Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Assessment > Midterm 1 > Flashcards

Midterm 1 Flashcards

1
Q

An organized & systematic process of providing goal-oriented care.

A

Nursing Process

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

5 Steps of the Nursing Process

A 
1- Assessment
2- Diagnosis
3- Planning
4- Implementation
5- Evaluation
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

A process whereby the nurse collects, synthesizes & analyzes information about the level of functioning of an individual in order to make a clinical judgment.

A

Nursing Assessment

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Types of Nursing Assessment: (4)

A

1- Initial Comprehensive
2- Partial/Ongoing Assessment
3- Focused
4- Emergency

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

The first detailed assessment of an individual.

A

Initial Comprehensive

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Assessment that occurs after the initial db has been established.

A

Ongoing/Partial

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Assessment that focuses on a specific health concern.

A

Focused

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Assessment that is rapid & occurs in life threatening circumstances.

A

Emergency

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

4 Steps of Assessment

A

1- Collection of Subjective Data
2- Collection of Objective Data
3- Validation of Data
4- Documentation of Data

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Data that can only be provided & verified by the client.

A

Subjective Data

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Data which is measurable or can be sensed.

A

Objective Data

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Organizational tools for the systematic collection of Data.

A

Assessment Frameworks

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

The Framework we’re using?

A

Head-to-Toe

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

“People are individuals that are part of other interacting wholes called systems” is an example of…

A

Context in Health Assessment

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

7 Context Considerations?

A 
1- Role in family
2- Place/role in peer group
3- Cultural beliefs
4- Religious beliefs
5- Cultural impact on communication/sharing health information
6- Biological/Anatomical variations
7- Socioeconomic community
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

This is define as a search for meaning & purpose in life, and to understand life in relation to the sacred.

A

Spirituality

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

T/F Sense of spirituality is related to health status.

A

TRUE - Spirituality can be a strong coping mechanism when confronted with threatening illness.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Has absence of spirituality been associated to illness?

A

Yes - Psychological Illness

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Two types of Spirituality Assessment:

A

1- Formal

2- Informal

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Examples of informal questions?

A
  • What in your life gives you internal support?
  • What gives you hope, strength, comfort?
  • What keeps you going?
  • What sustains you in difficult times?
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Examples of formal assessments?

A

Questionnaires that evaluate spirituality ex
1- Brief Religious Coping Ques. (RCOPE)
2- FICA Spiritual Assessment Tool

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

What does FICA stand for?

A

Faith and beliefs
Importance and influence
Community
Address (how can I address these?)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Mnemonic to help assess a sign/symptom or concern?

A

COLDSPA

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

What are the components of COLDSPA?

A 
Character
Onset
Location
Duration
Severity
Pattern
Associated Factors/ Affects Client
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

10 examples of subjective data

A

Beliefs, desires, feelings, ideas, judgments, personal information, perceptions, preferences, sensations, values.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

Subjective data is collected by interview which has 3 phases:

A

1- Introductory Phase
2- Working Phase
3- Closure

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

2 Goals of Introductory Phase:

A

1- Establish Rapport

2- Ensure Comfort

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

What should we do to establish rapport?

A

Extend a cordial greeting, address client by name (surname), introduce w/ name & title, offer a handshake, assume a position of equality.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

What should we do to ensure comfort?

A

Use private setting, State the purpose at the beginning, explain what types of questions, assure confidence, give a sense of how long it will take.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

The working phase involves the structured interview that elicits information about: (8)

A 
1- Biographical Data
2- Reasons for seeking care
3- History of present health concerns
4- Personal health history
5- Family health history
6- Review of body systems
7- Lifestyle & health practices
8- Developmental Level
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

T/F In the working phase use broad opening statements?

A

TRUE From Broad - Specific, leave sensitive topics for once rapport has been established

32
Q

Should you use technical language in the working phase?

A

NO - Use language the client will understand.

33
Q

We should ______________ to the client as the end of the interview is approaching, so he is prepared

A

Provide Clues

34
Q

In the Closure phase we….(2)

A

1- Summarize & Validate Data

2- Discuss any plans to resolve problems with client.

35
Q

Effective Communication Actions Include:

A

Appropriate grooming, name tag & credentials, attending body posture, calm & composed, neutral & friendly facial expressions, no judging, open ended question, use silence, summarize points.

36
Q

Ineffective Communication Actions:

A

Standing while client is sitting, attending to other tasks at the same time, insufficient or excessive eye contact, biased/leading question, rushing/reading the interview.

37
Q

In collecting objective data we have to:

A

1- Use an appropriate setting
2- Prepare ourselves
3- Prepare the client
4- Gather equipment

38
Q

There are 6 ways to position a client. They are:

A 
1- Standing
2- Sitting
3- Supine
4- Dorsal Recumbent
5- Lithotomy
6- Sim's
39
Q

Flat on back, with legs straight:

A

Supine

40
Q

Flat on back with knees raised, legs separated and feet flat on table:

A

Dorsal Recumbent

41
Q

On back, hips on edge of table, legs raised, knees bent in stirrups:

A

Lithotomy

42
Q

Lying on left or right side, with lower arm placed behind body, upper leg flexed and pulled forward

A

Sim’s

43
Q

Four physical examination techniques:

A

1- Inspection
2- Palpation
3- Percussion
4- Auscultation

44
Q

Palpation may be:

A

1- Light Palpation .5-1”
2- Deep Palpation 1.5-2”
3- Bilateral Palpation (Both hands)

45
Q

When percussing we listen for three qualities:

A

1- Intensity (Loudness)
2- Pitch (Frequency)
3- Quality (Hollow, booming, dull, drumlike)

46
Q

There are 5 Types of Percussion Sounds. They are:

A 
1- Tympany
2- Resonance
3- Hyperresonance
4- Flatness
5- Dullness
47
Q

Drumlike sound over air filled body parts:

A

Tympany (Air in stomach or bowels)

48
Q

A hollow sound, loud & low pitched:

A

Resonance (Normal Lung)

49
Q

Very loud, low & booming:

A

Hyperresonance (Lungs w/ trapped air)

50
Q

Soft sound, high pitched & flat quality:

A

Flatness (Muscle or Bone)

51
Q

Lower pitched than flat, moderately loud, thud like:

A

Dullness (Liver)

52
Q

The skill of listening to the body sounds is usually the last observation technique in the assessment:

A

Auscultation

53
Q

What tool do we need to auscultate?

A

Stethoscope

54
Q

For low pitched sounds we use the:

A

Bell

55
Q

For High pitched sound we use the:

A

Diaphragm

56
Q

In auscultation, we describe the sounds in terms of: (4)

A

1- Pitch (High, low)
2- Intensity (Loud, soft)
3- Duration (Length)
4- Quality/Character

57
Q

This is the process of verifying the subjective & objective data for accuracy.

A

Validation of Data

58
Q

When validating we look for 3 things:

A

1- Changes in what client reports
2- Abnormal objective findings
3- Inconsistencies between sub & obj data

59
Q

What 4 things can we do to validate?

A

1- Repeat the assessment element
2- Ask the client additional questions
3- Have a second opinion
4- Check perceptions w/ client

60
Q

Once we’ve validated we…

A

Document!

61
Q

Findings are documented for:

A

1- Establishment of data base
2- Communication w/ other HCW’s
3- Provision of legal record of care given
4- Chronological record of events in client care.

62
Q

Principles of Proper Documenting include…(5)

A

1- Permanent Ink!
2- Never overwrite, white-out or erase
3- If error made, draw line through and write error
4- Correct grammar, spelling & only accepted abbreviations
5- Don’t use slang/jargon unless direct quote.

63
Q

2 Types of Documentation Forms

A

1- Initial Assessment Forms

2- Ongoing assessment Forms

64
Q

Initial assessment forms tend to be…(3)

A

1- Long & Detailed
2- Done on admission
3- Provide Baseline data

65
Q

Ongoing Assessment forms tend to be…

A

Flow charts or Progress charts, used to compare ongoing data.

66
Q

This is the process of analyzing the data & drawing conclusions.

A

Diagnostic Reasoning.

67
Q

Diagnostic Reasoning consists of 6 components:

A 
1- Grouping/organizing data
2- Comparing to norms
3- Clustering data
4- Generating possible conclusions
5- Formulating professional judgment
6- Validating judgment with client
68
Q

The 7 Steps to a Nursing Diagnosis (ICDPCCD)

A 
Identify Abnormal Data
Cluster Data
Draw Inferences
Propose Nursing Diagnosis
Check for Defining Features
Confirm or Rule Out
Document Conclusions
69
Q

These are statements of actual or potential human problems that can be prevented, resolved or reduced through independent nursing actions.

A

Nursing Diagnosis Statements

70
Q

There are 3 Common Types of Nursing Diagnosis Statements. They are?

A

Wellness Diagnosis
Risk Diagnosis
Actual Diagnosis

71
Q

TYPE - Client does not have a problem, but can achieve a higher level of functioning.

A

WELLNESS

72
Q

TYPE - Problem is likely to occur without intervention.

A

RISK

73
Q

TYPE- Problem is identified. Health problem exists.

A

ACTUAL

74
Q

What are the three elements of a Nursing Diagnosis?

A

Problem
Etiology (RELATED TO)
Signs/Symptoms (AS EVIDENCED BY)

75
Q

3 Categories of Nursing Diagnosis

A 
Nursing Concern (On Own)
Collaborative Concern (Need someone else)
Referral Concern (Send to someone else)

Assessment (6 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions