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Nursing Study > Nursing Process > Flashcards

Nursing Process Flashcards

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1
Q

Other than caregiver and educator, what other roles does the nurse play?

A
  • Advocate (Ensure the health, welfare, and safety of pt)
  • Coordinator (Manage time, people and resources and care environment)
  • Change Agent (Address health/organizational/community concerns)
  • Discharge Planner (Assesses pt’s needs @ time of admission and links pt w/ available community resources)
  • Researcher (Promote growth in nursing science and develop a scientific basis for nursing practice)
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2
Q

What does it mean to use evidence-based nursing practice?

A

The conscientious and consistent use of scientific research (strength and quality) to make informed decisions in relation to patient-centered care

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3
Q

What is the WHO’s definition of health?

A

“A state of complete physical, mental, and social-being and not merely the absence of disease or infirmity.”

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4
Q

What factors can affect health?

A
  • Genetics (biological and genetic makeup)
  • Cognitive ability (affect a pt’s view of health and ability to seek out resources)
  • Demographic factors (certain diseases more prevalent in a certain age group or sex)
  • Geographic factors (predisposes a person to certain conditions)
  • Culture (determines a pt’s health perception, motivation to seek care, and types of health practices performed)
  • Lifestyle and environment (i.e. diet, level of activity, exposure to toxins)
  • Health beliefs and practices (can affect health positively or negatively)
  • Previous health experiences (influence reactions to illness and the decision to seek care)
  • Spirituality (affects a pt’s view of illness and healthcare)
  • Support systems (affect the degree to which a person adapts and copes w/ a situation)
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5
Q

How does an acute illness differ from a chronic one?

A

-Acute illnesses have a relatively abrupt onset, high intensity, and short duration.
- Chronic illness usually last 1 year or mor, needs continuous treatment and limits ADLs

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6
Q

The presence of illness in a family member can have a dramatic effect on the functioning of the family as a unit which depends on what factors?

A
  • Which family member is ill (primary breadwinner?)
  • The seriousness and duration of the illness
  • The family’s social and cultural customs
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7
Q

Good health practices can contribute to _____ illnesses, a _____ life span, and _____ healthcare costs.

A

fewer; longer; lower

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8
Q

Health promotion is the process of teaching _____ health practices and finding ways to help people avoid _____ health practices.

A

good; bad

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9
Q

Considering that aging is a state of mind and body; what would the patient education of an older adult pt focus on?

A
  • Continue as many activities as possible depending on mobility
  • Foster exploration of new interests or hobbies
  • Recommend community resources (i.e. seminars, fitness classes)
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10
Q

What are the 5 rights of delegation?

A
  • Task (within scope and practice)
  • Circumstance (pt condition, environment, caregiver training)
  • Person (legal authority to perform the task according to law and institutional policies)
  • Direction and Communication (clear, specific, and understood)
  • Supervision and follow-up (delegating nurse guides and evaluates performance and provide additional training and feedback)
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11
Q

Critical thinkers are open-minded, seek the truth, and actively pursue answers to questions to obtain the big pictures. TRUE or FALSE.

A

TRUE

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12
Q

What does ADPIE stand for?

A
  • Assessment
  • Diagnosis
  • Planning
  • Implementation
  • Evaluation
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13
Q

Assessment involves the gathering of information of what sources?

A
  • Pt’s S/S
  • Pt Hx
  • Subjective findings from the pt (Interviewing)
  • Objective findings (Physical Assessment/Vital Signs/Diagnostics/Labs)
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14
Q

In general, when interviewing a pt, what should you do to help facilitate a good interview?

A
  • Allow the pt time to think and reflect
  • Encourage the pt to talk
  • Encourage the pt to describe or elaborate on a particular experience
  • Indicate that you are listening to the pt utilizing therapeutic communication techniques (paraphrasing, clarifying, summarizing, and active listening)
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15
Q

What are some interview techniques that should be avoided?

A
  • Rushing the interview
  • Asking “why” or “how” questions
  • Asking probing or persistent questions
  • Using inappropriate or confusing language
  • Giving advice
  • Giving false reassurance
  • Sharing personal stories
  • Changing the subject or interrupting
  • Using cliches or stereotypical responses
  • Giving excessive approval
  • Using defensive responses
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16
Q

If you need to document during the interview using a computer or electronic device, make sure your back is not toward the pt. TRUE or FALSE.

A

TRUE. Making eye contact and nodding indicates understanding and are cues that will assure the pt that you are listening to them.

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17
Q

The pt’s health history consists of 5 major sections which are?

A
  • Biographic data
  • Health and illness patterns
  • Health promotion and protection patterns
  • Role and relationship patterns,
  • Summary of health history data
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18
Q

Other the the pt’s age, DOB, and sex what other information would be included in the pt’s biographic data?

A
  • Address
  • Telephone #
  • Race
  • Nationality
  • Marital status
  • Occupation
  • Education
  • Religion
  • Cultural background
  • Emergency contact person
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19
Q

What information would be included in the health and illness patterns section of the pt’s health history?

A
  • CC
  • Hx of present illness
  • Current, past, and family health hx
  • Status of physiologic systems/Review of systems (Head to Toe)
  • Any type of exposure to environmental hazards or contagious diseases
  • Social and developmental considerations
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20
Q

The PQRST mnemonic device provides a systematic approach for obtaining what type of information?

A

Additional details about a specific symptom or health concern

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21
Q

Name the components of the PQRST mnemonic device.

