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Nur 100 Assessment
Nursing 100 Assessment questions
| Question | Answer |
|---|---|
| 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
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