Key Terms #2

Question 1

Subjective Data

Answer 1

Info gathered from pt statements

Question 2

Objective Data

Answer 2

Info that can be observed by others

Question 3

Review of Systems (ROS)

Answer 3

list of questions arranged by organ systems designed to uncover dysfunction & disease

Question 4

Medical Diagnosis

Answer 4

Identification of disease condition, based on specific evaluation of physical signs & symptoms, medical history, diagnostic tests, and procedure results. Only made by provider

Question 5

Nursing Diagnosis

Answer 5

formal statement of actual or potential health problem that nurses can legally and independently treat.

Question 6

Expected Outcomes

Answer 6

measurable change in behavior, physical state, or perception that must be achieved to reach a goal.

Question 7

Patient Centered Care

Answer 7

encourages active collaboration and shared decision making, between patients, families, and providers

Question 8

Short Term Goals

Answer 8

goals that can be achieved within a short period of time, depending on the length of stay

Question 9

Long Term Goals

Answer 9

goals that can be achieved within longer period of time, depending on length of stay or type of pt

Question 10

Independent Nursing Intervention

Answer 10

nurse initiated intervention without supervision or direction from others

Question 11

Dependent Nursing Intervention

Answer 11

healthcare provider initiated intervention

Question 12

Clinical Judgement

Answer 12

thought process, clinical reasoning that allows providers to arrive at a conclusions, clinical decision making based on objective & subjective info

Question 13

Direct Care

Answer 13

treatment performed by direct interaction with pt

Question 14

Indirect Care

Answer 14

treatment performed by interactions with pt, completed on behalf of pt, such as documentation or collaborative care

Question 15

Adverse Reactions

Answer 15

harmful or unintended effective of a medication, diagnostic test, or therapeutic intervention

Question 16

Activities of Daily Living (ADL’s)

Answer 16

activities performed in a normal day in a pt’s life

Question 17

Auscultation

Answer 17

listening to body sounds to detect variation from normal

Question 18

Turgor

Answer 18

normal resiliency of the skin, ability of the skin change shape and return to normal

Question 19

Edema

Answer 19

abnormal accumulation of fluid in the interstitial space

Question 20

Cyanosis

Answer 20

bluish discoloration of the skin and mucous membranes caused by excess of deoxygenated hemoglobin in the blood or a structural defect in the hemoglobin molecule

Question 21

Erythema

Answer 21

redness or inflammation of the skin or mucous membrane, result of dilation and congestion of superficial capillaries.

Question 22

Thrill

Answer 22

continuous palpable sensation (cat purring)

Question 23

Bruit

Answer 23

abnormal sound or murmur heard while auscultating organ, gland, or artery

Question 24

Clubbing

Answer 24

bulging of tissues on nail base, caused by insufficient oxygen at the periphery

Question 25

Distention

Answer 25

generalized abdominal swelling caused by gas, tumor, or fluid accumulation