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health assessment Test 1 > chapter 1 * > Flashcards

chapter 1 * Flashcards

1
Q

AIDET stands for

A

acknowledge, introduce, duration,explain, thank you

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2
Q

A IN AIDET examples would be

A

knock, ask for and wait until permission given to enter, address patient and family by name. make eye contact, assess/fix, ask is there anything I can do for you before I leave.

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3
Q

I in AIDET examples would be

A

introduce yourself, your role, skill set, manage up others positively

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4
Q

D in AIDET examples would be

A

under promise over deliver, give them a time expectation that will absolutely be met, thinking of the patient perception of how long something will take always keep your promise

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5
Q

E in AIDET examples would be

A

explain step-by step what will happen next. give explanation of purpose “why” ask patient and family if they have any questions

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6
Q

T in AIDET examples would be

A

thank the patient for communication cooperation check is there anything else you can do before you leave.

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7
Q

SOAP stands for

A

Subjective data, Objective data, Assessment, and Planning.

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8
Q

Give an example of S in SOAP.

A

Subjective data

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9
Q

Give an example of O in SOAP.

A

Objective data are derived from the physical assessment, client records, and reports.

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10
Q

SBAR stands for

A

S situation B background A assessment R recommendation

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11
Q

Healthy People 2020 topics are:

A

physical activity, nutrition, tobacco use, alcohol and substance abuse, sexual and reproductive health, mental health, injury and violence prevention, occupational safety and health, environmental health, oral health, emerging issues, preventive services

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12
Q

Give an example of A in SOAP.

A

Assessment refers to conclusion drawn from the date.

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13
Q

Give an example of P in SOAP.

A

Planning indicates the actions to be taken to resolve problems or address client needs.

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14
Q

The letters APIE refers to

A

Assessment, Problems, Intervention, and Evaluation.

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15
Q

definition of Evidence Based Practice

A

an approach to decision making, intervention, and nursing care that requires integration of clinical expertise with the best evidence from systematic research and regard for the concerns and choices of the client

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16
Q

(abd) is the standard abbreviation for

A

Abdomen

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17
Q

(ADL) is the standard abbreviation for

A

Activities of daily living.

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18
Q

absence of disease is

A

health

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19
Q

WHO defines health as

A

a state of complete physical, mental,and social well-being. this is a holistic approach

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20
Q

health assessment is defined as

A

a systemic method of collecting data about a client for the purpose of determining the client’s current and on going health status, predicting risks to health and identifying health promoting activities

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21
Q

what is a systematic method of collecting data

A

health assessment

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22
Q

does the interview use objective data?

A

no, subjective

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23
Q

define interview

A

subjective data is gathered that includes health history and focused interview. data comes from primary and secondary sources

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24
Q

during the interview where does the information come from?

A

primary and secondary sources

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25
Q

what is subjective data?

A

information that the client experiences and communicates to the nurse.

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26
Q

what are 5 examples of subjective data?

A
  1. pain
  2. dizziness
  3. nausea
  4. itching sensation
  5. feeling nervous
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27
Q

is pain subjective or objective data

A

subjective

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28
Q

what is included in the health history

A

biographic data, perceptions about health, past and present history about illness or injury, family history, health patterns, and practices

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29
Q

what does the focused interview allow the nurse to do?

A

clarify points, obtain missing info, and follow up on cues

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30
Q

a hands on examination of the client is

A

physical assessment

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31
Q

what is objective data?

A

observed or measured by the professional nurse.

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32
Q

Give some examples of objective data

A

seen, felt, heard or measured by the nurse

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33
Q

Past documentation, charts, diagnostic reports or lab testing is all what type of data?

A

Secondary sources that are objective

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34
Q

Define client record

A

legal document used to plan care, communicate information between and among health care providers and to monitor quality of care

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35
Q

5 things a document must be is

A
  1. accurate
  2. confidential
  3. appropriate
  4. complete
  5. detailed
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36
Q

BP

A

blood pressure

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37
Q

CBC

A

complete blood count

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38
Q

CNS

A

Central Nervous System

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39
Q

CVA

A

Costovertebral angle

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40
Q

Dx

A

Diagnosis

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41
Q

Ht

A

height

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42
Q

Hx

A

History

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43
Q

LMP

A

last menstrual period

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44
Q

mg

A

milligram

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45
Q

P

A

pulse

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46
Q

RR

A

respirations rate

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47
Q

T

A

temperture

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48
Q

VS

A

vital signs

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49
Q

WBC

A

white blood cell

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50
Q

Wt

A

Weight

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51
Q

Confidentiality means?

A

that information sharing is limited to those directly involved in client care

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52
Q

Anterior (ventral)

A

Toward the front

53
Q

Cephalad

A

toward the head

54
Q

Distal

A

farthest from the center or medial line

55
Q

Deep

A

below the surface

56
Q

Extenal

A

outside of

57
Q

Medial

A

closer to the midline

58
Q

Superior

A

upper

59
Q

supine

A

face up

60
Q

Posterior (dorsal)

A

toward the back

61
Q

Caudad

A

toward the feet

62
Q

Proximal

A

closet to the center or a medial line

63
Q

Superficial

A

on or above the surface

64
Q

Internal

A

inside of

65
Q

Lateral

A

inside of

66
Q

inferior

A

lower

67
Q

Prone

A

face down

68
Q

Interpretation of findings can be defined as?

A

making determinations about all of the data collected in health assessment process

69
Q

Communication refers to

A

the exchange of information, feelings, thoughts, and ideas

70
Q

Communication occurs through ____ means and ____ methods?

A

nonverbal means and verbal methods

71
Q

Examples of nonverbal means are

A

facial expression, gestures, and body languages

72
Q

Examples of verbal methods are

A

spoken or written communication

73
Q

Holism can best be described as?

A

the overall factors that affected physical, spritrual and emotional well being

74
Q

The interpretation of findings include 8 things that are:

A
  1. knowledge 2. communication 3. holistic approach 4. developmental factors 5. psychologic and emotional factors 6. family factors 7. cultural factors 8. environmental factors
75
Q

Examples of internal environmental factors

A

emotional state, response to medication and treatment and physiologic or anatomic alterations

76
Q

External environmental factors examples are

A

inhaled toxins, irritants, noise light motion

77
Q

The nursing process is a _____, ___, _____ and _____ process used by the nurse for planning and providing care for the client

A

systematic, rational, dynamic and cyclic

78
Q

5 steps of the nursing process are

A

assessment, diagnosis, planning, implementation and evaluation

79
Q

What type of approach is the nursing process

A

client centered

80
Q

Step 1 of the nursing process is

A

assessment

81
Q

Assessment is:

A

the collection, organization and validation of subjective and objective data

82
Q

What type of data is collected during the assessment step?

A

subjective and objective data

83
Q

Step 2 of the nursing process is

A

Diagnosis

84
Q

What is the basis for planning and implementing nursing care?

A

nursing diagnosis

85
Q

3 types of nursing diagnoses are identified by NANDA. They are

A

actual problems, risk for problems and wellness issues

86
Q

what are the 4 components of the NANDA diagnosis

A

diagnostic label, definition, defining characteristics and risks or related factors

87
Q

How are NANDA diagnoses formulated?

A

Using the PES statement

88
Q

PES stands for (in the NANDA diagnoses)

A

P is the problem , E the Etiology, S signs and symptoms

89
Q

step 3 of the nursing process is

A

Planning

90
Q

3 parts of the planning process are

A
  1. setting priorities 2. stating client goals, and 3. selecting strategies to address the diagnoses
91
Q

The nurse uses the diagnostic statements to develop ______ and _______.

A

goals and interventions

92
Q

The goal is stated in terms of ________ includes a _____ ______, and is derived from the _____ part of the diagnosis

A

the expected client outcomes includes a time frame and is derived from the first part of the diagnosis

93
Q

Step 4 is what of the nursing process

A

Implementation

94
Q

what happens in the implementation phase of the process

A

the care plan is put into action

95
Q

Step 5 of the nursing process is

A

Evaluation

96
Q

Evaluation refers to

A

if the goal has been achieved within the stated time frame

97
Q

Critical thinking is a ___ skill

A

cognitive skill

98
Q

Define critical thinking

A

a process of purposeful and creative thinking about resolutions of problems or the development of ways to manage situations.

