NUR 210 Exam 1
what makes up an assessment - Answer-subjective data
objective data
data base
subjective data - Answer-What patient says about himself or herself during history taking
objective data - Answer-Observed when inspecting, percussing, palpating, and auscultating patient
during physical examination
data base - Answer-formed from subjective data, objective data, and a patient's record and diagnostic
studies
what is the nursing process - Answer-Assessment
Diagnosis
Outcome identification
Planning
Implementation
Evaluation
,First-level priority problems - Answer-- require immediate intervention
- ABCs (airway, breathing, circulation)
- vital signs
Second-level priority problems - Answer-Require prompt medical attention
ex:
- Mental status change
- Untreated medical problems requiring immediate attention
- Acute pain
- Acute urinary elimination problems
- Abnormal laboratory values
- Risks of infection, safety or security
Third-level priority problems - Answer-those that are important to the patient's health but can be
addressed after more urgent health problems are addressed.
- Knowledge deficit
- altered family processes
- low self esteem
- activity
- rest
- family coping
4 types of data base collection - Answer-- complete total health data base
- focused or problem-centered data base (for limited or short-term problems)
- follow up data base
- emergency data base
,what makes up a complete total health data base? - Answer-- Complete health history
- Head to Toe physical examination
- Describes current and past health state and forms baseline to measure all future changes
what makes up a focused or problem-centered data base - Answer-For limited or short-term problems
- Collect "mini" data base, smaller scope and more focused than complete data base
- Concerns mainly one problem, or one body system
- History and examination follow direction of presenting concern
what makes up a follow-up data base? - Answer-- Status of all identified problems should be evaluated
at regular and appropriate intervals
- Note changes that have occurred
- Evaluate whether problem is getting better or worse
- Identify coping strategies being used
what makes up an emergency data base? - Answer-- Rapid collection of data, often compiled
concurrently with lifesaving measures
- Diagnosis must be swift and sure
- Person is questioned simultaneously while his or her airway, breathing, circulation, level of
consciousness, and disability are being assessed
goals of the health interview - Answer-- Obtain and record complete health history
- Obtain subjective data
- Establish rapport
- Teach about health
- Begin health promotion teaching
, the process of communication - Answer-- mutual understanding by sender and receiver
- Communication can be learned and polished
- Communication is a tool, as basic to quality health care as tools of inspection or palpation
internal factors that influence communication - Answer-- Liking others
- Empathy
- Ability to listen
- Self-Awareness
eternal factors that influence communication - Answer-- Ensure Privacy
- Refuse Interruptions if possible
- Physical Environment
- Quiet
- 4 - 5 feet distance
- Equal-Status Seating
- Face-to-face position
- Don't allow computer screen to be a barrier between you and patient
communication techniques - Answer-- Use surname
- Introduce yourself
- Shake hands
what makes up an assessment - Answer-subjective data
objective data
data base
subjective data - Answer-What patient says about himself or herself during history taking
objective data - Answer-Observed when inspecting, percussing, palpating, and auscultating patient
during physical examination
data base - Answer-formed from subjective data, objective data, and a patient's record and diagnostic
studies
what is the nursing process - Answer-Assessment
Diagnosis
Outcome identification
Planning
Implementation
Evaluation
,First-level priority problems - Answer-- require immediate intervention
- ABCs (airway, breathing, circulation)
- vital signs
Second-level priority problems - Answer-Require prompt medical attention
ex:
- Mental status change
- Untreated medical problems requiring immediate attention
- Acute pain
- Acute urinary elimination problems
- Abnormal laboratory values
- Risks of infection, safety or security
Third-level priority problems - Answer-those that are important to the patient's health but can be
addressed after more urgent health problems are addressed.
- Knowledge deficit
- altered family processes
- low self esteem
- activity
- rest
- family coping
4 types of data base collection - Answer-- complete total health data base
- focused or problem-centered data base (for limited or short-term problems)
- follow up data base
- emergency data base
,what makes up a complete total health data base? - Answer-- Complete health history
- Head to Toe physical examination
- Describes current and past health state and forms baseline to measure all future changes
what makes up a focused or problem-centered data base - Answer-For limited or short-term problems
- Collect "mini" data base, smaller scope and more focused than complete data base
- Concerns mainly one problem, or one body system
- History and examination follow direction of presenting concern
what makes up a follow-up data base? - Answer-- Status of all identified problems should be evaluated
at regular and appropriate intervals
- Note changes that have occurred
- Evaluate whether problem is getting better or worse
- Identify coping strategies being used
what makes up an emergency data base? - Answer-- Rapid collection of data, often compiled
concurrently with lifesaving measures
- Diagnosis must be swift and sure
- Person is questioned simultaneously while his or her airway, breathing, circulation, level of
consciousness, and disability are being assessed
goals of the health interview - Answer-- Obtain and record complete health history
- Obtain subjective data
- Establish rapport
- Teach about health
- Begin health promotion teaching
, the process of communication - Answer-- mutual understanding by sender and receiver
- Communication can be learned and polished
- Communication is a tool, as basic to quality health care as tools of inspection or palpation
internal factors that influence communication - Answer-- Liking others
- Empathy
- Ability to listen
- Self-Awareness
eternal factors that influence communication - Answer-- Ensure Privacy
- Refuse Interruptions if possible
- Physical Environment
- Quiet
- 4 - 5 feet distance
- Equal-Status Seating
- Face-to-face position
- Don't allow computer screen to be a barrier between you and patient
communication techniques - Answer-- Use surname
- Introduce yourself
- Shake hands
