Weeks 1 and 2- Nurse's Role, Documentation, Health Hx, Social/cultural

Question 1

CAGE test

Answer 1

screening questionnaire to identify excessive drinking:

• C Cut down - Have you ever thought you should cut down your drinking?
• A Annoyed - Have you ever been annoyed by criticism of your drinking?
• G Guilty - Have you ever felt guilty about your drinking?
• E Eye-opener - Do you drink in the morning (i.e. an eye-opener?)

Question 2

PES

Answer 2

problem- etiology - symptoms/defining characteristics

Diagnosis (P) r/t Etiology (E) aeb Characteristics (S)

Question 3

disease condition based on specific evaluation of signs and symptoms

Answer 3

medical diagnosis

Question 4

nursing diagnosis

Answer 4

judgment about the PT in response to an actual or potential health problem

Question 5

an actual or potential physiological complication that nurses monitor to detect the onset of changes in patient’s status

Answer 5

collaborative diagnosis

Question 6

3 types of nursing diagnoses

Answer 6

actual
risk (potential)
wellness (health promotion)

Question 7

Healthy People 2020

Answer 7

framework for health promotion efforts. Objectives address most significant preventable threats to health with goals to reduce threats

Question 8

functional assessment

Answer 8

focuses on the functional patterns that all humans share: health perception and health management, activity and exercise, nutrition and metabolism, elimination, sleep and rest, cognition and perception, self-perception and self-concept, roles and relationships, cop- ing and stress tolerance, sexuality and reproduction, and values and beliefs

Question 9

role of the professional nurse

Answer 9

to promote health, prevent illness, treat human responses, and advocate for patients.

Question 10

SOAP

Answer 10

subjective-objective-assessment-plan

Question 11

PIE

Answer 11

problem-intervention-evaluation

Question 12

DAR

Answer 12

data-action-response

Question 13

CBE

Answer 13

charting by exception

Question 14

What is SBAR for?

Answer 14

it is a mental model for organizing verbal communication

**It does NOT replace written documentation!!

Question 15

Computerized provider order entry (CPOE)

Answer 15

allows providers to enter all orders directly into the computer, electronically communicating orders to the laboratory, pharmacy, and nursing unit

Question 16

purpose of auditing charting

Answer 16

To determine if staff members are providing and documenting standards of care

Agencies usually perform audits to look at systems, not individuals, and to determine whether staff members are meeting the standard of care

Question 17

what are the 4 phases of an interview

Answer 17

preinteraction (always review the record chronologically)
beginning (introduce yourself)
working (assessing, asking questions, head to toe, etc)
closing (summarize!)

Question 18

aphasia

Answer 18

name given to a collection of language disorders caused by damage to the brain

Question 19

what does it mean to be culturally sensitive

Answer 19

Possessing basic knowledge of and constructive attitudes toward diverse cultural populations

Question 20

what does it mean to be culturally appropriate

Answer 20

Applying underlying background knowledge necessary to provide the best possible health care

Question 21

what does it mean to be culturally competent

Answer 21

Understanding and attending to the total context of the individual’s situation, including immigration status, stress factors, other social factors, and cultural similarities

Question 22

Race

Answer 22

genetic in origin and includes physical characteristics:

 Skin color, bone structure, eye color, and hair color

Question 23

What are the CLAS standards

Answer 23

There are 14 standards, made to ensure equitable and effective treatment

Organized around 3 themes:

1) Culturally Competent Care (Standards 1–3),
2) Language Access Services (Standards 4 –7), and
3) Organizational Supports for Cultural Competence (Standards 8–14).

Question 24

Purnell model of cultural care

Answer 24

Addresses subjective (attitudes, beliefs, values, behaviors) culture and does not address objective (material) culture. This is NYU’s model for culturally competent care

Question 25

The nurse assessing an older adult focuses the health history on

Answer 25

sensory deficits, illness history, and lifestyle factors

Question 26

CAM therapies used ______of conventional treatments to restore health are often termed _______, whereas CAM therapies used _____conventional medicine are often labeled _______.

Answer 26

INSTEAD, alternative

WITH, complementary

Question 27

Culture can be defined as

Answer 27

a shared, learned, and symbolic system of values, beliefs, and attitudes that shapes and influences the way people see and behave in the world

Question 28

The purpose of comparing culture care needs of the specific individual to the general themes of people from similar cultural background is to:

Answer 28

provide a picture of the individual’s culture-based health care needs

Question 29

With transcultural assessment, the nurse must

Answer 29

determine which questions to ask (the list is too extensive to ask everything!)