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Nur 100 Assessment

Nursing 100 Assessment questions

QuestionAnswer
Nursing process is defined as a systematic, rational method of planning and providing nursing care, a logical approach to providing nursing care and ensuring that patient needs are met
Assessment collect organize, validate and document patient data
diagnosing analyze and synthesize data
planning determine how to prevent reduce, and resolve client problems
implementing perform planned nursing interventions, reassessment of patient and documentation
evaluation measure the degree to which goals have been achieved
four types of assessments are initial, problem focused emergency, time lapsed reassessment
collecting data gathering information about clients health status
organizing data writing data into an organized format
validating data verifying that data is complete and accurate
documenting data recording data in a factual manner
health history includes biographic data, chief complaint or reason for visit, history of present illness, past history, family history of illness, lifestyle, social data, psychological data, and patterns of health care
subjective data is symptoms, described, verified by the person affected, including sensations, feelings, values, beliefs, attitudes and perceptions
objective data is signs, can be observed, measured and tested, obtained by observation or physical examination
interviewing is a planned communication or conversation with a purpose
directive interview is structure and obtains specific information
nondirective interview/rapport is builds a relationship and understanding between the patient and nurse
a closed question is restrictive "yes or no" answers
open-ended questions allow clients to explore and talk about feelings
neutral questions client may answer with out influence of the nurse
leading questions are closed ended that directs the client's answer
Maslow's hierarchy of needs include self- actualization, esteem, love/belonging, safety, and physiological
validating data verify or "double check" data to confirm that it is accurate
documenting data recorded in a factual manner, includes all data collected about clients health status, subjective data recorded in clients own words
two components of health status health history and physical examination
what is the purpose of a physical exam? obtain baseline data, to validate data obtained in the nursing history, and to aid in establishing nursing diagnoses and the plan of care for patients
what items do you need to preform a health exam? stethoscope, pen light, blood pressure cuff, thermometer, otoscope, nasal speculum, lubricant, tongue blades, reflex hammer, tuning fork, cotton applicators and gloves
what position is the patient lying on their back with bent knees flexed and hips externally rotated, with a small pillow under the head; soles of feet on the surface? dorsal recumbent
what position is the patient lying on their back legs extended with or without pillow under their head? supine (horizontal recumbent)
what position is the patient lying on their back with their feet supported in stirrups; hips in line with the edge of the table? lithotomy
what position is the patient lying on their side with lowermost arm behind the body, uppermost leg flexed at hip and knee, upper arm flexed at shoulder and elbow sims'
what position is the patient in lying on their abdomen with their head turned to the side, with or without a small pillow? prone
what to look for during a visual inspection moisture, color, texture of body surfaces, shape, position, size, and symmetry
what to determine while palpating texture, temperature, vibration, position, size, and mobility of organs, distention, pulsation, tenderness or pain
what to determine during percussions shape and size of internal organs by establishing their borders, indicates whether tissue is filled with air, fluid or is solid.
what are the five sounds to listen to during percussions? flatness, dullness, resonance, hyperresonance, and tympany
two types of percussions direct; strike area with pads of fingers. indirect; strike an object held against the body
two types of ausculation direct; use of unaided ear. indirect; use of a stethoscope
ausculatated sounds are described according to pitch; frequency of vibrations, intensity; loudness or softness, duration; length of sound, and quality; description of sound
general survey involves observation of the clients general appearance, assessed while taking client's health history
what do you look for during a general survey? appearance and mental status; culture, educational level, socioeconomic status, and current situation
vital signs are used to establish baseline data against current findings, detect health care problems
vital signs include temperature, pulse, respirations, blood pressure, oxygen saturation and pain
Gerontology study of again or older adults
geriatrics medical car of older adults
the role of a geriatric nurse is provider of care, teacher, manager, advocate, and research consumer
care setting for the older adult include acute care, long term care, hospice, rehabilitation, and community
neuromuscular loss of height, loss of bone mass, joint stiffness, and impaired balance
interventions for neuromucular active and passive range of motion, physical activity programs, adequate vitamin d and calcium intake, and fall prevention
changes in vision include decreased visual acuity, decreased adaptation to the dark, decreased vision of near and far, and difficulty distinguishing colors
Created by: katpeterson on 2013-10-04



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