Holistic Assessment Exam 1 Questions and Answers

Holistic Assessment Exam 1 Questions and Answers What are the steps in the nursing process? assessment, diagnosis, outcome & planning, implementation, evaluation What is the correct way to assess the abdomen? inspection, auscultation, palpation, (percussion?) What is done in assessment? cluster data, gathering data from subjective and objective data. What assessments are done when gathering objective data? Inspection, palpation, percussion, Auscultation What is the highest priority in assessment? Airway, breathing, circulation, vital signs What is the secondary priority when assessing a patient? safety, security, mental status, unrelated emergent, acute pain, infection What is the third priority when assessing a patient? non urgent, long term intervention What is orthostatic hypotension? taking the blood pressure at different positions (laying, sitting, standing). decrease in 20 or greater btw each bp. If the blood pressure continues to drop until last phase, it is a positive test. if negative, may mean the symptoms are from a different cause like vertigo. What happens during a nursing diagnosis? assessment of data- organization and prioritizing. -actual vs potential risk -collaborative medical and nursing interventions What happens during outcome identification? identify expected outcomes. goal related, broad statements regarding to patient. realistic and measurable. a SMART goal What happens during the orientation phase of the nurse client relationship? introduction & purpose, set the contract; time and duration, confidentiality. the goal is to develop trust and security What happens during the working phase of the nurse client relationship client begins identifying problems to work on. development of strategies to help What happens during the termination phase? gives client the time to talk about the therapeutic work. summarize goals and achievements. What are the phases in a nurse client relationship? orientation, working, termination What is a SMART goal? Specific, Measurable, Achievable, Realistic, Timed What happens during the planning stage? -setting goals and measurable outcomes -identify nursing interventions needed to meet the goals. How long are should a short term goal be? a week, unless in acute care a few hours How long are long term goals? a few days/week/month T/F it is important to involve a patient & their family when setting/planing a goal T What is the implementation phase? the "doing phase", actually carrying out the plan What is the evaluation phase? How effective was the plan? Assess the response. Were the goals met? Plan and rework process as needed. Whats the difference between nursing and medical assessments? Nursing- diagnosis and treatment of responses to actual and potential health risks. Medical- diagnosis and treatment of disease Collecting data consists of? subjective, objective, observation from both the primary source (patient) and secondary source (caregiver) What are four types of data? 1. complete (total health)- complete body data. 2. focused or problem-centered data (single) 3. follow up database 4. emergency data base What is collected during a complete (total health) data ? complete health history and a full physical examination. It describes the current and past health state and forms a baseline. yields first diagnosis What is collected in a focused or problem centered database? used for limited or short term problem. "mini" database, smaller scope, and a more targeted complete database. Concern is "one body system" What is collected in an emergency database? rapid collection of crucial information and is often compiled with lifesaving measures. What is intrapersonal communication ? self talk What is interpersonal communication? One on one talk with another person. What is transpersonal communication? talking to others across disciplines What is small group communication? a huddle of people regardless of discipline What does SOLER mean? S-sit facing patient O- open stance L-lean toward patient E-establish and maintain eye contact R-relax When should open ended questions be asked? to begin a interview, to introduce a new section of questions, whenever the patient introduces a new topic When should close ended questions be asked? when specific information is needed When encountering confrontation, how should it be handled? frame of reference should shift from patient's perspective to yours. give honest feedback about what you see and feel What are the steps in the nursing process? 1. assessment 2. diagnosis 3. outcome & planning. 4. implementation 5. evaluation