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N1115 - Trans. to Associates > Exam 1 > Flashcards

Exam 1 Flashcards

1
Q

Systematic way of planning and providing care; involve decision making process, judgement and problem solving

A

The Nursing Process

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2
Q

ADPIE

A 
Assessment
Diagnosis
Planning
Implementation
Evaluation
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3
Q

Level of nursing that is task oriented, rule oriented, inflexible.

Slow, methodical

A

Novice nurse

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4
Q

Level of nursing that is intuition oriented, uses patterns

Fast, fluid.

A

Expert nurse

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5
Q

Part of the nursing process that is systemic, continuously gathering, organizing, and validating date

A

Assessment

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6
Q

TJC requires H&P to be completed with __ hours of admission

A

24

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7
Q

Types of assessment date

A

Objective

Subjective

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8
Q

Types of assessment sources

A

pt
pt significant other
pt records
HCPs

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9
Q

Methods of collecting assessment data

A

Observation
Interview
Examination

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10
Q

The 4 types of nursing diagnosis

A 
actual problem (present issue)
potential problem (risk for)
health promotion (ready to learn)
syndrome (several similar problems)
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11
Q

part of the nursing process that uses assessment data and nursing diagnosis to formulate a goal and design interventions to meet the goal

A

Planning

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12
Q

any treatment based upon clinical judgement and knowledge that a nurse performs to enhance pt/client outcomes

A

nursing intervention

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13
Q

independent interventions

A

license to implement based on our knowledge skills

emotional support, basic care

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14
Q

dependent interventions

A

require an order from a provider

medication administration

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15
Q

collaborative interventions

A

works with other members of healthcare team to carry out

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16
Q

things to keep in mind when choosing a nursing intervention

A 
safe and appropriate
achievable
congruent with client goals
congruent with other therapies
based on nursing knowledge
within scope of practice
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17
Q

Who is responsible for implementing interventions?

A

RN

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18
Q

What must be done after every intervention?

A

Reassess

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19
Q

Key points when implementing interventions

A 
assess before, after
determine need for assistance
base on nursing knowledge
know what you're doing
adapt to pt needs
be safe
teach, support, comfort
holistic
respect dignity
encourage pt participation
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20
Q

What are the 2 modes of communication

A

verbal

nonverbal

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21
Q

erect posture, purposeful steady gait shows ___

A

confidence

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22
Q

slouched posture, slow shuffling gait shows ___

A

depression, discomfort

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23
Q

tense posture, rapid determined gait shows ___

A

anxiety

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24
Q

avert eyes shows ___

A

embarrassment

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25
Q

intimate spacing

A

0-1.5 feet
touching, assessing

we often need to violate the pts personal space for assessments

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26
Q

person spacing

A

1.5-4 feet
more comfortable for conversation, often informal
people tense when someone enters their personal space

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27
Q

social spacing

A

4-12 feet
formal communication
making rounds

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28
Q

public spacing

A

more than 12 feet

lose individuality

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29
Q

what are the phases of helping (healthy??) relationship

A

preinteraction
introduction
working phase
resolution

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30
Q

preinteraction phase

A

gather information, plan

31
Q

introductory phase

A

sets tone, develops trust

sets pt at ease

32
Q

working phase

A

exploring and understanding

working

33
Q

communication with older adults

A 
assistive devices
communication aids
decrease distractions
speak sport, simple sentences
face the pt
allow time to respond
include family in convo
34
Q

safety alert: faxing

A

let receiver know its coming
cover sheet
correct number
remove pt identifiers if able

