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Nursing process

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Approach to identify, diagnose, and treat human responses to health and illness

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Assessment

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Collection, verification, and analysis of data (1st step in nursing process)

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Database

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The client's perceived needs, health problems, and responses

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Cue

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Information that was obtained through the use of the senses

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Inference

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Your judgment or interpretation of cues

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List Gordon's 11 functional health patterns.

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1. health perception-health management pattern 2. nutritional-metabolic pattern 3. elimination pattern 4. activity-exercise pattern 5. sleep-rest pattern 6. cognitive-perceptual pattern 7. self-perception-self-concept pattern 8. role-relationship pattern 9. sexuality-reproductive pattern 10. coping-stress tolerance pattern 11. value-belief pattern

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What are the two primary sources of data

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Subjective Data & Objective Data

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Subjective Date

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Client's verbal descriptions of health problems

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Objective Data

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Observations of measurement of a clients health status

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Identify the variety of sources where data can be obtained.

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a. client b. family and significant others c. health care team d. medical records e. literature

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During the initial interviewing process, nurses have the opportunity to...

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a. introduce yourself, explain your role b. establish a caring therapeutic relationship c. get insight about the client's concerns d. determine the client's goals and expectations e. obtain cues about which parts of the data collection phase require further investigation

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Protected health information includes demographic data that relates to:

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a. an individual's past, present, or future physical or mental health or condition b. the provision of health care to the individual c. the past, present, or future payment for provision of health care to the individual

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Nursing health history includes...

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Data about the client's current level of wellness, review of systems, family history, sociocultural history, spiritual history, and mental and emotional reactions to illness

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Open-ended questions

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prompts clients to describe a situation in more than one or two words

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Back channeling

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active listening prompts

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Closed-ended questions

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limit the client's answers to one or two words

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Biographical information

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factual demographic data about the client

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Reasons for seeking health care

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Client's perception

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Clients expectations

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What is important to the client

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Present illness / Health Concerns

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Essential and relevant data about the nature and onset of symptoms

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Health history

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Health care experiences and current health habits and lifestyle patterns

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Family history

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Data about the immediate and blood relatives

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Environmental history

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Client's home and work, focusing on determining the client's safety

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Psychosocial history

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Reveals the client's support systems, coping mechanisms

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Spiritual history

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Represents the totality of one's being

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Review of systems

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Systematic method for collecting data from all body systems

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Data Validation

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Is the comparison of data with another source to determine data accuracy

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Data analysis

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Involves recognizing patterns or trends in the clustered data, comparing them with standards, and then coming to a conclusion about the client's responses to a health problem

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Identify some common practices related to documentation, the last part of a complete assessment.

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Timely, thorough, and accurate; record all observations; pay attention to facts and be descriptive; record objective information in accurate terminology; do not generalize or form judgments

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The interview technique that is most effective in strengthening the nurse-client relationship by demonstrating the nurse's willingness to hear the client's thoughts is?

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Open-ended question

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While obtaining a health history, the nurse asks Mr. jones if he has noted any change in his activity tolerance. This is an example of which interview technique?

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Direct Question

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Mr. Davis tells the nurse that he has been experiencing more frequent episodes of indigestion. The nurse asks if the indigestion is associated with meals or a reclining position and asks what relieves the indigestion. This is an example of which interview technique?

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Problem-solving

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Review of systems (ROS)

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Systematic method for collecting data on all body systems.

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The information obtained in a review of systems (ROS) is? (objective or subjective)

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Subjective

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The Five Steps to the Nursing Process

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assessment, diagnosis, planning, implementation, and evaluation.

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Inference

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Taking one proposition as a given and guessing that another proposition follows.

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Nursing

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Diagnosis and treatment of human responses to actual or potential health problems.

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Functional health patterns

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Method for organizing assessment data based on the level of client function in specific areas (e.g., mobility).

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Interview

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Type of communication with a client that is initiated for a specific purpose and focused on a specific content area.

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Standards

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Measure or guide that serves as a basis for comparison when evaluating similar phenomena or substances.

Nursing Intro Ch16 – Nursing Assessment – Flashcards

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