Test Bank for Fundamental Concepts and Skills for Nursing
EXAM WITH VERIFIED QUESTIONS AND ANSWERS
LATEST UPDATED
what is an example of focused assessment.. - if the patient has slurred speech and
doesnt know whats going on. you would than order a head scan and check eyes out
and run tests to see if its neurologic.
What is subjective data? - data obtained from patient directly.
What is objective data? - What the nurse sees/ovbserves.
how is an assessment done? - it is done by collecting data and putting it into a database
and than documented, it also requires a planning stage in which it includes health status
of patient and family.
What is focused assessment? - factors causing or affecting the pain. It is focused on
one very specific problem
An example of subjective and objective - subjective- I have a headache objective-
temperature is 101.4
What is implementation? - giving care to a patient. making a plan
What is intervention? - are the actions listed on nursing care plan that are carried out.
what is dependent nursing action? - requires a physician order. such as ordering a
heating pad or administering medications.
what is independent nursing action? - does not require a physician order. Such as giving
side affects to patient on medications or giving a back massage.
What does a medical record contain? - all orders, tests,treatments,and care that
occurred while the person was under the care of the health care provider
What is the purpose of a medical record? - it is used for communication for all health
care members assisting that patient. also used for reimbursement from insurance
, companies.Used for court of law if necessary. but can be used for research purposes as
well. it provides a way to show that standards of care have been met.
What is problem oriented medical record charting? - POMR focuses on patient
status,emphasizing the problem solving approach to patient care and providing a
method for communicating what when and how things are to be done to meet patients
needs.
POMR has five basic parts - Database, problem list, plan, progress notes, discharge
summary
Database - initial assessment, general health history, findings from exams, diagnostic
and lab tests, psycho-social info, nursing assessment, and patients response to illness
or problem.
Problem list - list of problems derived from the info in the database. it is continually
updated with resolved problems deleted and new problems added,. they are listed in
chronological order not by priority. Both actual and potential problems are listed.
Plan - Three part plan of care is devised based on the identified problems. for each
problem there is a plan for diagnostic studies, a therapeutic plan, and a teaching plan.
THe physician orders therapies for medical problems, and the nurse orders care for
nursing problems.
Progress notes - contain the assesments, plans and orders of physicians, nurses, and
any therapists involved. notes are organized by problem number from problem list and
is addressed in SOAP format
5 components of nursing diagnosis - Assessment, nursing diagnosis,
planning,implementation,evaluation
Assessment - Is obtained from patient, the family, the physician, tests, and info about
patient from other health professionals
Assessment - Collecting,organizing, documenting, and validating data about a patients
health status
Nursing diagnosis - the process by which the assessment data are sorted and analyzed
so that specific actual and potential health problems are identified.
Nursing diagnosis - the factors contributing to the problems are considered, and specific
nursing diagnoses are chosen for the patients care plan
EXAM WITH VERIFIED QUESTIONS AND ANSWERS
LATEST UPDATED
what is an example of focused assessment.. - if the patient has slurred speech and
doesnt know whats going on. you would than order a head scan and check eyes out
and run tests to see if its neurologic.
What is subjective data? - data obtained from patient directly.
What is objective data? - What the nurse sees/ovbserves.
how is an assessment done? - it is done by collecting data and putting it into a database
and than documented, it also requires a planning stage in which it includes health status
of patient and family.
What is focused assessment? - factors causing or affecting the pain. It is focused on
one very specific problem
An example of subjective and objective - subjective- I have a headache objective-
temperature is 101.4
What is implementation? - giving care to a patient. making a plan
What is intervention? - are the actions listed on nursing care plan that are carried out.
what is dependent nursing action? - requires a physician order. such as ordering a
heating pad or administering medications.
what is independent nursing action? - does not require a physician order. Such as giving
side affects to patient on medications or giving a back massage.
What does a medical record contain? - all orders, tests,treatments,and care that
occurred while the person was under the care of the health care provider
What is the purpose of a medical record? - it is used for communication for all health
care members assisting that patient. also used for reimbursement from insurance
, companies.Used for court of law if necessary. but can be used for research purposes as
well. it provides a way to show that standards of care have been met.
What is problem oriented medical record charting? - POMR focuses on patient
status,emphasizing the problem solving approach to patient care and providing a
method for communicating what when and how things are to be done to meet patients
needs.
POMR has five basic parts - Database, problem list, plan, progress notes, discharge
summary
Database - initial assessment, general health history, findings from exams, diagnostic
and lab tests, psycho-social info, nursing assessment, and patients response to illness
or problem.
Problem list - list of problems derived from the info in the database. it is continually
updated with resolved problems deleted and new problems added,. they are listed in
chronological order not by priority. Both actual and potential problems are listed.
Plan - Three part plan of care is devised based on the identified problems. for each
problem there is a plan for diagnostic studies, a therapeutic plan, and a teaching plan.
THe physician orders therapies for medical problems, and the nurse orders care for
nursing problems.
Progress notes - contain the assesments, plans and orders of physicians, nurses, and
any therapists involved. notes are organized by problem number from problem list and
is addressed in SOAP format
5 components of nursing diagnosis - Assessment, nursing diagnosis,
planning,implementation,evaluation
Assessment - Is obtained from patient, the family, the physician, tests, and info about
patient from other health professionals
Assessment - Collecting,organizing, documenting, and validating data about a patients
health status
Nursing diagnosis - the process by which the assessment data are sorted and analyzed
so that specific actual and potential health problems are identified.
Nursing diagnosis - the factors contributing to the problems are considered, and specific
nursing diagnoses are chosen for the patients care plan
