NSG 3160 Exam 1 Questions & answers
Know how to collect data and the pitfalls to avoid when interviewing the patient
and collecting data.
Communication is going to carry the interview; you should build and establish
rapport with the patient. Show the patient that you are interested and concerned
about their health to gain trust from the patient. If the patient sees this, they are
more likely to open and share vital information regarding their health and health
concerns. This will allow us to understand and assess the patient at a better
standpoint. Communication can be Verbal or Non-verbal. Verbal communication
is spoken words, vocalizations, tone of voice. Non-verbal communication is body
language - gestures, facial expressions, posture, eye contact, foot tapping, touch,
where you sit to talk to them. Non-verbal is more of an unconscious form of
communication and is a reflection of true feelings. Be aware of the messages you
send a receive to the patient. Think about how you may be interpreted to the
patient.
First level priorities:
-Are those that are emergent, life threatening, and immediate, such as
establishing an airway or supporting breathing.
-ABC's (breathing
Second level priorities:
-Are those that are next in urgency- those requiring your prompt intervention to
forestall further deterioration.
-Mental status change, acute pain, acute urinary elimination problems, untreated
medical problems, abnormal lab values, risks of infection, or risk to safety or
security. (Pain, pee, poop).
Third level priorities:
-Are those that are important to the patient's health but can be attended to after
more urgent health problems are addressed. Interventions to treat these
,problems may require a collaborative effort between the patient and health care
professionals.
-Nutrition, long-term, hygiene, family, coping, and discharge.
Fourth level priorities:
-Collaborative problems.
-Get someone to help.
Evidence based practice:
Health care is ever changing, Evidence Based Practice are the best techniques
used to treat patients. Findings are implemented into daily practice. EBP is
multi-faced and reflects holistic practice. EBP encompasses of the integration of
research evidence, clinical expertise, clinical knowledge (physical assessment),
and patient values and preferences. Clinical decision making depends on all four
factors: the best evidence from critical review of research literature, the patient's
own experience and expertise, and physical examination and assessment.
4 types of health assessments:
-Complete (Total Health) Database
-Focus or Problem Centered Database
-Emergency Database
-Follow-up Database
Six steps of nursing diagnosis:
1. Assessment
2. Diagnosis
3. Outcome identification
4. Planning
5. Implementation
6. Evaluation
-The nursing process is the standard of practice in nursing. It is a process that
allows practitioners to move back and forth while caring for the needs of complex
patients. Nurses use this process to formulate a nursing diagnosis and plan care,
, establish goals, implement the goals for healing, and reassessing the patient to
ensure goals are met. If goals are not met, reassess the patient and maybe think
about formulating a new nursing diagnosis plan of care.
Use of open-ended questions:
-Open ended questions are a useful technique to use as they provide a way for
the patient to be more open and talk about their concerns. Open-ended
questions are seeking narrative information. It is unbiased, the person is free to
answer in their own way. The patient is encouraged to respond in paragraphs
and give a spontaneous account. EXPRESSION!! Make eye contact and actively
listen. Typically, the patient will provide an answer and look at you for direction on
whether to continue. "Tell me about your headaches"
-Direct/Closed-ended questions ask for specific information. They elicit a one- or
two-word answer, such as yes/no questions are vague and do not get the point
across and do not let the patient express their concerns as they should. They are
less likely to express themselves if they are given yes/no questions. They limit
the patient's answer. "Where are your headaches located?"
Distractions- Note taking, cellphones, etc.:
Excessively taking notes and not making eye contact with your patient while they
are speaking will tell the patient that you are uninterested or not paying attention
to what they are telling you. This can also distract the patient as they are focused
on you and what you are doing. Excessive leg shaking can also distract the
patient. If you are expecting a phone call or to be taken out of the room during
the interview let the patient know ahead of time. Do not look at your watch
excessively.
Use of an interpreter:
Interpreters must be used when working with patients that you both do not speak
the same language. The best interpreter to use of the one provided by the facility.
Family members can be interpreters, but they may not say everything that is
needed to know about the patient or what the patient says. Family is not the best
interpreters.
