Week 4 Assessment Flashcards

1
Q

CUS communication tool

A

Concerned:

Clearly state your concern. Express your worry or unease about a specific aspect of the patient’s condition or care.

Uncomfortable:

Clearly communicate that you feel uncomfortable with the current situation. This emphasizes the emotional aspect of your concern and the impact it may have on the patient.

Safety:
Explicitly reference the safety implications. Connect your concern and discomfort to

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2
Q

ability to understand and share the feelings of another person. It involves putting oneself in someone else’s shoes,

A

Empathy

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3
Q

A __________ is a professional and purposeful connection between a (counselor, therapist, nurse, or mentor) and an individual seeking assistance or support

A

helping relationship

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4
Q

_________, also known as lateral violence or workplace bullying, refers to aggressive, intimidating, or disruptive behavior that occurs among individuals at the same hierarchical level within an organization.

A

Horizontal violence

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5
Q

__________ refers to the exchange of information, thoughts, feelings, and meaning between individuals

A

Interpersonal communication

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6
Q

_____ communication refers to the internal dialogue and self-talk that occurs within an individual’s mind.

A

Intrapersonal

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7
Q

The SBAR communication tool helps ensure that essential information is effectively communicated, reducing the risk of miscommunication and improving patient safety.

It is widely used during shift handoffs, when escalating concerns to a higher level of care, or when collaborating among healthcare team members.

What does SBAR stand for?

A

Suitation
Background
Assessment
Recommendation

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8
Q

study of meaning in language.

How words, phrases, and sentences convey meaning,

A

Semantics

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9
Q

What does SOAP / SOAPIE(R) Charting

A

Subjective
Objective
Assessment
Plan
Intervention
Evaluation
Revision

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10
Q

SOAP/SOAPIER

how does the client feel

A

Subjective

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11
Q

SOAP/SOAPIER

Results of physical exam, vital signs

A

Objective

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12
Q

SOAP/SOAPIER

What is the client’s status

A

Assessment

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13
Q

SOAP/SOAPIER

Is a changed needed in the treatment

A

Plan

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14
Q

SOAP/SOAPIER

What occurred, what did the nurse do?

A

Intervention

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15
Q

SOAP/SOAPIER

What is the client’s outcome after the intervention

A

Evaluación

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16
Q

SOAP/SOAPIER

What changes are needed to the care plan?

A

Revision

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17
Q

SOAP/SOAPIER

Paitent is hypotensive

A

Assessment

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18
Q

SOAP/SOAPIER

Patient instructed not to get out of bed, notify provider

A

Plan

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19
Q

SOAP/SOAPIER

0.9 NS 500 cc bolus IV x 1 given per order

A

Intervention

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20
Q

SOAP/SOAPIER

After intervention:

BP = 110 / 62, patient denies dizziness and light headedness

A

Evaluation

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21
Q

_____ assessment is an on going process integrated with nursing care. Uses to determine the status of a particular problem identified in an earlier assessment

Exp.

Hourly I&O

A

Problem focused assessment

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22
Q

This type of assessment is preformed during a crisis to ID life threatening problems

Exp.

Rapid Assessment of patients airway, breathing status, and circulation during cardiac arrest.

A

Emergency assessment

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23
Q

Examples

Reassessment of a patient’s health status outpatient or home care or a shift assessment in the hospital

A

Time-lapsed assessment

24
Q

____ involves including patients, families, and healthcare professionals in shared decision making

A

Patient-centered care

25
Q

Represents a person’s own internal sense of gender (formed by age 3)

A

Gender identity

26
Q

____ is how someone presents gender within context of culture and society

A

Gender expression

27
Q

3 phases of an interview

A

Introduction, Discussion, Summary

28
Q

At the end of an interview summarize data with patient allowing them to clarify information

Everyone is on the same page

True or False

A

True

29
Q

8 parts of comprehensive health history (Betty Chased Her Pet Puppy, Finding Pink Rabbits)

A

Biographical data
Cheif Complaint
History of Present Illness
Present Health Status
Past Health History
Family History
Personal and Psychosocial History
Review of systems

