question

the patient

answer

primary source of information

question

- initial comprehensive - focused - emergency - time-lapsed

answer

four types of nursing assessments

question

performed shortly after the patient is admitted to a healthcare agency or service

answer

initial comprehensive assessment

question

the nurse gathers data about a condition that has already been diagnosed

answer

focused assessment

question

when a physiologic or psychological crisis presents

answer

emergency assessment

question

compares a patient's current status to baseline data obtained earlier

answer

time-lapsed assessment

question

focus on the patient's response to health problems

answer

nursing assessment

question

target data pointing to pathologic conditions

answer

medical assessment

question

observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing them (ex.elevated temperature, skin moisture, vomiting)

answer

objective data

question

information perceived only by the affected person (ex. pain experience, feeling dizzy, feeling anxious)

answer

subjective data

question

- patient - family and significant others - patient record - other healthcare professionals - nursing and other healthcare literature

answer

sources of data

question

specifies the information that must be collected from every patient and uses a structured assessment form to organize or cluster data

answer

minimum data set

question

- preparatory phase - introduction phase - working phase - termination phase

answer

four phases of a nursing interview

question

the nurse prepares the patient and the environment for the interview

answer

preparatory phase

question

sets the tone for the remainder of the interview

answer

introduction phase

question

the patient database is obtained

answer

working phase

question

the conclusion of the interview

answer

termination phase

question

- appraisal of health status - identification of health problems - establishment of a database for nursing intervention

answer

purpose of a nursing physical assessment

question

- focus on the patient during the interview - listen to the patient attentively - ask about patient's main problem first - pose questions and comments in appropriate manner - avoid comments and questions that impede communication - use silence and touch appropriately

answer

successful interview techniques

question

allow patient to verbalize freely

answer

open-ended question

question

elicit specific information

answer

closed question

question

validate what is heard

answer

validating question

question

avert misconceptions

answer

clarifying question

question

encourage patient to elaborate on thoughts and feelings

answer

reflective question

question

place events in chronological order

answer

sequencing question

question

obtain more patient information

answer

directing question

question

- health orientation - developmental stage - culture - need for nursing

answer

establishing assessment priorities

question

- inappropriate organization of the database - omission of pertinent data - inclusion of irrelevant or duplicate data, erroneous or misinterpreted data - failure to establish rapport and partnership - recording an interpretation of data rather than observed behavior - failure to update the database

answer

problems related to data collection

question

- when there is a discrepancy between what the person is saying and what the nurse is observing - when the data lack objectivity

answer

when to verify data

question

- performing a physical examination using proper equipment and procedure - using clarifying statements - sharing inferences with other team members - checking findings with research reports - comparing cues to knowledge base of normal function - checking consistency of cues

answer

validating inferences

question

- immediately give verbal reporting of data whenever a critical change in the patient's health status is assessed - enter initial database into computer or record in ink on designated forms the same day patient is admitted - summarize objective and subjective data in concise, comprehensive, and easily retrievable manner - use good grammar and standard medical abbreviations - whenever possible, use patient's own words - avoid nonspecific terms subject to individual interpretation or definition

answer

documentation of data

question

the interpretation/analysis of patient data

answer

diagnosing

question

- recognizing signs and symptoms of common health problems and those that may indicate the need for more expert diagnosis - predicting problems in those at risk and taking steps to manage risks and prevent complications - identifying human responses and promoting optimum function, independence, and quality of life - initiating actions and referrals in a timely way to ensure appropriate, qualified treatment

answer

nursing concerns and responsibilities

question

describes patient problems nurses can treat independently

answer

nursing diagnosis

question

describes problems for which the physician directs the primary treatment

answer

medical diagnosis

question

managed by using physician-prescribed and nursing-prescribed interventions; focus on potential complications

answer

collaborative problems

question

- recognizing significant data - recognizing patterns or clusters - identifying strengths and problems - reaching conclusions (no problem, possible problem, actual/potential problem, clinical problem)

answer

four steps of data interpretation and analysis

question

diagnosed as a conclusion of data (ex. high blood pressure)

answer

reaching conclusions/possible problem

question

the comparison of data to a standard or norm (ex. normal blood pressure values)

answer

recognizing significant data

question

a grouping of patient data or cues that points to the existence of a problem (ex. a series of readings)

