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Nur 103 > Exam 5 > Flashcards

Exam 5 Flashcards

1
Q

what is the act of recording client assessments and care in written or electronic form?

A

Documentation

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2
Q

TRUE or FALSE
If you didn’t document it, it didn’t happen!!!

A

TRUE

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3
Q

why is communication important?

A

it provides safe & quality care

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4
Q

why do students use client data as a case study?

A

to better understand illness and symptoms

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5
Q

compared findings =

A

data

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6
Q

what has changed the nursing practice and is linked to improved outcomes?

A

Analyzing

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7
Q

what contributes to evidence based?

A

results

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8
Q

what charting gets audited?

A

care plan, interventions, discharge planning, client education

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9
Q

what might scattered data lead to?

A

fragmentation

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10
Q

what does the source-oriented system contain?

A

admission, H&P, diagnostic, graphs, progress notes, labs, rehab

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11
Q

what are the 4 components of a problem-oriented system

A

database, problem list, plan of care, and progress notes

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12
Q

what type of charting can you use with source- or problem- oriented system?
has a “story format”

A

narrative

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13
Q

when is PIE charting used
(problem, interventions, evaluation)

A

only in problem-oriented charting
establishes an ongoing plan of care

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14
Q

SOAPIER charting

A

subjective
objective
assessment
planning
interventions
evaluation
revision

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15
Q

what form of charting highlights the client’s main concerns?

A

focus charting

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16
Q

what is DAR charting and when is it used

A

Data, Action, Response
used during column 3 of focus charting

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17
Q

what form of charting only charts significant findings or exceptions to norms

A

Charting by Exception

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18
Q

FACT documentation pneumonic

A

Flow sheets individualize specific services
Assessment with baseline data
Concise progress notes
Timely entries

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19
Q

what form of charting improves the quality of care

A

computerized charting

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20
Q

what words are important to avoid when documenting client care

A

appears, seems, apparently

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21
Q

when is keep it CUBAN used?

A

during handoff reports

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22
Q

CUBAN pneumonic

A

confidential
uninterupted
brief
accurate
named nurse

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23
Q

after providing patient care, the nurse charts in the permanent record. Which is considered appropriate documentation?
A. Pt appears restless when sitting up for lunch
B. Apparently enjoyed breakfast with family
C. Drank adequate amounts of water
D. Skin pale and cool

A

D.

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24
Q

The nurse has just medicated a client for pain. Documentation of this intervention would be found on the:

A

Flowsheet and MAR

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25
Q

sensory systems:

A

vision, hearing, taste, smell, touch

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26
Q

what environment do the senses provide?

A

internal and external

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27
Q

what triggers a stimulant receptor?

A

stimulus

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28
Q

examples of a stimulus

A

loud noise, bright light, sour taste

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29
Q

what is the process of receiving stimuli from nerve endings?

A

reception

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30
Q

what are some types of receptors

A

mechanoreceptors (vibration)
proprioceptors (body in space)
chemoreceptors (taste)
hair cells (balance)
thermoreceptors
photoreceptors

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31
Q

what is the ability to interpret sensory impulses as well as give meaning?

A

perception

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32
Q

what is perception affected by?

A

location of receptor
number of receptors

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33
Q

what is composed of consciousness and alertness?

A

Arousal

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34
Q

what is mediated by reticular activating system (RAS)

A

arousal

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35
Q

what is arousal affected by?

A

environment and some medications

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36
Q

what are factors that affect response?

A

intensity of stimuli (bright light)
contrasting stimuli (cold outside)
adaption to stimuli (noise)

37
Q

what factors affect the sensory experience?

A

the developmental stages
culture
lifestyle
medications

38
Q

what is the lack of meaningful stimuli

A

sensory deprivation

39
Q

overwhelmed by environmental and internal stimuli

A

sensory overload

40
Q

the client who has had a stroke states to the nurse, “you know I can’t even tell where my left leg is.” this reflects a lack of response to stimuli by the

A

proprioceptors

41
Q

is pain objective or subjective

A

subjective

42
Q

what are classifications of pain

A

origin, cause, duration, quality

43
Q

what is deep somatic pain

A

pain that originates in the ligaments, tendons, nerves, blood vessels, and bone

44
Q

where is visceral pain located

A

abdomen, cranium or thorax

45
Q

nociceptive pain

A

normal pain processing- result of actual or potential tissue damage

46
Q

somatic pain

A

pain arising from the skin and musculoskeletal structures (well localized)

47
Q

what pain is NOT well localized

A

visceral

48
Q

what is most important when assessing a client’s pain?

