Nursing Exam 1, with verified answers, Exams of Nursing

Download Nursing Exam 1, with verified answers and more Exams Nursing in PDF only on Docsity! Nursing Exam 1 -subjective + objective data - assessment who are ALWAYS assessing - nurses ___________ defines nursing as the The "protection promotion, and optimization of health abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human responses and advocacy in the care of individuals, families, communities, and populations" - ANA which standard of nursing practice is this: the registered nurse collects comprehensive data pertinent to the patients health or situation - standard 1 which standard of nursing practice is this:t he registered nurse analyzes the assessment data to determine the diagnosis or issues - standard 2 what has changed significantly over the years? - nurses role in health assessment nursing is the first health profession to see an individual in many_________ - communities nursing is the only health profession that continually at the_____________ - bedside who is the only person that sees the patient during rounds? - NP/MD what do nurses use to arrive at professional clinical judgments? - communication and physical assessment techniques what has expanded the role of assessment and the development of managed care and has increased the necessity for assessment? - technology collects holistic subjective and objective data to determine a clients overall level of functioning in order to make a professional clinical judgment - holistic nursing assessment focuses primarily on the clients physiologic development status - physical medical assessment -assessment -diagnosis -planning -implementation -evaluation - phases of the nursing process ____________helps to organize information and promotes the collection of holistic data - framework Initial comprehensive assessment Ongoing or partial assessment Focused or problem-oriented assessment Emergency assessment - types of health assessment -collection of subjective data -collection of objective data -validation of data -documentation of data - steps of the assessment phase Biographic information History of present health concerns: physical symptoms related to each body part of system Personal health history Family and lifestyle practices Review of systems - subjective data Physical characteristics -permanent legal record of the care -forms client acuity system -provides access to significant epidemiological data -promotes compliance with legal accreditation, reimbursement, and professional standard requirements - purpose of documentation Keep confidential• Document legibly Use correct grammar and spelling Avoid wordiness Use phrases instead of sentences Record data findings Write entries objectively Record the clients understanding and perception of problems Avoid recording the word "normal" for normal findings- explain and give details• Support objective data with specific observations obtained during the physical examination are all important in_________ - documenting data -initial assessment form -frequent or ongoing assessment form -focused or speciality area assessment form - assessment forms for documentation SBAR is what nurse does before calling a dr. what does it stand for - Situation, background, assessment, recommendation communicate face to face allow time for the reciever to ask questions allow time to ask questions provide documentation validate what the receiver had heard by question for summery reporting over the telephone- ask the receiver to read back what they heard - communicating SBAR diagnostic phase or clinical reasoning phase - data analysis how nurses process information using knowledge, past experiences, intuition, cognitive abilities - critical thinking is the identification of a nursing diagnosis, collaborative problem, or need for referral to. another healthcare professional - purpose of analysis of data 1. Keep an open mind 2. Use rationale to support opinions or decisions 3. Reflect on thoughts before reaching a conclusion 4. Use past clinical experiences to build knowledge 5. Acquire an adequate knowledge base that continues to build 6. Be aware of the interaction of others 7. Be aware of the environment - Essential critical thinking characteristics Group and organize data Validate and compare with normal findings / values Cluster data to make inferences• Generate hypothesis regarding clients problems Formulate a professional clinical judgment Validate the judgment with the client - essential components of the diagnostic phase Step one: identify strengths and abnormal data Step two: cluster data Step three: draw inferences Step four: propose possible nursing diagnosis Step five: check for defining characteristics Step six: confirm or rule out diagnosis• Step seven: document conclusion - diagnostic reasoning process expertise comes with___________and____________ - knowledge and experience when do pitfalls occur? - assessment phase and the analysis of data phase 1. identify abnormal cues (problems) and supportive cues (strength) 2. cluster cues 3. draw inferences to propise clinical judgments (areas of health improvement, risks, problems, referral) 4. identify possible client concerns 5. validate concerns (with the client, family/caregivers, health team members 6. document - steps to making clinical judgements what does AIDET stand for? - acknowledge, introduce, duration, explanation, thank you when does the general survey start? - the moment you meet the patient what is the initial objective data you collect when doing a general survey? - general impression of the client what are anthropometric measurments? - height, weight, vital signs how well your body balances heat from metabolism, exercise, food digestion, external factors - temperature sweat, ovulation/menstruation, strenuous exercise, age, stress, time of day, exposure to cold or heat, or illness - alterations in temperatures what are four ways to take temps? - tympanic, oral and axillary, temporal, rectal non invasive and non traumatic - tympanic inexpensive and easy to read - oral and axillary quick and convenient and well tolerated - temporal