exam 2

Question 1

define percussion

Answer 1

two objects striking to make sound; use fingertips to tap body to produce vibrations

Question 2

define auscultation

Answer 2

using a stethoscope to listen to body sounds

Question 3

what are the four characteristics of sound

Answer 3

pitch, loudness, quality, duration

Question 4

what are the four types of assessment

Answer 4

initial comprehensive, lapsed-time, focus, and emergent

Question 5

define initial comprehensive assessment

Answer 5

performed slightly after admittance to the hospital, performed to establish a complete database for problem identification and care planning, performed by nurse to collect data on all aspects of patients health

Question 6

define focused assessment

Answer 6

may be performed during initial assessment or as a routine, used to gather data about a specific problem already identified, or to identify new or overlooked problems

Question 7

define time-lapsed assessment

Answer 7

performed to compare a patients current status to base lined data, used to reassess health status and make necessary revisions in plan of care

Question 8

define emergent assessment

Answer 8

performed when a physiologic or psychologic crisis occurs, used to identify life threatening problems

Question 9

what are the parts to thoughtful nursing practice

Answer 9

reflective practice, clinical reasoning, patient centered care

Question 10

What are potential errors in decision making using the nursing process

Answer 10

Bias, Failure to consider the total situation, and impatience

Question 11

What are the five steps to the nursing process

Answer 11

Assessing, diagnosing, planning, implementing, and evaluating

Question 12

Briefly describe assessing as one of the five steps of the nursing process

Answer 12

Collecting, validating, and communicating patient data

Question 13

Briefly describe diagnosing as one of the five steps of the nursing process

Answer 13

Analyzing patient data to identify patient strength and problems

Question 14

Briefly describe planning as one of the five steps of the nursing process

Answer 14

Specifying patient outcomes and related nursing interventions

Question 15

Briefly describe implementing as one of the five steps of the nursing process

Answer 15

Carrying out the plan of care

Question 16

Briefly describe evaluating that’s one of the five steps of the nursing process

Answer 16

Measuring extent to which patient achieved outcomes

Question 17

What are the benefits of the nursing process for the patient

Answer 17

• Scientifically-based, holistic individualized patient care, -Continuity of care
• Clear, efficient, cost effective plan of action

Question 18

What are the benefits of the nursing process for the nurse

Answer 18

• opportunity to work collaboratively with other healthcare workers/ increased communication
• satisfaction of making a difference in the lives of patients
• Opportunity to grow professionally

Question 19

What are the five characteristics of the nursing process

Answer 19

Systemic, dynamic, interpersonal, outcome oriented, universally Applicable

Question 20

Briefly describe reflection IN action

Answer 20

Happens in the here and now of the activity and is also known as “thinking on your feet “

Question 21

Briefly describe reflection ON action

Answer 21

Occurs after the fact and involves thinking through a situation that has occurred in the past

Question 22

Briefly describe reflection FOR action

Answer 22

Helps a person to think about how future actions might change as a result of the reflection

Question 23

What is critical thinking

Answer 23

A bridge between information we have an actions we need to take. Imply a search for a reason, purpose, meaning and value. Way to initiate inquiry, provide logic, and Justify conclusions

Question 24

How can we identify a nurse who uses critical thinking consistently versus one who does not

Answer 24

A critical thinking nurse always explains what they are doing, ask questions, teachers every patient, rechecks everything, says it’s on their mind, is the person you want to work with

Question 25

What are the parts of the nursing process?

Answer 25

assessing, diagnosing, planning, implementing, evaluating

Question 26

What is assessing as it relates to the nursing process?

Answer 26

collecting, validating, and communicating patient data

Question 27

What is diagnosing as it relates to the nursing process?

Answer 27

analyzing patient data to identify patient strengths and problems

Question 28

What is planning as it relates to the nursing process?

Answer 28

specifying patient outcomes and related nursing interventions

Question 29

What is implementing as it relates to the nursing process?

Answer 29

carrying out the plan of care

Question 30

What is evaluating as it relates to the nursing process?

Answer 30

measuring extent to which patient achieved outcomes

Question 31

What are the 4 types of nursing assessments?

Answer 31

initial comprehensive, focused, emergency, time-lapsed

Question 32

What is the difference between objective and subject data?

Answer 32

objective- observable and measurable that can be seen, heard, or felt by someone other than patient

subjective- only patient can perceive it

Question 33

What are the 4 phases of the nursing interview?

Answer 33

preparatory phase, introduction, working phase, termination

Question 34

What is the only “risk for” nursing diagnosis that is priority?

Answer 34

risk for suicide

Question 35

What are the parts of a nursing diagnosis statement?

Answer 35

problem, etiology, defining characteristics

Question 36

What are the types of nursing diagnoses?

Answer 36

problem focused (aka actual diagnosis)
risk nursing diagnosis
health promotion

Question 37

What are the 3 elements of comprehensive planning?

Answer 37

initial
ongoing
discharge

Question 38

What are NAM’s 6 aims to be met by health care systems regarding quality of care?

Answer 38

safe, effective, patient-centered, timely, efficient, equitable

Question 39

What are the categories of outcomes?

Answer 39

cognitive (increase in pt knowledge or intellectual behaviors)
psychomotor (describes pt’s achievement of new skill)
affective (changes in pt values, beliefs, attitudes)
physiologic (physical changes in pt)

Question 40

What are common errors in writing patient outcomes?

Answer 40

expressing pt outcome as nursing intervention,
using verbs that are not observable or measurable,
including more than one pt behavior or manifestation in short-term outcomes,
writing vague outcomes

Question 41

What are the parts of a measurable outcome?

Answer 41

subject, verb, conditions, performance criteria, target time

Question 42

What is the focus of implementation?

Answer 42

help pt achieve valued health outcomes, promote health, prevent disease and illness, restore health, facilitate coping with altered functioning

Question 43

What’s the difference between a collaborative intervention and a nursing intervention?

Answer 43

** I looked everywhere for this answer and can’t find it. All I can find on the internet is collaborative nursing intervention is with multiple healthcare professionals and nursing intervention is just the nurse but it doesn’t sound right. Powerpoint says nurse initiated and other provider initiated interventions but does not mention collaborative or nursing **

Question 44

How do you evaluate psychomotor outcomes?

Answer 44

asking pt to demonstrate new skill

Question 45

How do you evaluate affective outcomes?

Answer 45

observing pt behavior and conversation

Question 46

How do you evaluate affective outcomes?

Answer 46

observing pt behavior and conversation

Question 47

How do you evaluate physiologic outcomes?

Answer 47

using physical assessment skill to collect and compare data

Question 48

What are the 5 classic elements of evaluation?

Answer 48

identifying evaluative criteria and standards,
collecting data to determine if criteria and standards are met,
interpreting and summarizing findings,
documenting judgment,
terminating, continuing, or modifying the plan