SEMI-FINALS Flashcards

1
Q

A systematic,rational method of planning providing nursing care

A

NURSING PROCESS

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2
Q

TYPES OF ASSESSMENT

A

Initial assessment
Problem-focused assessment
Emergency assessment
Time-lapsed reassessment

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3
Q

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

A

data collection

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4
Q

Referred to a symptoms or covert data , appeared only to the person affected ( client’s sensations, feelings,values)

A

subjective data

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5
Q

referred to as signs or overt data, are detectable by an observer or can be measured

A

objective data

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6
Q

is the client

A

primary source

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7
Q

family or anyone else that is not the client

A

secondary source

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8
Q

methods of data collection

A

observing
interviewing
examining

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9
Q

is gather data by using the sense, conscious,deliberate skill that is developed through effort and with an organized

A

observing

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10
Q

is planned communication or a converstation with purpose, for example, to get or give informartion

A

interviewing

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11
Q

two approaches of interviewing

A

directive interview
nondirective interview

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12
Q

directs interview,client responds to question and has limited chances to discuss concerns

A

directive interview

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13
Q

rapport-building where the client is in control of the purpose

A

nondirective interview

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14
Q

invites client to discover and explore,elaborate,clarity, or illustrate their thoughts and feelings

A

open-ended

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15
Q

used in directive interviewing, are question that is recquire yes or no

A

close-ended

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16
Q

a question that the client can answer without direction,’‘what do you think you had the operation?’’

A

neutral question

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17
Q

directs the clients answer,’’ your are stressed about the surgery tommorow,aren’t you?’’

A

leading question

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18
Q

systematic data-collection method that uses observation to detect health problems

A

examining

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19
Q

using a written or computerized format that organizes the assessment data

A

organizing data

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20
Q

is the act of ‘‘double checking or veriyfing data to confirm that is accurate or factual

A

validation

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21
Q

subjective or objective data can be observed by the nurse,either what the client says or what the nurse can see

A

cues

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22
Q

nurse intrepretations or conclusions based on the cues

A

inferences

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23
Q

to complete the assessment phase, the nurse records client data

A

documenting data

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24
Q

TYPES OF NURSING DIAGNOSIS

A

actual diagnosis
risk nursing diagnosis
wellness diagnosis
possible nursing diagnosis
syndrome diagnosis

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25
client problem that is present at the time of the nursing assessment
actual diagnosis
26
clinical judgement that a problem does not exist,but the presence of risk factors indicates that a problem is likely to develop unless nurse intervene
risk nursing diagnosis
27
describes human responses to levels of wellness in an individual,family or community that have a readiness for enhancement
wellness diagnosis
28
one in which evidence about health problem is incomplete or unclear
a possible nursing diagnosis
29
is associated with a cluster of other diagnosis
syndrome diagnosis
30
is cognitive process during which a person reviews data and considers explanation before forming an opinion
critical thinking
31
THE DIAGNOSTICS PROCESS
analyzing data indentifying health problems,risks, and strengths formulating diagnostics statements
32
describes the client's health problem or response for which nursing theraphy is given
problem satement
33
added words to give additional meaning to diagnosis statement
qualifiers
34
change from baseline
altered
35
made worse, weakened, damaged
impaired
36
smaller in size, amount or degree
decreased
37
not producing the desired effect
ineffective
38
severe or short duration
acute
39
lasting a long time
chronic
40
describe's the client's health problem or response for which nursing therapy is given
diagnostic labels
41
areas of health care that are unique to nursing and seperate and distinct from medical management
independent function
42
nurses are obligated to carry out physicians-prescribed therapies and treatments
dependent function
43
monitoring the client's condition and preventing development of the potential complication and using physicians-prescribed interventions
collaborative
44
involve human response, which vary from one peson to the next
nursing diagnosis
45
is done by all nurses who work with the client
ongoing planning
46
process of anticipating and planning for discharge, is crucial part of comprehensive health care and should be addressed in each client's care plan
discharge planning
47
TYPES OF NURSING CARE PLAN
informal nursing care plan formal nursing care plan standardized nursing care plan individualized nursing care plan
48
strategy for action that exist in the nurse's mind
informal nursing cae plan
49
written or computerized guide for organizing information
formal nursing care plan
50
formal plan that specifies the nursing care for groups of clients with common needs
standardized nursing care plan
51
is tailored to meet the unique needs of the specific client
individualized nursing care plan
52
is the process of establishing a preferential sequence for addressing nuring diagnosis and intereventions
planning process
53
TYPES OF NURSING INTERVENTIONS
independent interventions dependent interventions collaborative interventions
54
are those activities that nurse are liscensed to initiate on the basis of their knowledge and skills
independent interventions
55
are activities carried under the physician's orders or supervision or according t specified routines
dependent interventions
56
are actions that nurse carries out in collaboration with other health team members,such as physical therapist, social workers, dietitians, and physicians
collaborative interventions
57
are instructions for the specific individualized activites that nurses performs to help the client meet established health care goals
nursing orders
58
such as analyzing the problem, problem solving, critical thinking and making judgements
cognitive or intellectual skills
59
therapeutic communication,active listening,conveying knowledge and information, developing trust or rapport- building
intrapersonal skills
60
includes knowledge and skills needed to properly and safely manipulate and handle appropriate equipment needed by the patient
technical skills
61
PROCESS OF IMPLEMENTING
reassessing the client determinig the nurse's need for assistance implementing the nursing interventions supervisng delegated care documenting nursing activities
62
is planned,ongoing,purposely activity in which clients and health care professionals determine
evaluating
63
PROCESS OF EVALUATING CLIENT RESPONSES
collecting data comparing data with outcomes relating nursing activites to outcomes drawing conclusions about problem status continuing,modifying,and terminating the nursing care plan
64
is an ongoing,systematic process designed to evaluate and promote excellence in the health care provided to clients
quality assurance
65
quality assurance consist of:
the structure evaluation the process evaluation outcome evaluation
66
focuses on the setting in which care is given.It answer this questions; what effect does the setting have on the quality of care?
structure evaluation
67
focuses in how the care is given
process of evaluation
68
focuses on demonstrable changes in client's health status as the result of nursing care
outcome evaluation