30
Q

When recording the Cheif Complaint use medical terminology in the report

True or False

A

False

Use patients own words

31
Q

What are the (9) parts of History of Present Illness

A

Previous history
Onset
Location
Duration

Characteristics
Aggravating/ Alleviating factors
Related Symptoms
Treatment
Severity

32
Q

Current health conditions

Medications

Allergies

Are all part of which part of the Comprehensive Data

A

Present Health Status

33
Q

Personal Status
Family/ Social relationships
Diet
Functional ability
Mental Health
Drug use
Health Promotion activities
Environment/ recent travel

A

Personal / Psychosocial History

34
Q

Childhood illnesses
Surgies
Hospitalizations
Accidents / injuries

A

Past Health History

35
Q

DM
CAD
Stroke
Cancer
Mental Illness
HTN
Alzheimer
Kidney
Endocrine
Seizures
High cholesterol

Are conditions to ask about during this part of a Complete History

A

Family History

36
Q

Screen for these 2 violence related problems during the interview

A

Domestic violence

Human trafficking

37
Q

Do these things

Noticing verbal and nonverbal Cues

Not making assumptions

Listening to full answer

A

Active listening

38
Q

Do these things

Exp.

Go on. Uh huh, then? Nodding shift forward in seat

A

Facilitation

39
Q

Do these things

Exp.

I feel so on edge.

What do you mean by on edge?

A

Clarification

40
Q

Do these things

Uses to gain clarification by restating phrase patient used in the form of a question

A

Reflection

41
Q

Do these things

When noticing inconsistencies

Try not to sound accusatory

Tone matters

A

Confrontation

42
Q

Shares the conclusions drawn from data given

You shared you only sleep 4 hours a week and work 60. I am wondering if this is why your so fatigued

A

Interpretation

43
Q

Do these things

Condenses data into clear and concise order. Helpful when patient is all over the place

A

Summarization

44
Q

Which is better

Why did you wait so long to come to the hospital

I am wondering what made you decide to come to the hospital when you did

A

2nd

45
Q

Is it ever appropriate to share personal stories with patients

A

Yes

Be breif

46
Q

Are silences good during an interview

A

Yes, they can be used to get more information

47
Q

Assessment Overview

Collect data ( Nursing history interview, physical exam)

Ongoing Assessment
(Interview , examination)

______, ________, ______

A

Validate, organize, record data

48
Q

In male adults above 50 years of age () , does administering pain relief medication throughout the surgery () compared to taking the same medicine post-surgery () reduce pain relatively () six hours after the surgery (_)

A

P
I
C
O
T

49
Q

In adult cancer patients experiencing fatigue (), what is the effect of meditation (), compared with standard care (), on quality of life () within 6 months (_)

A

P
I
C
O
T

50
Q

Does telemonitoring blood pressure () in patients with hypertension () affect blood pressure control () within one year of initiation of the medication ()

A

I
P
O
T

51
Q

Step of Evidence Based Practice (EBP) to assess and ask when researching to formulate a searchable Clinical Question by helping to develop key terms.

A

Patient
Intervention
Comparison
Outcome
Time.

52
Q

Current health condition, Medications, Allergies

Make up what?

A

Present Health Status

53
Q

Is tone of voice verbal or nonverbal communication

A

Nonverbal

54
Q

Readiness for enhanced communication

A

Wellness diagnosis

55
Q

Impaired verbal communication

R/T insufficient stimuli, cultural incorgruence, physiological condition, alternation in perception, emotional disturbance

AEB difficulty speaking,  slurred speech, inappropriate verbaliztion, disoriented to person, place or time, inability to speak language of caregiver
A

Nursing Diagnosis

56
Q

Assessment Documentation is written how?

A

Subjective
Objective
Assessment
Plan
Intervention
Evaluation
Revision

57
Q

Privacy
Age
Culture
Gender expression & Identity
Language
Physical/ Emotional Distress
Sensory / Cognitive

Are all concerned with

A

Paitent-Centered Approach