NURSING PROCESS INTRO & ASSESSMENT

Question 1

• systematic and client centered method that provides a structure in the delivery of nursing care
• goal oriented method that provides a framework for nursing practice

Answer 1

nursing process

Question 2

• patients as central figure
• gathering and analyzing data to identify health issues / concerns

Answer 2

nursing process

Question 3

what are the phases or nursing process?

Answer 3

ADPIE assessment, diagnosis, planning, implementation, evaluation

Question 4

systematic continuous collection, organization, validation and documentation of data

Answer 4

assessment

Question 5

• establish a complete database for problem identification, reference and future comparison
• within a specified time after admission

Answer 5

initial / comprehensive assessment

Question 6

• determine the status of a specific problem
• ongoing process

Answer 6

problem-focused assessment

Question 7

• to identify life-threatening and overlooked problems
• during any physiologic or psychologic crisis

Answer 7

emergency assessment

Question 8

• compare the client’s status to baseline data
• several months after initial assessment

Answer 8

time-lapsed assessment

Question 9

4 major activities done during assessment

Answer 9

COVD collecting, organizing, validating, documenting

Question 10

gives subjective information on how a health condition came about

Answer 10

nursing health history

Question 11

true or false: the chief complaint must be recorded as direct quotes from the client

Answer 11

true

Question 12

how can the family history be presented as?

Answer 12

genogram / family tree

Question 13

infancy

Answer 13

trust vs mistrust

Question 14

early childhood

Answer 14

autonomy vs shame and doubt

Question 15

preschool

Answer 15

initiative vs guilt

Question 16

school age

Answer 16

industry vs inferiority

Question 17

adolescence

Answer 17

identity vs role confusion

Question 18

young adulthood

Answer 18

intimacy vs isolation

Question 19

middle adulthood

Answer 19

generativity vs stagnation

Question 20

maturity

Answer 20

ego integrity bs despair

Question 21

person’s description of his current health

Answer 21

health perception - health management

Question 22

person’s nourishment

Answer 22

nutritional - metabolic

Question 23

• person’s excretory pattern
• disease of digestive, urinary system, or skin

Answer 23

elimination

Question 24

• person’s description of his weekly pattern of activities, leisure, exercise, and recreation
• any disease that affects his cardio-respiratory and/or musculoskeletal systems

Answer 24

activity - exercise

Question 25

person’s description of the person’s sleep-wake cycle

Answer 25

sleep - rest

Question 26

• person’s ability to express himself clearly and logically
• person’s education

Answer 26

cognitive - perceptual pattern

Question 27

• if person is comfortable with his appearance
• description of the person’s feeling state

Answer 27

self-perception / self-concept

Question 28

person’s description of his various roles in life

Answer 28

role - relationship

Question 29

person’s satisfaction with his situation related to sexuality

Answer 29

sexuality - reproductive

Question 30

person’s means/actions of coping with problems

Answer 30

coping - stress tolerance

Question 31

• principals that the person learn as a child which are still important to him
• person’s identification with any cultural, ethnic, religious, regional, or other groups

Answer 31

value - belief

Question 32

the patient’s subjective response to a series of body system-related questions

Answer 32

review of systems

Question 33

• also referred to as symptoms or covert data
• can be described or verified only by the individual

Answer 33

subjective data

Question 34

• also referred to as signs or overt data
• can be measured or tested against an accepted standard

Answer 34

objective data

Question 35

best source of data

Answer 35

primary / client

Question 36

refers to all sources other than the client

Answer 36

secondary source

Question 37

• a conscious and deliberate skill in gathering data using
  the senses
• involves noticing data then selecting, organizing, and interpreting data

Answer 37

observing

Question 38

planned communication or a purposeful conversation

Answer 38

interviewing

Question 39

• highly structured
• nurse establishes the purpose and controls the interview

Answer 39

directive interview

Question 40

• a rapport-building interview
• the client controls the purpose, subject matter, and pacing

Answer 40

nondirective interview

Question 41

• used during direct interviews
• generally restrictive; requires a yes, no, or short factual responses
• often used when information is needed quickly

Answer 41

closed questions

Question 42

• associated with non-directive interviews
• invites longer responses from the clients
• provides the client with freedom to share information

Answer 42

open-ended questions

Question 43

• open-ended, used in non-directive interviews
• can be answered by the client without direction or pressure

Answer 43

neutral questions

Question 44

• closed questions and are used in directive interviews
• directs the client’s answers
• gives the client less opportunity to decide if responses are true or not

Answer 44

leading questions

Question 45

• complete health assessment
• orderly and systematic

Answer 45

examining

Question 46

4 basic skills of examining

Answer 46

IPPA inspection palpation percussion auscultation

Question 47

approaches of examining

Answer 47

cephalocaudal, body system approach

Question 48

• assessment of the patient’s general appearance
• uses the sense of sight, hearing and smell

Answer 48

inspection

Question 49

uses the sense of touch; “therapeutic touch”

Answer 49

palpation

Question 50

• the skin is depressed for about 1-2 cm using the finger pads
• used to assess texture, tenderness, temp., moisture, elasticity

Answer 50

• light palpation

Question 51

• can be done with 1 or 2 hands, skin is depressed for about 4-5 cm
• this is used when trying to feel for the internal organs

Answer 51

deep palpation

Question 52

involves the striking of a body surface, usually with a tip of the finger to elicit a sound or vibration

Answer 52

percussion

Question 53

• uses pads of 2, 3, or 4 fingers or with a pad of the middle finger
• commonly used when percussing adult sinuses

Answer 53

direct percussion

Question 54

• the nurse strikes an object (another finger) held against a body area
• uses pleximeter (finger placed on the skin), plexor (striking finger)

Answer 54

indirect percussion

Question 55

involves the process of listening to sounds produced within the body and could either be direct or indirect

Answer 55

ausculation

Question 56

use of unaided ear

Answer 56

direct ausculation

Question 57

use of stethoscope

Answer 57

indirect auscultation

Question 58

constitutes another source of objective data, which is important in assessing many health problems and conditions

Answer 58

using laboratory results

Question 59

enumerate the hierarchy of needs from the lowest to highest level

Answer 59

physiological, safety, love and belonging, esteem, self-actualization

Question 60

This model describes the client’s need for adequate nutrition, normal elimination, and adequate rest to promote normal human functioning and development

Answer 60

orem’s self care model

Question 61

• the act of double-checking or verifying data to confirm that it is accurate and factual
• differentiate between cues and inference

Answer 61

validation

Question 62

• should include all data collected about the client’s health status
• recorded in a factual manner and not interpreted by the nurse

Answer 62

documentation