Brainscape's Knowledge GenomeTM

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


See full index

VA > chapters 33-37 & 101-103 > Flashcards

chapters 33-37 & 101-103 Flashcards

0
Q

The systematic method in which the nurse and client work together to plan and carry out effective nursing care (steps include assessment, nursing diagnosis, planning, implementation, and evaluation)

A

Nursing process

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

An experimental approach that test ideas to decide which methods work and which do not.

A

Trial and error

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

The basic skill of identifying a problem and taking steps to resolve it

A

Problem solving

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

Precise method of investigating problems and arriving at solutions

A

Scientific problem solving

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

Mix of inquiry, knowledge, intuition, logic, experience, and common sense.

A

Critical thinking

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

NCP

A

Nursing care plan

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Guidelines used by healthcare facilities to plan the care for clients

A

Nursing care plans

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

The systematic and continuous collection and analysis of data/information about a client

A

Nursing assessment

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

The statement or label of the clients ACTUAL or potential problem

A

Nursing diagnosis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

The development of goals for care and possible activities to meet them

A

Planning

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

The giving of actual nursing care

A

Implementation

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

The measurement of the effectiveness of nursing care

A

Evaluation

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

The nursing process is…

A

Systematic, client oriented, goal oriented, continuous, and dynamic

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

Specific, orderly, and logical steps based on the clients most important and vital needs

A

Prioritization

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

The needs of the client are identified, not the needs of the nurse, family or other healthcare providers

A

Client oriented

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

Goals, objectives, or expected outcomes are established as a part of the nursing process.

A

Goal oriented

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

The nursing process consists of the following steps:

A 
Nursing assessment 
Nursing diagnosis 
Planning
Implementation 
Evaluation
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Nurses and clients work together as partners to…

A

Promote health
Prevent disease/illnesses
Restore health
Facilitate coping with altered functioning

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

In the nursing process, needs which may occur identified as “at risk for”..

A

Potential needs

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

All measurable and observable pieces of information about the client and his or her overall state of health. Only precise, accurate measurements or clear descriptions are used.

A

Objective data

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Clients opinions or feelings about what is happening. Only the client can tell you that he or she is afraid or has pain. Communicating via body language, gestures, facial expressions

A

Subjective data

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Things that you directly see or measure

A

Objective data

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Things the client feels and expresses either verbally or non verbally

A

Subjective data

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

An assessment took that relies on the use of the five senses

A

Observation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

5 senses of observation

A

Visual observation
Tactile observation
Auditory observation
Olfactory or Gustatory Observation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

Way of soliciting information from the client

A

Health interview or nursing history

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

Interview conducted when a client is admitted to a healthcare facility

A

Admission interview

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

Physician obtaining information from an admission interview

A

Medical history

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

Documentation by nurses of care given and observations made, charting data input

A

Nursing progress notes

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

Components of nursing history/health interview

A

Biographical data: name age DOB
Reason for coming to facility: the primary reason or clients chief complain (CC) or perception of illness
Recent health history
Important medical history
Pertinent psychosocial information: addresses family relationships, employment, living condition
Activities of daily living (ADL)- how well client is able to meet basic needs, eating, drinking, bathing etc.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

Analyzing each piece of information to determine it’s relevance to a clients health problems and it’s relationship to other pieces of information

A

Data analysis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

NANDA

A

North American Nursing Diagnosis Association

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

Identifies the disease a person had or is believed to have which provides a basis for prognosis and treatment decisions

A

Medical Diagnosis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

Projected client outcome

A medical diagnosis provides a basis for this and medical treatment decisions

A

Prognosis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

Three part nursing diagnostic statement

A

Problem, etiology, signs and symptoms (airway clearance, excessive mucus, wheezes)

Problem, cause, symptoms

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

Portion of nursing diagnostic statement that describes clearly the problem the client is having

A

Problem

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
36
Q

The part of the nursing diagnostic statement that is the cause of the problem

A

Etiology

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
37
Q

The third part of the nursing diagnostic statement that summarizes all the data (how the client feels)

A

Signs and symptoms

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
38
Q

AEB

A

As evidenced by

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
39
Q

You will work together with the physician or the healthcare providers

A

Collaborative problem

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
40
Q

PRN

A

As needed

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
41
Q

The nursing diagnosis is a statement about the clients actual or potential health concerns that can be managed through:

A

Independent nursing interventions by establishing data and writing a 2-3 part diagnostic statement

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
42
Q

The development of goals to prevent, reduce, or eliminate problems and to identify nursing interventions that will assist clients in meeting these goals

A

Planning

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
43
Q

A measurable client behavior that indicates whether the person has achieved the expected benefit of nursing care, may also be called goal or objective.