answer

data cluster

question

determine if the patient is motivated to address them

answer

identify strengths and problems

question

- problem - etiology - defining characteristics

answer

formulation of nursing diagnoses

question

identifies what is unhealthy about patient

answer

problem

question

identifies factors maintaining the unhealthy state

answer

etiology

question

identifies the subjective and objective data that signal the existence of a problem

answer

defining characteristics

question

- writing diagnoses in terms of needs, not responses - making legally inadvisable statements - identifying as a problem what is not necessarily unhealthful - identifying as a problem signs and symptoms - reversing the clauses - identifying as a patient problem what cannot be changed - identifying environmental factors rather than patient factors as the problem - having both clauses say the same thing - including value judgments in nursing diagnosis - including medical diagnosis in diagnostic statement

answer

sources of error when writing nursing diagnoses

question

- premature diagnoses based on incomplete database - erroneous diagnoses resulting from inaccurate or faulty database - routine diagnoses resulting from failure to tailor data to patient - errors of omission

answer

common sources of error in nursing diagnoses

question

c) smoking cigarettes The etiology is the factor that maintains the unhealthy condition (smoking cigarettes). Lung cancer is the problem, and the remaining factors are the distinguishing characteristics.

answer

A patient who admits to smoking two packs of cigarettes a day is diagnosed with lung cancer based on his symptoms and a series of test results. Which of the following is the etiology in this scenario? a) lung cancer b) test results c) smoking cigarettes d) the subjective and objective data

question

- actual - risk - possible - wellness - syndrome

answer

types of nursing diagnoses

question

- Is my database sufficient, accurate and supported by nursing research? - Does my synthesis of data (significant cues) demonstrate the existence of a pattern? - Are the subjective and objective data I used to determine the existence of a pattern characteristic of the health problem I defined? - Is my tentative nursing diagnosis based on scientific nursing knowledge and clinical expertise? - Is my tentative nursing diagnosis able to be prevented, reduced, or resolved by independent nursing action? - Is my degree of confidence >50% that other qualified practitioners would formulate the same nursing diagnosis based on my data?

answer

to validate nursing diagnoses, ask the following questions

question

- individualizing patient care - defining domain of nursing to healthcare administrators, legislators, and providers - seeking funding for nursing and reimbursement for nursing services

answer

benefits of nursing diagnoses

question

- if used incorrectly, patient might be "misdiagnosed" - nursing practice might be restricted

answer

limitations of nursing diagnoses

question

a) True A nursing diagnosis may be used to seek reimbursement for nursing services.

answer

A nursing diagnosis may be used to seek reimbursement for nursing services. a) True b) False

question

- establish priorities - identify and write expected patient outcomes - select evidence-based nursing interventions - communicate the plan of care

answer

purpose of outcome identification and planning

question

- individualize care that maximizes outcome achievement - set priorities - facilitate communication among nursing personnel and colleagues - promote continuity of high-quality, cost-effective care - coordinate care - evaluate patient response to nursing care - create a record used for evaluation, research, reimbursement, and legal reasons - promote nurse's professional development

answer

a formal plan of care allows the nurse to

question

- the law - national practice standards - specialty professional organizations - the joint commission - the agency for health care research and quality (AHRQ) - your employer

answer

applying standards to plan nursing care

question

- initial - ongoing - discharge

answer

three elements of comprehensive planning

question

- developed by the nurse who performs the nursing history and physical assessment - addresses each problem listed in the prioritized nursing diagnoses - identifies appropriate patient goals and related nursing care

answer

initial care planning

question

- carries out by any nurse who interacts with patient - keeps the plan up to date - states nursing diagnoses more clearly - develops new diagnoses - makes outcomes more realistic and develops new outcomes as needed - identifies nursing interventions to accomplish patient goals

answer

ongoing planning

question

- carried out by the nurse who worked most closely with the patient - begins when the patient is admitted for treatment - uses teaching and counseling skills effectively to ensure home care behaviors are performed competently

answer

discharge planning

question

- high priority - medium priority - low priority

answer

prioritizing nursing diagnoses

question

greatest threat to patient well-being

answer

high priority

question

nonthreatening diagnoses

answer

medium priority

question

diagnoses not specifically related to current health problem

answer

low priority

NUR 112: Taylor Ch 12-16 – Flashcards

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