A

the client’s own perception of the pain

49
Q

what activates neurons existing throughout the body response

A

transduction

50
Q

what is the first process of nociception

A

transduction

51
Q

what is the conduction of pain that messages through the spinal cord via nerve fibers

A

transmission

52
Q

what marks the end of nerve transmission and involves the conscious awareness of pain

A

perception

53
Q

what requires activation of higher brain structures

A

perception

54
Q

what changes pain receptors

A

modulation

55
Q

what maintains perfusion to vital organs, minimizes blood loss, fights infection, and promotes healing.
“fight or flight”

A

sympathetic nervous system

56
Q

consumes thoughts and changes daily living patterns

A

parasympathetic nervous system

57
Q

the storage and recall of information are?

A

cognitive domains of learing

58
Q

PCA example
(patient-controlled analgesia)

A

morphine pump

59
Q

what form of a domain of learning changes feelings, beliefs, attitudes and values?

A

affective learning

60
Q

five rights of teaching

A

time, context, goal, content, method

61
Q

the client needs to be taught how to find and check his own pulse. the nurse will complete this teaching.
A. only if the client asks her to do so, to avoid causing stress
B. when the client recognizes the need to learn the skill
C. before pain medications are administered and the patient is alert
D. right before the client is discharged so he can remember the skill

A

B.

62
Q

what is loss?

A

the undesired change or removal of a valued object, person, or situation

63
Q

what is psychological loss

A

internal loss (trust, fairness, hope)

64
Q

the student nurse has earned “A’s” in all her gen-ed courses. For the first nurse’s exam, she got a “D” and now feels that she is not smart enough for nursing school. What type of loss is the student experiencing?

A

perceived

65
Q

what is grief?

A

physical, psychological, and spiritual responses to a loss

66
Q

what is bereavement?

A

mourning and adjustment time following a loss

67
Q

what is disenfranchised grief?

A

not socially supported
(affair)

68
Q

what is anticipatory grief?

A

negative
(the survivors friend dying)

69
Q

examples of facilitating grief

A

expressing feelings
recalling memories
finding meaning
bibliotherapy

70
Q

rigor
algor
livor

A

stiffing of body
blood stops circulating (body temp. decreases 2 degrees per hr.)
bluish body, no blood circulating

71
Q

ethnicity
race
religion

A

share a common culture/heritage
biological simularties
system of beliefs

72
Q

example of indigenous healthcare systems

A

self-healing, folk medicine

73
Q

what is complementary medicine?

A

therapy
chiro.

74
Q

ethnocentrism

A

your group is better than the rest

75
Q

what is religion

A

a “map” that outlines beliefs, values, and codes of conduct into a manner of living

76
Q

what is spirituality

A

a “journey” that take place over time and involves the accumulation of life experiences and understandings

77
Q

how many chains or linked to infection

A

6

78
Q

what are infectious agents?

A

bacteria, fungi, viruses, protozoa

79
Q

what is a reservoir

A

where pathogens live and multiply

80
Q

what are examples of the portal of exit

A

all body fluids

81
Q

what causes the mode of transmission

A

touching, kissing, coughing, air conditing

82
Q

what are examples of the portal of entry

A

eye, nose, mouth, cuts, scrapes, vagina, IV/drainge tube, bites

83
Q

when can breaking the chain of infection occur

A

at any point

84
Q

stages of infection

A

incubation- time of infection (can infect others)
prodromal- vague symptoms
illness- s/s are present
decline- pathogens decline
convalescence- tissue repair (becoming healthy)

85
Q

local infection

A

occur in limited region of the body

86
Q

systemic infection

A

spread through the body, affecting many regions

87
Q

latent infection:

A

infection with no S/S for a long time (STD)

88
Q

medical asepsis

A

a state of cleanliness that decreases the potential for the spread of infection

89
Q

how is the prevention of infection promoted

A

maintaining a clean environment, clean hands, following CDC guidelines

Nur 103 (4 decks)

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