Ch. 3 Timby for test 1
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| Actual diagnosis | nursing diagnosis that identifies an existing problem
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| Assessment | step in the nursing process that involves the careful observation and evaluation of a client's health status.
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| Client database | collection of information from the client's medical and nursing history, physical examination and diagnostic studies
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| Collaborative problems | complications with a physiologic origin that nurses manage using physician-prescribed and nursing prescribed intervention
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| Concept Mapping | method that links important ideas about the care a client requires and provides a means for students and nurses to consider all the client's problems and develop a plan to treat them.
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| Critical Thinking | intentional, contemplative, outcome-directed thinking
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| Documentation | written record of client care
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| Evaluation | step in the nursing process that involves the assessment and review of the quality and suitability of care and the client's response to that care
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| Expected Outcomes | client goals derived from nursing diagnoses that are measurable, achievable and developed with the client, family, and other healthcare providers
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| Health Promotion diagnosis | reflects clinical judgement of a client's motivation to increase well-being and enhance health behaviors
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| Implementation | Step in the nursing process that involves carrying out the written plan of care, performing the interventions, monitoring the client's status, and assessing and reassessing the client before, during, and after treatments
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| Intervention | actions for achieving outcomes in a plan of care
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| Nursing diagnosis | step in the nursing process in which the nurse identifies and defines health-related problems
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| Nursing orders | specific nursing directions given so that all health-care team members understand exactly what to do for the client
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| Nursing process | problem-solving approach for planning and implementing client care to achieve desired outcomes; the five steps of the nursing process are assessment, diagnosis, planning, implementing, and evaluation
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| Planning | step of the nursing process that involves setting priorities, defining expected outcomes, determining expected outcomes, determining specific nursing interventions, and recording the plan of care
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| Risk diagnosis | nursing diagnosis that identifies potential problems
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| Syndrome diagnosis | nursing diagnosis that is associated with a cluster of other diagnoses
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| Wellness diagnosis | category of nursing diagnoses that begins with the stem "potential for enhanced" and does not include related factors or supporting data
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| Goal-directed | characteristic of the nursing process where the nurse and the client work together to achieve set goals
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| Prioritized | characteristic of the nursing process where focused care resolves the health problems with the greatest risk first
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| Dynamic | Nursing process is always changes as the client changes
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| Process or Processing- | typically describes the actions of taking something through an established and routine set of procedures or steps to convert it from one form to another.
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| During the assessment stage of the nursing process..... | the nurse collects and organizes data
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| Objective data | observable and measurable facts (Signs)
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| Subjective data | Information that only the client feels and can describe (symptoms)
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| Initial observation | Breathing, how is the patient feeling. Appearance, Affect(attitude or mood), skin color
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| When doing a quick head-to-toe assessment what should the nurse observe with the patient's head? | Level of consciousness (LOC), Ability to communicate, mental status, Appearance of Eys
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| What are the vital signs? | Temperature, pulse, respiration, blood pressure (Pain assessment)
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| Through systematic assessment, the nurse identifies the clients: | Current and past health status, Current and past functional status, Coping patterns, health beliefs and relevant cultural practices, risks for potential heath problems, responses to care, nursing care needs, referral needs
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| what are the LVN roles of the assessment phase of the nursing process? | gather data, preforms assessment, identifies client's strengths
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| what are the LVN roles of the Diagnosis phase of the nursing process? | does not establish nursing diagnosis, but needs to understand diagnoses written by RN
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| what are the LVN roles of the Planning phase of the nursing process? | Contributes to development of care plans
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| what are the LVN roles of the Implementation phase of the nursing process? | Provides basic therapeutic and preventive nursing measures, provides client education, records information
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| what are the LVN roles of the Evaluation phase of the nursing process? | Evaluates effects of care given
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| Maslow's hierarchy of needs: | Self-actualization
Self-Esteem
Love and Belonging
Safety & Security
Physiological
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| Name the three parts to the diagnostic statement: | 1)name (or label of the problem), 2)cause of the problem, 3) S/S (signs & symptoms) or data that indicate the problem
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| What are expected outcomes? | Client goals derived from a nursing diagnoses that are measurable and achievable and developed with the client, family or other health providers
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| Why should patients be included when creating their care plan? | When planning care, clients must be included in order for them to accept responsibility for their choices and the consequences of their choices. They have the right to accept or reject health care
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| Accurate and thorough documentation in the medical record serves which five functions? | Communicates care, shows trends and patterns in client status, creates a legal document, supplies validation for reimbursement, and Provides a foundation for evaluation, reasearch, and quality improvement
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| By law nurses must document......... | all nursing actions, observations, and client responses
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| Objective data | facts obtained though observation
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| Subjective data | are statements that the client makes about what he/she feels
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| Through a systematic assessment the nurse identifies the client's: | Current and past health status; current and past functional status; coping patterns; health beliefs and relevant cultural practices; risks for potential health problems; responses to care; nursing care needs; referral needs
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| Symptoms- | physical feelings experienced by patient
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| Signs- | when objective data are abnormal ex. elevated blood pressure
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| During the preinterview period you should: | establish rapport, explain the purpose of the interview
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| Open-ended questions | questions asked during a client interview that require discussion
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| Closed questions | questions asked during a client interview that require only "yes" or "no" answers
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| Components of the interview: | psychosocial and cultural history; chief complaint; functional status (self care ability); history of the present illness; Past health history; family history;review of body systems
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| Psychosocial history | - information obtained during a client interview about the client's age occupation, religious affiliation, cultural background, marital status, and home and working environments
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| Auscultation | - listening with a stethoscope for normal and abnormal sounds generated by organs and structures such as the heart, lungs, intestines, and major arteries
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| chief complaint | that which the client percieves to be the health problem that needs treatment
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| cultural history | information obtained during a client interview about the client's religious affiliation, cultural background, and health beliefs
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| focus assessment | detailed information about one body system or problem
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| functional assessment | how well the client can manage activities of daily living (ADL) ex. bathing, walking, and toileting
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| head to toe method | technique used for carrying out an examination by beginning at the top of the body and progressing downward
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| Inspection | systematic and thorough observation of a client and specific areas of a client's body
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| Palpation | assessing the characteristics of an organ body part by touching and feeling it with the hands or fingertips
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| past health history | information obtained during a client interview regarding a client's childhood diseases, previous injuries, major illnesses, prior hospitalizations, surgical procedures and drug history
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| percussion | tapping a portion of the body to determine if there is tenderness or to elicit sounds that vary according to the density of underlying structures
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| physical assessment | examination of a client's body structures
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| systems method | technique for carrying out an examination by assessing each body system separately
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| "Imbalanced nutrition: Less than body requirements related to loss of appetite, difficulty swallowing and effects of chemotherapy" is an example of: | actual nursing diagnosis
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| A student nurse is assigned to care for a client who just had bowel surgery. When the nurse enters the client's room, the nurse knows that assessment of the client begins with: | the initial contact with the client
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| What are the four assessment techniques performed during a physical assessment? | inspection, palpation, percussion, and auscultation
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| A client is recovering from abdominal surgery complains of feeling full and bloated after a clear liquid lunch. Which type of assessment should be done? | Focus Assessment
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| How many sections should you check for bowel sounds? | 4
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