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12-BSN-02 > HEALTH ASSESSMENT LAB > Flashcards

HEALTH ASSESSMENT LAB Flashcards

1
Q

is a critical thinking process that professional nurses use to apply the best available evidence to caregiving and promoting human functions and responses to health and illness

A

Nursing process

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2
Q

is a systematic method of providing care to clients

A

Nursing process

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3
Q

is a systematic method of planning and providing individualized nursing care

A

Nursing process

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4
Q

PURPOSES OF NURSING PROCESS

A
  • To identify a client’s health status and actual or potential health care problems or needs.
  • To establish plans to meet the identified needs.
  • To deliver specific nursing interventions to meet those needs.
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5
Q

CHARACTERISTICS OF NURSING PROCESS

A
  • Cyclic
  • Dynamic nature
  • Client centeredness
  • Focus on problem solving and decision making
  • Interpersonal and collaborative style
  • Universal applicability
  • Use of critical thinking and clinical reasoning.
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6
Q
  • Collect data
  • Organize data
  • Validate data
A

ASSESSMENT

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7
Q

is the systematic and continuous collection, organization, validation, and documentation of data (information).

A

Assessment

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8
Q

TYPES OF ASSESSMENT

A
  1. Initial nursing assessment
  2. Problem-focused assessment
  3. Emergency assessment
  4. Time-lapsed reassessment
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9
Q

Performed within specified time after admission

A

Initial nursing assessment

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10
Q

To establish a complete database for problem identification

A

Initial nursing assessment

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11
Q

Eg: Nursing admission assessment

A

Initial nursing assessment

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12
Q

To determine the status of a specific problem

identified in an earlier assessment.

A

Problem-focused assessment

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13
Q

Eg: hourly checking of vital signs of fever patient

A

Problem-focused assessment

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14
Q

During emergency situation to identify any life

A

Emergency assessment

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15
Q

Rapid assessment of an individual’s airway, breathing status, and circulation during a cardiac arrest.

A

Emergency assessment

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16
Q

Several months after initial assessment

A

Time-lapsed reassessment

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17
Q

To compare the client’s current health status with the data previously obtained.

A

Time-lapsed reassessment

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18
Q

is the process of gathering information about a client’s health status

A

Data collection

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19
Q

It includes the health history, physical examination, results of laboratory and diagnostic tests, and material contributed by other health personnel.

A

Data collection

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20
Q

also referred to as symptoms or covert data, are clear only to the person affected and can be described only by that person

A

Subjective data

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21
Q

Itching, pain, and feelings of worry are examples of

A

Subjective data

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22
Q

also referred to as signs or overt data, are detectable by an observer or can be measured or tested against an accepted standard

A

Objective data

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23
Q

They can be seen, heard, felt, or smelled, and they are obtained by observation or physical examination

A

Objective data

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24
Q

For example, a discoloration of the skin or a blood pressure reading is

A

Objective data

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25
Q

It is the direct source of information

A

Primary

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26
Q

It is the indirect source of information

A

Secondary

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27
Q

All sources other than the client are considered

A

Secondary

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28
Q

Observation, interview and examination are

A

METHODS OF DATA COLLECTION

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29
Q

It is gathering data by using the senses. Vision, Smell, and Hearing are used.

A

Observation

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30
Q

is a planned communication or a conversation with a purpose

A

Interview

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31
Q

is highly structured and directly asks the questions. And the nurse controls the interview.

A

directive interview

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32
Q

or rapport building interview and the nurse allows the client to control the interview.

A

nondirective interview

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33
Q

STAGES OF AN INTERVIEW

A
  1. The opening or introduction
  2. The body or development
  3. The closing
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34
Q

is a systematic data collection method to detect health problems

A

physical examination

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35
Q

uses techniques of inspection, palpation, percussion and auscultation.

A

physical examination

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36
Q

uses a format that organizes the assessment data systematically

A

Organization of data

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37
Q

often referred to as nursing health history or nursing assessment form

A

Organization of data

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38
Q

The information gathered during the assessment is “double-checked” or verified to confirm that it is accurate and complete

A

Validation of data

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39
Q

To complete the assessment phase, the nurse records client data

A

Documentation of data

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40
Q
  • Analyze data
  • Identify health problems, risks, and strengths
  • Formulate diagnostic statements
A

DIAGNOSIS

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41
Q

is the second phase of the nursing process. In this phase, nurses use critical thinking skills to interpret assessment data to identify client problems

A

Diagnosis

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42
Q

“a clinical judgment concerning a human response to health conditions/life processes, or a vulnerability for that response, by an individual, family, group, or community.”

A

The official NANDA definition of a nursing diagnosis

43
Q

is a client problem that is present at the time of the nursing assessment

A

actual diagnosis

44
Q

relates to clients’ preparedness to improve their health condition

A

health promotion diagnosis

45
Q

is a clinical judgment that a problem does not exist, but the presence of risk factors indicates that a problem may develop if adequate care is not given

A

risk nursing diagnosis

46
Q

A nursing diagnosis has three components

A

(1) The problem and its definition
(2) The etiology
(3) The defining characteristics.

47
Q

statement of the client’s health problem

A

Problem

48
Q

causes of the health problem

A

Etiology

49
Q

defining characteristics manifested by the client

A

Signs and symptoms

50
Q

is a statement of nursing judgment that made by nurse, by their education, experience, and expertise, are licensed to treat.