A

Expected outcome

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
44
Q

Expected outcome includes:

A

Client oriented, specific, reasonable, measurable

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
45
Q

An expected outcome it goal that a client can reasonably meet in a matter of hours or a few days

A

Short term objective

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
46
Q

Outcome that the client ultimately hopes to achieve but which requires a longer period of time to accomplish

A

Long term objective

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
47
Q

Activities (actively doing something) that will most likely produce desired outcomes (short term/long term)

Ex: teaching client deep breathe exercises, offering fluids frequently.

A

Nursing intervention

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
48
Q

The entire nursing team usually formulated the nursing care plan at a meeting called…

A

The nursing care conference or team conference

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
49
Q

Nursing care plan must exist within how many hours?

A

12-24 hours

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
50
Q

Steps in Planning are:

A

Setting priorities
Establishing expected outcomes
Selecting nursing interventions
Writing a nursing care plan

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
51
Q

The carrying out of nursing care plans, also called interventions •just do it•

A

Implementation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
52
Q

Nursing implementation performs 3 actions…

A

Dependent actions
Interdependent actions
Independent actions

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
53
Q

Actions that carry out a physicians orders regarding medication or treatments (MD/physicians requires)

A

Dependent actions

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
54
Q

Perform collaborative with other care providers. Interventions for collaborative problems.

Ex: a physician writes an order to give a client an enema when necessary, the nurse uses their best judgement to determine when client needs enema

A

Interdependent action

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
55
Q

Nursing actions that do not require a physicians orders based on the nurses judgement (bathing, toileting)

A

Independent actions

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
56
Q

A legal requirement in nursing practice in which you the nurse are responsible for all your actions you perform, whether they are dependent, interdependent, independent.

A

Accountability

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
57
Q

Knowing and understanding essential information before caring for clients (critical thinking is an example)

A

Intellectual skills

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
58
Q

Believing, behaving, and relating to others

A

Interpersonal skills

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
59
Q

Changing a sterile dressing or administering an injection is what kind of skill?

A

Technical skills

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
60
Q

Nursing implementation means the carrying out of the nursing care plan which includes 4 steps:

A

Putting the nursing care plan into action
Continuing the collection of data
Communicating care with the healthcare team
Document care

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
61
Q

Communication with the health care team

A

Client planning conference

Or discharge planning conference (if client is being discharged)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
62
Q

Measuring the effectiveness of assessing, diagnosing, planning, and implementing.

A

Evaluation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
63
Q

Steps in evaluation for nursing care

A

Analyzing the clients responses
Identifying factors contributing to success or failure
Planning for future care (discharge planning)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
64
Q

3 means to evaluate the effectiveness of nursing care

A

the client
Team conference
Community health agencies

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
65
Q

The process by which the client is prepared for continued care outside the healthcare facility or for independent living at home

A

Discharge planning

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
66
Q

Manual or electronic account of a clients relationship with a healthcare facility

A

Health record

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
67
Q

Accurate and complete documentation in a clients health record is an essential communication tool because…

A

Maintains communication among all caregivers
Provides written evidence of accountability
Meets legal, regulatory, and financial requirements
Provides data for research and educational purposes

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
68
Q

Health record that supports the healthcare agency and providers have acted responsibly and effectively

A

Documented evidence

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
69
Q

If it was not documented…

A

It was NEVER done

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
70
Q

Standards of care (regulatory requirements for document keeping)

A

Record keeping
Providing safe and effective healthcare and verifying it through QA
Complete and accurate healthcare records

71
Q

Financial accountability (health record)

A

Clients and third party payers depend on complete list of services and products provided before paying for healthcare. All treatments must be given, examinations, and special
Equipments used and recorded in health care records

72
Q

Electronic documents found in a computer network

A

Medical information system - MIS

Electronic medical records - EMRS

73
Q

Collection of various forms and documents (binder, notebook in nurses station or main administration office)

A

Manual health record

74
Q

Documentation systems include -

A

EMR, MIS, or manual record/binder notebook

75
Q

Health records contain four categories:

A

Assessment documents
Plans for care and treatment
Progress records
Plans of continuity of care

76
Q

Documents that record all information about the client obtained through interview, examination, diagnostic procedures, or consultation.

A

Assessment documents

77
Q

Long term care and some home cares use a standard form as part of the admitting nursing history / measures a clients ability to perform the activities of daily living and identifies functional losses that affect this ability

A

Minimum data set (MDS)

Resident assessment protocol (RAP)

78
Q

Purpose for the plans of care

A

To ensure that all caregivers provide the same care and treatments for the client

79
Q

The development of planning care used both

A

LPN/LVN and RNs

80
Q

The physicians plan of care contains goals for treating the client and specific instructions to guide the nursing staff

A

Orders

81
Q

A plan that specifies expected outcomes and treatments at specified times for all members of the healthcare team

A

Clinical care path

82
Q 
Establish a baseline of data 
Enter data at regular intervals 
Summarize the clients condition 
Document changes in clients condition 
Document a response to treatment.
A

Progress notes

83
Q

Demonstrates how the nursing process and diagnoses are used to create collaboration and consistency for client care

A

NANDA-I

North American nursing diagnosis association international

84
Q

Narrative- Chronological

Summarizes the progress of the client toward achieving his or her care plan goals

A

Progress or nurses notes

85
Q

Type of nurses note that essentially documents what is occurring throughout the day in a chronological manner.

A

Narrative charting

86
Q

Body system assessment starting with general observation, than assessments of the neurological, integumentary, cardiovascular, gastrointestinal, and genitourinary systems.

A

Head to toe charting

87
Q

Type of charting used to focus on specific problems

A

Focus charting or area charting

88
Q

The whole healthcare team works collaboratively to identify priority problems and they work collectively to solve these problems

A

Problem-oriented medical records (POMR)

89
Q

Type of charting: SOAP

A

Subjective
Objective
Assessment/Analysis
Plan

90
Q

SOAPIER

A 
Subjective 
Objective 
Assessment/analysis 
Plan 
Intervention 
Evaluation 
Revision
91
Q

APIE

A

Assessment
Plan
Intervention
Evaluation

92
Q

Seperate notes by physicians, nurses, dietary, healthcare team members used as specific forms for a particular field

A

Documentation by discipline

93
Q

Type of narrative charting that usually used a flow sheet listing body systems and their typical findings, such as lung sounds: clear, crackles, or rhonchi. The nurse checks off the correct assessment findings on a sheet

A

Charting by exception - CBE

94
Q

This type of narrative charting would be best for a client who is physically stable with an uncomplicated care plan

A

Charting by exception : CBE

95
Q

Emphasis is on quality care that is delivered in the most cost effective manner - also known as case studies, care mapping, critical pathway, and collaborative pathways

A

Case management

96
Q

A graph, form, or picture that records large amounts of information collected at intervals over a specified period in brief concise entries

A

Graphic flow chart

97
Q

Lists all medications that the physician has ordered for the client, with spaces for the caregiver to mark when medications are given

A

Medication administration record : MAR

98
Q

Graphic flow sheet include:

A

Vital signs, intake and output, ADLs, dietary or eating patterns, neurological checks, restraint observation and documentation, frequent blood sugar monitoring, postoperative records, wound care and monitoring

99
Q

Skills in documentation

A 
Document what you see 
Be specific 
Use direct quotes 
Be prompt 
Be consistent 
Record all relevant information 
Respect confidentiality 
Record documented errors
100
Q

Error in documenting/ Recorded in error - RIE

A

Draw a line through the statement, enclose in parenthesis and write ERROR and your initials next to it. Original note must be readable.