A
  • P: Provocative/Palliative
  • Q: Quality or quantity
  • R: Region or radiation
  • S: Severity
  • T: Timing
22
Q

What type of questions would be asked for the P of the PQRST mnemonic?

A
  • What makes the symptom better
  • What makes the symptom worse
  • What triggers the symptom (position, emotion, etc.)?
23
Q

What type of questions would be asked for the P of the PQRST mnemonic?

A
  • What does the symptom feel like, look like, or sound like?
  • Are you having the symptom right now? If so, is it more or less severe than usual?
  • To what degree does the symptom affect your normal activities?
24
Q

Questions including “Where in the body does the symptom occur?” and “Does the symptom appear or move to other regions? If so, where?” are components of what part of the PQRST mnemonic?

A

R (Region or radiation)

25
Q

When reviewing over the S of the PQRST mnemonic, what questions would you ask concerning severity?

A
  • How severe is the symptom? how would you rate it on a scale of 1 to 10, w/ 10 being the most severe?
  • Does the symptom seem to be diminishing, intensifying, or staying about the same?
26
Q

What questions would you ask concerning the T (timing) of the PQRST mnemonic?

A
  • When did the symptoms begin?
  • Was the onset sudden or gradual?
  • How often does the symptom occur?
  • How long does the symptom last?
27
Q

Why is it important to inquire about a pt’s health promotion and protection patterns?

A

Asking a pt to describe a typical day will help reveal the pt’s health beliefs which frames their health behaviors– many facets of life and the pt choices influence their health

28
Q

A pt’s role and relationship pattern can impact the pt’s _____ ( psychological, emotional, social, spiritual, and sexual) health.

A

psychosocial

29
Q

For the summary of health history data, what would you focus on for a well pt? Or if there is a significant health need?

A
  • For a well pt, list the pt’s health promotion strength, and resources along w/ defined health education needs
  • For a pt w/ a significant health need, inform the pt and begin to formulate a plan of care (i.e. referral to a doctor or education, etc.)
30
Q

The physical assessment technique order is usually inspection, palpation, percussion and auscultation except for which system?

A

Abdominal assessment: Inspection, auscultation, percussion, and palpation

31
Q

When you are performing an assessment, what you observing for?

A
  • Mood, behavior, and general appearance
  • Each body system: Color, size, location, movement, texture, symmetry, odor, and sounds
32
Q

During palpation, when should tender areas be palpated?

A

Last

33
Q

As you palpate each body system, what features are you evaluating for?

A
  • Texture
  • Size
  • Masses
  • Temperature
  • Moisture
  • Motion
  • Consistency of structures
  • Tenderness
34
Q

What physical assessment technique involves tapping your fingers or hands quickly and sharply against parts of the pt’s body?

A

Percussion

35
Q

Percussion serves to help located what features of the organs?

A
  • Borders
  • Shape and position
  • Determine if organ is solid of filled w/ fluid or gas
36
Q

Auscultation involves listening for what 3 different types of sounds w/ the stethoscope?

A
  • Breath
  • Heart
  • Bowel
37
Q

After completing the pt assessment, analyze the data in the 4 following steps: group significant data into logical clusters; identify data gaps and conflicting data; recognize and analyze cues and trends in assessment findings; and form a list of _____ patient needs.

A

priority

38
Q

Prioritize your pt’s needs addressing life-threatening issues first, followed by health-threatening concerns. TRUE or FALSE.

A

TRUE

39
Q

What are the 5 levels of Maslow’s hierarchy of needs?

A

1.) Physiologic needs
2.) Safety and security
3.) Love and belonging
4.) Self-esteem
5.) Self-actualization

40
Q

According to Maslow’s hierarchy, what are some examples of physiological needs?

A
  • Oxygen
  • Food
  • Water
  • Temperature control
  • Elimination
  • Movement
  • Rest
  • Comfort
41
Q

The need for protection, emotional and physical safety/security, order, law, and shelter is examples of which level in Maslow’s hierarchy?

A

2.) Safety and Security

42
Q

According to Maslow’s hierarchy, what are some examples of love and belonging needs?

A
  • Giving and receiving affection
  • Having meaningful relationships
  • Belonging to group(s)
  • Support and reassurance
43
Q

According to Maslow’s hierarchy, what should be addressed in the 4th level self esteem?

A

Sense of self-worth, self-respect, independence, dignity, privacy, and self-reliance

44
Q

Which Maslow’s hierarchy level is associated w/ recognition and realization of one’s potential, growth, health, and autonomy?

A

Self-actualization

45
Q

Implementation is where the “rubber meets the road” and your plan of _____ becomes the road map.

A

care

46
Q

Interventions should always be evidence-based, provide pertinent rationale, and also _____ to your pt.

A

individualized

47
Q

How do short-term goals and long-term goals differ in when they are expected to be met?

A

Short-term goals are expected to be met by the time of discharge or transfer to another level of care whereas long-term are not

48
Q

What does the goal mnemonic SMART stand for?

A

S: Specific (clearly state the desired result)
M: Measurable (quantifiable markers of progress)
A: Achievable (identify any barriers and create a plan to address them)
R: Realistic (determine if results can be achievable w/ resources available)

49
Q

Why is it important for the nurse to monitor and gauge pt’s response to interventions?

A

Helps nurses to review, revise, and adapt the plan of care as needed

50
Q

_____ is the final step in the nursing process but also a step that can start the whole thing over again. It gives the nurse insight about the effectiveness of the plan and helps to focus future nursing care.

A

Evaluation

51
Q
A

Nursing Study (6 decks)

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