99
Q

Critical thinking is more than ____ _____; it is a way to apply _____ and cognitive skills to the complexities of client care.

A

problem solving, it is a way to apply logic

100
Q

5 essential elements of critical thinking are

A

collection of information, analysis of the situation, generation of alternatives, selection of alternatives and evaluation

101
Q

what is the first of the 5 essential elements in critical thinking

A

collection of information

102
Q

what does collection of information involve (5)

A
  1. identifying assumptions, 2. organizing data collection, 3. determining the reliability of the data,4. identifying relevant vs. irrelevant data, and 5. identifying inconsistencies in the data
103
Q

the second skill of collection of information is?

A

data collection

104
Q

Data collection involves both ____ and ____ data

A

subjective and objective data

105
Q

The third skill of collection of information is

A

determining the reliability of the data

106
Q

what is the best source of information especially historic for information

A

the client

107
Q

What is the fourth critical thinking skill

A

determine the relevance of the information in relation to the client’s current, evolving or potential condition or situation

108
Q

What is the fifth skill of the collection of information assessment

A

identifying inconsistencies is the last skill

109
Q

What is the second element of critical thinking

A

analysis of the situation

110
Q

what 5 skills are linked to the second element of critical thinking

A
  1. distinguish data as normal or abnormal, 2. cluster related 3. identify patterns in the data 4. identify missing information 5. draw valid conclusions
111
Q

what is alopeia

A

hair loss

112
Q

when critically thinking the nurse will cluster information by sorting and categorizing information into groupings. These techniques are:

A

cue, symptoms, body systems or health practices

113
Q

what are the two skills associated with critical thinking in regards to element of generations of alternatives

A

articulating options and establishing priorities

114
Q

what are the two skills associated with critical thinking in regards to selection of alternatives

A

articulate options and establish priorities

115
Q

the last element of critical thinking is

A

evaluation

116
Q

what are the two types of teaching

A

informal teaching and formal teaching

117
Q

what are the three conditions represent the three types of nursing diagnoses in the NANDA taxonomy

A

teaching that occurs as a natural part of a client encounter.

118
Q

define informal teaching

A

occurs as a natural part of a client encounter. it may be to provide instructions, to explain a question or procedure or to reduce anxiety

119
Q

Define formal teaching

A

occurs in response to an identified lecturing need of an individual or group or community. Teaching plans are part of the formal process

120
Q

what are the 6 parts of the teaching plan

A

the identified learning need, the goal, objectives, content, teaching strategies and rationales, and evaluation

121
Q

what are some cognitive verbs

A

apprasies, changes, composes, concludes, converts, creates, criticizes, defines, designs, diagrams, discriminates, explains, generates, matches, modifies, names, reorganizes, separates, solves, states, subdivision, summarizes

122
Q

what are some affective verbs

A

acts, adheres, describes, discusses, displays, explains, greets, justifies, modifies, presents, proposes

123
Q

what are some psychomotor verbs

A

assembles, calibrates, changes, demonstrates, dismantles, fixes, makes, manipulates, operates

124
Q

what type of teaching methods are cognitive?

A

one-on-one discussion, explanation, lecture, group discussion, case study, role-play, printed material, media audiovisual presentation, computer-assisted instruction

125
Q

what type of teaching methods are affective?

A

one-on-one discussion, group discussion, role-play, media audiovisual presentation, computer-assisted instruction

126
Q

what type of teaching methods are psychomotor?

A

demonstration, practice, media audiovisual presentation, computer-assisted instruction

127
Q

what are the roles of the professional nurse?

A

Teacher,caregiver, nurse researcher, nurse practitioner, clinical nurse specialist, nurse administrator, nurse educator

128
Q

what are the four types of data collected in a patient assessment

A

objective, subjective, reflective and introspective

health assessment Test 1 (10 decks)

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