(mistaken entry)

101
Q

AC

A

Before meals

102
Q

ABG

A

Arterial blood gas

103
Q

Ad lib

A

As desired

At liberty

104
Q

AEB

A

As evidenced by

105
Q

AMB

A

As manifested by

106
Q

AMA

A

Against medical advice

107
Q

Amb

A

Ambulate

108
Q

BM

A

Bowel movement

109
Q

BID

A

Twice per day

110
Q

BRP

A

Bathroom privileges

111
Q

Cc

A

Chief complaint

112
Q

C/o

A

Complains of

113
Q

CPR

A

Cardiopulmonary resuscitation

114
Q

DNR

A

Do not resuscitate

115
Q

DSG

A

Dressing

116
Q

Dx

A

Diagnosis

117
Q

FOB

A

Foot of bed

118
Q

Fx

A

Fracture

119
Q

Gtt

A

Drops

120
Q

H or hr

A

Hour

121
Q

HOB

A

Head of bed

122
Q

Hx

A

History

123
Q

I&O

A

Intake and output

124
Q

IM

A

Intramuscular

125
Q

IV

A

Intravenous

126
Q

KVO, TKO

A

Keep vein open, to keep open

127
Q

L

A

Left

128
Q

L

A

Liter

129
Q

LMP

A

Last menstrual period

130
Q

MEq

A

Milliequivalent’s

131
Q

NG

A

Nasogastric

132
Q

NKA

A

No known allergies

133
Q

Npo

A

Nothing by mouth

134
Q

NS

A

Normal saline

135
Q

N/V or N/V/D

A

Nausea and vomiting ; nausea, vomiting, diarrhea

136
Q

O

A

Oral

137
Q

PC

A

After meals

138
Q

PO

A

By mouth

139
Q

PR

A

Per rectum

140
Q

Pulse ox

A

Pulse oximetry

141
Q

Q, q

A

Every

142
Q

Qh

A

Every hour

143
Q

R, r

A

Respiration, rectum

144
Q

rt

A

Right

145
Q

S/P, s/p

A

Status post, after

146
Q

STAT

A

Immediately

147
Q

Subq

A

Subcutaneous

148
Q

Supp

A

Suppository

149
Q

Susp

A

Suspension

150
Q

S&S

A

Signs and symptoms

151
Q

Sx

A

Symptoms

152
Q

TF

A

Tube feeding

153
Q

TPN

A

Total parenteral nutrition

154
Q

TPR

A

Temperature, pulse, respiration

155
Q

TX, Tx

A

Treatment

156
Q

VS

A

Vital signs

157
Q

ROM

A

Range of motion

158
Q

Caregivers move from client to client discussing important information

A

Walking rounds

216
Q

Exchanging of information between the outgoing and incoming staff on each shift given verbally in person, in writing, or by tape recorder

A

Change of shift reporting

217
Q

CAT

A

Computer adaptive test

218
Q

The LPN does not perform nursing assessment per se and does independently develop nursing care plan

A

Good fact

219
Q

The four phases of nursing process associate a to NCLEX-PN examination include:

A

Data collection
Planning
Implementation.
Evaluation

220
Q

CLTC

A

Certified in long term care for lpns

221
Q

A person who used specific skills such as role modeling

A

Leader

222
Q

Coordinates and controls the work of others

A

Manager

223
Q

Behavior used by a leader in a specific situation

A

Leadership style

224
Q

Leader makes decisions and the group is expected to carry out orders (dictatorship)

A

Autocratic leadership

225
Q

Leadership that relies on policies and procedure manual of the healthcare facility

A

Bureaucratic leadership

226
Q

Guiding staff in the right direction by using a free flow of ideas, plans, and information between leaders and followers

A

Democratic leadership

227
Q

Loosely structured goals with no firm guidelines, encourages followers to choose their own goals and plans to implement. Trying new things without fear of mistakes

A

Laissez- faire leadership

228
Q

Writing summary evaluations of staff members (charge nurse writes this)

A

Performance reviews

229
Q

First step if employee is showing deficiencies in due process

A

Oral reprimand p

230
Q

If deficiency continues after oral reprimand… The second process is

A

Written reprimand

231
Q

Procedure that ensures fair labor practices for employees and employers

A

Due process

232
Q

A plan made for an employee who has not followed or improved deficiency after being orally and written reprimand

A

Plan of assistance

VA (1 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2025 Bold Learning Solutions. Terms and Conditions