Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

NUR102 > chapter 12 > Flashcards

chapter 12 Flashcards

1
Q

First phase of the nursing process in which data are gathered to identify actual or potential health problems is called?

A

assessment

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

pieces of data, subjective or objective, about a patient are?

A

cues

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

observable, measurable information that can be validated or verified is?

A

objective data

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

symptoms or covert cues that include the patients feelings and statements about his or her health problems is?

A

subjective data

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

assessment is done for the following reasons:

A
  • to establish baseline information on the patient
  • to determine the patients normal function
  • to determine the patients risk for dysfunction
  • to determine the presence or absence of dysfunction
  • to determine the patients strengths
  • to provide data for the diagnosis phase
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What activités make up the assessment phase?

A
  • collection of data
  • validation of data
  • organization of data
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What is the phases of the nursing process in order?

A

Assessment > Diagnosis > Outcome identification > Planning > Implementation > Evaluation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What are the four types of assessment?

A
  • admission assessment
  • focus assessment
  • time- lapse reassessment
  • emergency assessment
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Admission assessment
AIM:
TIME FRAME:

A

AIM: initial id of normal function, functional status, and collecting of data concerning actual or potential dysfunction, baseline for reference and future comparison.

TIME FRAME: Within the specified time frame after admission to a hospital, skilled nursing facility, ambulatory health care center, or home healthcare setting

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Focus assessment:
AIM:
TIME FRAME:

A

AIM: Status determination of a specific problem identified during previous health assessment

TIME FRAME: Ongoing process; integrated with nursing care; a few minutes to a few hours between assessments

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Time-lapse reassessment:
AIM:
TIME FRAME:

A

AIM: Comparison of the patients current status to baseline obtained previously; detection of changes in all functional areas after an extended period of time has passed

TIME FRAME: Several months (3, 6, or 9 months or more) between assessments

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Emergency assessment:
AIM:
TIME FRAME:

A

AIM: Identification of life threatening situation

TIME FRAME: Any time a physiologic, psychological, or emotional crisis occurs

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

In an emergency assessment setting the patients difficulties are often the ABC’s. What are the ABC’s?

A

airway, breathing, and circulatory problems.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Is an emergency assessment comprehensive?

A

NO

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Nurses use the clinical skills of ______, ______, ______, and intuition to assess patients across the lifespan in various settings.

A

observation, interviewing, physical examination

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

The act of noticing patient cues is?

A

observation

17
Q

The interaction and communication process for gathering data by questioning and information exchange is called?

A

interviewing

18
Q

The analysis of bodily functioning using the techniques or inspections, palpation, percussion, and auscultation is called?

A

physical examination

19
Q

Observation of a patient includes?

A
  • vision
  • smell
  • hearing
  • touch
20
Q

The interview can be divided into four phases what are they?

A
  • preparatory
  • introductory
  • maintenance
  • concluding
21
Q

What is done in the preparatory phase:

A
  • Review as much information as possible about the patient.
  • Decide what data are needed and what type of data collection form will be used.
  • Review the literature pertinent to the patient’s developmental age, psychosocial aspects, and pathophysiologic considerations, if needed.
  • Assess your own feelings or reactions to previous patients that might interfere with the nurse–patient relationship.
  • Seek assistance from more experienced nurses, mentors, or supervisors if concerned about how to carry out the interview.
  • Plan for a private, quiet setting for the interview; schedule a mutually convenient time of day; and determine the length of time needed for data collection.
  • Modify the environment to facilitate the interview.
22
Q

What is done in the introductory phase?

A
  • Introduce yourself by name and position, and explain the purpose and content of the interview.
  • Begin to establish rapport with the patient by conveying a caring, interested attitude; rapport is essential for a trusting, helpful nurse–patient relationship.
  • Observe the patient’s behavior, and listen attentively to determine the patient’s self-perceptions and how the patient views his or her health problems; validate the patient’s perceptions as the interview progresses.
  • Let the patient know how long the interview is expected to last.
  • Inform the patient how the information collected will be used and that confidentiality will be maintained.
  • Start with nonthreatening, specific questions and proceed to open-ended questions.
  • Establish a verbal contract with the patient, incorporating the goals of the interview.
23
Q

What is done in the maintenance phase?

A
  • Keep focused on the tasks or goals to ensure that needed data are obtained and goals are achieved.
  • Encourage the patient to express his or her feelings, concerns, and questions.
  • Use techniques that facilitate communication between the nurse and patient (e.g., silence, general leads, validation).
  • Observe the nonverbal behavior that accompanies verbal responses (e.g., a patient may say she is not nervous, worried, or anxious while biting her fingernails or moving constantly).
  • Assess the patient’s ability to continue the interview (e.g., grimace of pain, shortness of breath, fatigue).
  • Facilitate goal attainment by moving to the next topic of discussion after needed data are collected.
24
Q

What is done in the concluding phase?

A
  • Review goal or task attainment; such a review can foster a sense of achievement in the patient and nurse.
  • Summarize the highlights of the interview and its meaning to the nurse and the patient.
  • Encourage the patient to express and share his or her feelings regarding the termination of the interview.
  • Use language congruent with the patient’s cultural background and local custom (e.g., “goodbye” may mean a final farewell in some cultures; promises to contact the patient in the future may be taken literally).
25
Q

What are the types of data collection?

A

subjective, and objective

26
Q

What is the method of obtaining subjective data?

A

interview

27
Q

What is the method of obtaining objective data?

A 
Inspection
Palpation
Percussion
Auscultation
Measurement devices
Health record
Lab studies
radiologic tests
diagnostic tests

NUR102 (12 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions