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Nur 245 / Nur245 Exam 1. Questions With 100% Correct Answers.

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(TUG) Timed up and go quantify functional ability rise from chair, walk 10 feet, turn, walk back to chair, sit down factors to note sitting balance transferring (sitting-- standing) gait pace and stability ability to turn without staggering sitting back down in chair 12 seconds = high fall risk, further eval MMSE Mini mental state exam Tests cognitive function through orientation, registration, attention and calculation, recall language score up to 30, =, 23 = cognitive impairment can help diagnose dementia Considerations about MMSE Use with caution in low educated patients or with learning disabilities Not sensitive for mild cognitive impairment MoCA Montreal cognitive assessment examines more domains than MMSE More sensitive to MILD COGNITIVE IMPAIRMENT 10 mins to administer total score = 30, 26 normal What does MoCA measure visuo-constructive ability language function memory auditory attention conceptual thinking working memory and calculations speech/language Inspection Concentrated watching Palpation applies your sense of touch to assess the body, especially while perceiving/diagnosing a disease or illness Percussion tapping on the person's skin with shirt, sharp, strokes to assess underlying structures Auscultation listening to sounds produced by the body

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EXAM 1 NUR 245
Phases of Nursing
ADPIE or ADOPIE
Assessment
Diagnosis
planning
Implementation
Evaluation




Nursing process A
Assessment
-collect data
-review of clinical record
-health history
-physical exam
-function assessment
-risk assessment
-use EBP
-document relevant data

,Nursing process D
Diagnosis- compare clinical findings with normal and abnormal variation
-interpret data
-ID clusters of cues
-make hypothesis
-test hypothesis
-derive dx
-validate dx
-document dx




Nursing process P
Planning- establish priorities, developmental outcomes/goals (SMART goals),
identify nursing interventions, document POC




Nursing process I
implementation- implement the plan in a safe and timely manner, use EBP
interventions, collaborate with colleagues, coordinate care delivery, provide teaching
and health promotion, document implementation and modifications




Nursing process E

, Evaluate progress towards goals/outcomes,
conduct systematic, ongoing, criterion based evaluation
include patient and significant others
use ongoing assessment to revise diagnosis, outcome, plan
disseminate results to patient and family




Closed-ended (direct) questions
elicit a one or two word response
help you elicit specific information
helpful in filling in any details originally left out
highly stressed people and people with difficulty hearing will find these easier




Open-ended questions
unbiased
associated with non-directive interview
invite clients to discover, explore, elaborate, clarify, or illustrate a thought or feeling




What are the 10 traps of interviewing
providing false assurance or reassurance
giving unwanted advice

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