35
Q

purpose of EHR

A 
interdisciplinary communication
data for planning care
audits
research
education
reimbursement
legal/evidence
analysis/quality improvement
36
Q

types of nursing documentation

A 
narrative
SOAP
ADPIE
focus charting
charting by exception (DBE)
37
Q

narrative documentation

A

write it out

38
Q

SOAP

A

subjective
objective
assessment
plan

39
Q

focus charting

A

action, response

40
Q

CBE

A

flow sheets and defined norms

41
Q

sums up care and instructions

used when transferring to another facility or sending home

A

discharge summary

42
Q

what should discharge instructions include

A 
condition, procedures
care of wounds/incisions/drains
med list and education
restrictions (driving, lifting)
instructions (activity, exercise)
appointments
when to seek care (fever, pain)
43
Q

charting guidelines

A 
chart changes (show f/u)
read prior nurse notes
be timely (avoid late charting)
objective, subjective factual
correct errors
chart teachings
use pt "actual words"
review
sign
eliminate blank spaces
44
Q

latin verb meaning “to suffer”

A

patient

45
Q

latin verb meaning “to lean”

A

client

46
Q

Maslow Hierachy of Needs

A 
physiologic
safety and security
sense of belonging and affection
esteem and self-respect
self-actualization
47
Q

WHO defines ____ as a “state of complete physical, mental, and social well being an not merely the absence of disease and infirmity”

A

health

48
Q

What are the 4 components of wellness

A

capacity of perform to the best of ones ability
ability to adjust and adapt to varying situations
reported feeling of well-being
feeling that “everything is together” and harmonious

49
Q

this focuses on the potential for wellness and targets appropriate alterations in personal habits, lifestyle, and environment in ways that reduce risks and enhance health and well-being

A

health promotion

50
Q

cognitive process that utilizes thinking that is purposeful, insightful, reflective, and goal directed in order to develop conclusions, solutions, and alternatives that are appropriate for the given situation

includes reasoning and judgement

A

critical thinking

51
Q

___ ___ has been identified as an essential core competency for nurses

A

critical thinking

52
Q

the examination of one’s own reasoning or thought process

involves reflective thinking as well as awareness of the nursing skill needed for pt-centered care

A

metacognition

53
Q

critical components of clinical reasoning

A

communication and relationships
educational level
knowledge and ability to use critical thinking
familiarity with the environment and context of care
experience and exposure to a variety of situations
professionalism

54
Q

justification of actions or interventions used to address pt problems and help pts move towards desired outcomes

A

explanation

55
Q

process of determining whether outcomes have been met

A

evaluation

56
Q

examining the care provided and adjusting the intervention as needed

A

self-regulation

57
Q

decision making skills include:

A

systematic and comprehensive assessment
recognition of assumptions
inconsistencies and biases
verification of reliability and accuracy
identification of missing info
distinguishing relevant from irrelevant info
support of the evidence with facts and conclusions
priority setting with timely decision making
determination of pt-specific outcomes
reassessment of responses and outcomes

58
Q

certain physiologic complications that nurses monitor to detect changes in the status or onset of complications

A

collaborative problems

59
Q

when does the implementation phase of the nursing process end?

A

when the interventions have been completed

60
Q

formal, systematic study of moral beliefs to understand, analyze, and evaluate matters of right and wrong

A

ethics

often used interchangeably with morality

61
Q

includes specific values, characteristics, or actions whose outcomes are often examined through systematic ethical analysis

A

morality

often used interchangeably with ethics

62
Q

when to obtain wound culture?

A

after wound care has been performed

63
Q

care to be provided to NGT pts

A

oral care

assess nares

64
Q

SQ locations

A 
abdomen
top of thighs
upper buttock
scapula
back of arms
65
Q

Deltoid can not receive more than __ mL.

Must use a __ inch needle

A

1 mL

1 inch needle

66
Q

Needle size and mL amount for IM, besides deltoids

A

3mL

1.5 ich

67
Q

what to draw back in syringe before placing in vial

A

air

68
Q

ID angle

A

15 degree, almost parallel to arm

69
Q

___ before ___ insulin

A

clear before cloudy

70
Q

Can you shake NPH insulin (cloudy)?

A

No, roll between hands

71
Q

___ for SQ, hold ___ for IM

A

pinch - SQ

taut - IM

72
Q

Subjective data

A

information gathered from pt statements

pt feelings and perceptions

73
Q

Objective data

A

information that can be observed by others

74
Q

Primary source

A

obtained from the pt

N1115 - Trans. to Associates (21 decks)

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