q

What are the three components of a nsg dx:

A

1=the problem w/its definition, 2=etiology, 3=defining characteristics

73
Q

What part of the nsg dx describes in a few words the pt’s health problem or response for which nursing therapy is given:

A

Diagnostic label/problem

74
Q

What part of the nsg dx identifies one or more probable causes of the health problem, gives direction to the desired nsg therapy, and enables the nsg to individualize the pt’s care:

A

etiology

75
Q

What pat of the nsg dx are the cluster of S/S that indicate the presence of a particular diagnostic label and what are the differences between actual dx and risk nsg dx:

A

defining characteristics; actual dx=pt’s S/S and risk-nsg dx=no objective or subjective data is present

76
Q

Which changes most often: nsg dx or medical dx?

A

nsg dx due to pt’s response changing whereas medical dx stays the same as long as the disease process is present

77
Q

What are the 4 types of nsg dx:

A

Actual dx; health promotion; risk nsg dx; wellness dx

78
Q

What is used in a two-part nsg dx:

A

(PE) problem and etiology (r/t) (e.g., constipation r/t anxiety)

79
Q

What is used in a three-part dx:

A

(PES) problem, etiology, and S/S (used for beginning a dx before doing ADPIE)

80
Q

How many parts are there in a wellness/syndrome dx:

A

one part statement (readiness for enhanced…)

81
Q

What are the 4 types of nsg dx:

A

Actual dx; health promotion; risk nsg dx; wellness dx

82
Q

What is used in a two-part nsg dx:

A

(PE) problem and etiology (r/t) (e.g., constipation r/t anxiety)

83
Q

What is used in a three-part dx:

A

(PES) problem, etiology, and S/S (used for beginning a dx before doing ADPIE)

84
Q

How many parts are there in a wellness/syndrome dx:

A

one part statement (readiness for enhanced…)

Health Assessment (13 decks)

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