Know how to collect data and the pitfalls to avoid when interviewing the patient
and collecting data.
Communication is going to carry the interview; you should build and establish
rapport with the patient. Show the patient that you are interested and concerned
about their health to gain trust from the patient. If the patient sees this, they are
more likely to open and share vital information regarding their health and health
concerns. This will allow us to understand and assess the patient at a better
standpoint. Communication can be Verbal or Non-verbal. Verbal communication
is spoken words, vocalizations, tone of voice. Non-verbal communication is body
language - gestures, facial expressions, posture, eye contact, foot tapping, touch,
where you sit to talk to them. Non-verbal is more of an unconscious form of
communication and is a reflection of true feelings. Be aware of the messages you
send a receive to the patient. Think about how you may be interpreted to the
patient.
First level priorities:
-Are those that are emergent, life threatening, and immediate, such as
establishing an airway or supporting breathing.
-ABC's (breathing
Second level priorities:
-Are those that are next in urgency- those requiring your prompt intervention to
forestall further deterioration.
-Mental status change, acute pain, acute urinary elimination problems, untreated
medical problems, abnormal lab values, risks of infection, or risk to safety or
security. (Pain, pee, poop).
Third level priorities:
-Are those that are important to the patient's health but can be attended to after
more urgent health problems are addressed. Interventions to treat these
,problems may require a collaborative effort between the patient and health care
professionals.
-Nutrition, long-term, hygiene, family, coping, and discharge.
Fourth level priorities:
-Collaborative problems.
-Get someone to help.
Evidence based practice:
Health care is ever changing, Evidence Based Practice are the best techniques
used to treat patients. Findings are implemented into daily practice. EBP is
multi-faced and reflects holistic practice. EBP encompasses of the integration of
research evidence, clinical expertise, clinical knowledge (physical assessment),
and patient values and preferences. Clinical decision making depends on all four
factors: the best evidence from critical review of research literature, the patient's
own experience and expertise, and physical examination and assessment.
4 types of health assessments:
-Complete (Total Health) Database
-Focus or Problem Centered Database
-Emergency Database
-Follow-up Database
Six steps of nursing diagnosis:
1. Assessment
2. Diagnosis
3. Outcome identification
4. Planning
5. Implementation
6. Evaluation
-The nursing process is the standard of practice in nursing. It is a process that
allows practitioners to move back and forth while caring for the needs of complex
patients. Nurses use this process to formulate a nursing diagnosis and plan care,
, establish goals, implement the goals for healing, and reassessing the patient to
ensure goals are met. If goals are not met, reassess the patient and maybe think
about formulating a new nursing diagnosis plan of care.
Use of open-ended questions:
-Open ended questions are a useful technique to use as they provide a way for
the patient to be more open and talk about their concerns. Open-ended
questions are seeking narrative information. It is unbiased, the person is free to
answer in their own way. The patient is encouraged to respond in paragraphs
and give a spontaneous account. EXPRESSION!! Make eye contact and actively
listen. Typically, the patient will provide an answer and look at you for direction on
whether to continue. "Tell me about your headaches"
-Direct/Closed-ended questions ask for specific information. They elicit a one- or
two-word answer, such as yes/no questions are vague and do not get the point
across and do not let the patient express their concerns as they should. They are
less likely to express themselves if they are given yes/no questions. They limit
the patient's answer. "Where are your headaches located?"
Distractions- Note taking, cellphones, etc.:
Excessively taking notes and not making eye contact with your patient while they
are speaking will tell the patient that you are uninterested or not paying attention
to what they are telling you. This can also distract the patient as they are focused
on you and what you are doing. Excessive leg shaking can also distract the
patient. If you are expecting a phone call or to be taken out of the room during
the interview let the patient know ahead of time. Do not look at your watch
excessively.
Use of an interpreter:
Interpreters must be used when working with patients that you both do not speak
the same language. The best interpreter to use of the one provided by the facility.
Family members can be interpreters, but they may not say everything that is
needed to know about the patient or what the patient says. Family is not the best
interpreters.