A

nursing diagnosis

51
Q

describe the human response to an illness or a health problem

A

Nursing diagnoses

52
Q

may change as the client’s responses change

A

Nursing diagnoses

53
Q

EXAMPLES OF NURSING DIAGNOSIS

A
  • Ineffective breathing pattern
  • Activity intolerance
  • Acute pain
  • Disturbed body image
54
Q

diagnosis is made by a physician

A

Medical diagnoses

55
Q

diagnoses refer to disease processes

A

Medical diagnoses

56
Q

remains the same for as long

as the disease is present.

A

Medical diagnoses

57
Q

EXAMPLES OF MEDICAL DIAGNOSIS

A
  • Asthma
  • Cerebrovascular accident
  • Appendicitis
  • Amputation
58
Q
  • Prioritize problems/diagnoses
  • Formulate goals/desired outcomes
  • Select nursing interventions
  • Write nursing interventions
A

PLANNING

59
Q

involves decision making and problem solving

A

Planning

60
Q

It is the process of formulating client goals and designing the nursing interventions required to prevent, reduce, or eliminate the client’s health problems

A

Planning

61
Q

Planning which is done after the initial assessment

A

Initial Planning

62
Q

It is a continuous planning

A

Ongoing Planning

63
Q

Planning for needs after discharge

A

Discharge Planning

64
Q

Planning includes;

A
  • Establishing client goals/desired outcomes
  • Selecting nursing interventions and activities
  • Writing individualized nursing interventions on care plans
65
Q

food, water, warmth, rest

A

Physiological needs

66
Q

security, safety

A

Safety needs

67
Q

intimate relationships, friends

A

Belongingness and love needs

68
Q

prestige and feeling of accomplishment

A

Esteem needs

69
Q

achieving one’s full potential, including creative activities

A

Self-actualization

70
Q

is any treatment, that a nurse performs to improve patient’s health.

A

NURSING INTERVENTIONS

71
Q

are those activities that nurses are licensed to initiate on the basis of their knowledge and skills.

A

Independent interventions

72
Q

are activities carried out under the orders or supervision of a
licensed physician.

A

Dependent interventions

73
Q

are actions the nurse carries out in collaboration with other
health team members

A

Collaborative interventions

74
Q

is a written or computerized information about the client’s care

A

Nursing care plan

75
Q

consists of doing and documenting the activities

A

Implementation

76
Q

The process of implementation includes;

A
  • Implementing the nursing interventions

* Documenting nursing activities

77
Q

is a planned, ongoing, purposeful activity in which the nurse determines:

(a) the client’s progress toward achievement of goals/outcomes and
(b) the effectiveness of the nursing care plan.

A

Evaluation

78
Q

The evaluation includes;

A
  • Comparing the data with desired outcomes

* Continuing, modifying, or terminating the nursing care plan.

79
Q

Communication is a series of experience of

A
  • Hearing
  • Smell
  • Seeing
  • Taste
  • Touch
80
Q

is the ability to use language (receptive) and express (expressive) information.

A

Communication skills

81
Q

are a critical element in your career and personal lives

A

Effective communication skills

82
Q

COMMUNICATION GOALS

A
  • To change behavior
  • To get action
  • To ensure understanding
  • To persuade
  • To get and give information
83
Q

MOST COMMON WAYS TO COMMUNICATE

A
  • Speaking
  • Writing
  • Visual Image
  • Body Language
84
Q

-On The Basis Of Organization Relationship:

A
  • Formal

* Informal

85
Q

-On the basis of Flow:

A
  • Vertical
  • Crosswise/Diagonal
  • Horizontal
86
Q

-On the basis of Expression:

A
  • Oral
  • Written
  • Gesture
87
Q 
> Symbols with different meaning
> Badly expressed message
> Faulty translation
> Unclarified assumption
> Specialist's language
A

Semantic Barriers

88
Q 
> Premature evolution
> Inattention
> Loss of transmission & poor retention
> Undue reliance on the written word
> Distrust of communication
> Failure to communicate
A

Emotional Or Psychological Barriers

89
Q

> Organizational policy
Organization rules & regulation
Status relation
Complexity in organization

A

Organizational Barriers

90
Q
  • Attitude of Superior
  • Fear of challenge of authority
  • Lack of time
  • Lack of awareness
A

Barriers in Superior

91
Q
  • Unwillingness to communicate

* Lack of proper incentive

A

Barriers in Subordinates

92
Q

the process of sending and receiving information among people

A

Communication

93
Q

COMMUNICATION CODE SCHEME

A
  1. Codifying
  2. Sending the message
  3. Decodifying
94
Q

the words we choose

A

Verbal Messages

95
Q

how we say the words

A

Paraverbal Messages

96
Q

our body language

A

Nonverbal Messages

97
Q

EFFECTIVE VERBAL MESSAGES ARE

A

> Are brief, succinct, and organized
Are free of jargon
Do not create resistance in the listener

98
Q

are the primary way that we communicate emotions

A

NONVERBAL MESSAGES

99
Q

refers to the messages that we transmit through the tone, pitch, and pacing of our voices.

A

PARAVERBAL MESSAGES

100
Q

Giving full physical attention to the speaker

A

Nonverbal

101
Q

Paying attention to the words and feelings that are being expressed

A

Verbal

102
Q

WHAT MAKES A GOOD COMMUNICATOR?

A
  • Clarity
  • Adequacy
  • Timing
  • Integrity
103
Q

TIPS TO GOOD COMMUNICATION SKILLS

A 
> Maintain eye contact with the audience
> Body awareness
> Gestures and expressions
> Convey one's thoughts
> Practice effective communication skills
104
Q

EFFECTIVE COMMUNICATION IS

A
  • It is two way.
  • It involves active listening.
  • It reflects the accountability of speaker and listener.
  • It utilizes feedback.
  • It is free of stress.
  • It is clear.

12-BSN-02 (1 decks)

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