Nursing 100 Assessment questions
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| 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
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| Assessment | collect organize, validate and document patient data
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| diagnosing | analyze and synthesize data
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| planning | determine how to prevent reduce, and resolve client problems
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| implementing | perform planned nursing interventions, reassessment of patient and documentation
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| evaluation | measure the degree to which goals have been achieved
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| four types of assessments are | initial, problem focused emergency, time lapsed reassessment
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| collecting data | gathering information about clients health status
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| organizing data | writing data into an organized format
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| validating data | verifying that data is complete and accurate
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| documenting data | recording data in a factual manner
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| 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
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| subjective data is | symptoms, described, verified by the person affected, including sensations, feelings, values, beliefs, attitudes and perceptions
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| objective data is | signs, can be observed, measured and tested, obtained by observation or physical examination
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| interviewing is | a planned communication or conversation with a purpose
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| directive interview is | structure and obtains specific information
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| nondirective interview/rapport is | builds a relationship and understanding between the patient and nurse
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| a closed question is | restrictive "yes or no" answers
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| open-ended questions | allow clients to explore and talk about feelings
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| neutral questions | client may answer with out influence of the nurse
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| leading questions are | closed ended that directs the client's answer
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| Maslow's hierarchy of needs include | self- actualization, esteem, love/belonging, safety, and physiological
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| validating data | verify or "double check" data to confirm that it is accurate
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| documenting data | recorded in a factual manner, includes all data collected about clients health status, subjective data recorded in clients own words
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| two components of health status | health history and physical examination
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| 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
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| 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
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| 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
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| what position is the patient lying on their back legs extended with or without pillow under their head? | supine (horizontal recumbent)
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| 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
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| 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'
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| what position is the patient in lying on their abdomen with their head turned to the side, with or without a small pillow? | prone
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| what to look for during a visual inspection | moisture, color, texture of body surfaces, shape, position, size, and symmetry
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| what to determine while palpating | texture, temperature, vibration, position, size, and mobility of organs, distention, pulsation, tenderness or pain
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| 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.
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| what are the five sounds to listen to during percussions? | flatness, dullness, resonance, hyperresonance, and tympany
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| two types of percussions | direct; strike area with pads of fingers. indirect; strike an object held against the body
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| two types of ausculation | direct; use of unaided ear. indirect; use of a stethoscope
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| ausculatated sounds are described according to | pitch; frequency of vibrations, intensity; loudness or softness, duration; length of sound, and quality; description of sound
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| general survey | involves observation of the clients general appearance, assessed while taking client's health history
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| what do you look for during a general survey? | appearance and mental status; culture, educational level, socioeconomic status, and current situation
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| vital signs are used to | establish baseline data against current findings, detect health care problems
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| vital signs include | temperature, pulse, respirations, blood pressure, oxygen saturation and pain
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| Gerontology | study of again or older adults
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| geriatrics | medical car of older adults
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| the role of a geriatric nurse is | provider of care, teacher, manager, advocate, and research consumer
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| care setting for the older adult include | acute care, long term care, hospice, rehabilitation, and community
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| neuromuscular | loss of height, loss of bone mass, joint stiffness, and impaired balance
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| interventions for neuromucular | active and passive range of motion, physical activity programs, adequate vitamin d and calcium intake, and fall prevention
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| changes in vision include | decreased visual acuity, decreased adaptation to the dark, decreased vision of near and far, and difficulty distinguishing colors
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