• Exam-Ready Client Centered Care Notes &
nn n n n n n
Guides – Grab Now!"
n n n n
1. •
whatis thenursingprocess?:assessment,diagnosis,planning,implementing,
nn
n n n n n n n n
evaluation
n
2. what is assessment in the nursing process?:gather information about the
n n n n n n n n n n
client's condition.
n n
- view data (lab tests) investigation reports is part of assessment
n n n n n n n n n
- collect pertinent data and information relative to the healthcare consumer's health or
n n n n n n n n n n n
the situation
n n
3. what is the nursing diagnosis in the nursing process?:identify the client's
n n n n n n n n n n n
problem
n
- analyze the assessment data to determine the actual or potential diagnosis,
n n n n n n n n n n
problems, and issues
n n n
4. what is planning in the nursing diagnosis?:set goals of care and desired
n n n n n n n n n n n n
outcomes and identify appropriate nursing actions
n n n n n n
- analyze the assessment data to determine the actual or potential diagnosis,
n n n n n n n n n n
problems, and issues
n n n
5. what is implementing in the nursing diagnosis?:perform the nursing actions
n n n n n n n n n n
identified in planning
n n n
- american nurses association standard implements the plan, which includes care
n n n n n n n n n
coordination,healthteaching,healthpromotion,consultation,prescriptiveauthority,
n n n n n n n n
and treatment
n n
- Coordination of care, using therapeutic procedures for patient care. n n n n n n n n
- Health teaching and health promotion - RNs employs strategies to teach and
n n n n n n n n n n n
promote health and wellness.
n n n n
6. what is evaluating in the nursing process?:determine if goals met and out-
n n n n n n n n n n n n
comes achieved
n n
- nursing goals and outcomes should be individualized
n n n n n n
- evaluates progress towards attainment of goals and outcomes n n n n n n n
7. what is culture competence skills?:- Respecting a patient's health beliefsand
n n n n n n n n n n n
understanding the effect of the patient's beliefs on health care delivery
n n n n n n n n n n n
- Shiftingamodelof understandingapatient'sexperiencefromadiseasehappening in the
n n n n n n n n n n n n n
patient's organ systems to that of an illness occurring in the context of culture
n n n n n n n n n n n n n n
- Ability to elicit a patient's explanation of an illness and it causes
n n n n n n n n n n n
-Ability to explain to a patient the health care provider's perspective on the illness and its
n n n n n n n n n n n n n n n
perceived causes
n n
- Being able to negotiate a mutually agreeable, safe, and effective treatment plan
n n n n n n n n n n n
8. what are the tools of physical assessment?:Inspection
n n n n n n n
Palpation
n
Percussion
Auscultation
n
n n
, • Exam-Ready Client Centered Care Notes &
nn n n n n n
Guides – Grab Now!"
n n n n
9. what•are the tools of a abdominal assessment?:inspect, auscultate,percuss,
n
nn
n n n n n n n n n
palpate
n
10. what is the general survey of the assessment?: physical appearance, body
n n n n n n n n n n
structure and position, body movement, and emotional mental status and behavior
n n n n n n n n n n n
11. what are three phases of the interview?: orientation + setting an agenda,
n n n n n n n n n n n
working phase, and terminating interview
n n n n n
12. what are the four c's with patient centered techniques?:Courtesy
n n n n n n n n n
Comfort
n
Connection
Confirmation
n
13. What are the ten traps of interviewing?:False assurance
n n n n n n n n
Unwanted advice
n n
Using authority Avoidance
n n
language Engaging in
n n n
distancing Using
n n
professional jargon
n n
Leading/biasedquestions
n n
Talking too much
n n n
Interruption
n
Why question
n
14. what are some communication skill for interviewing a patient?:Open-end- ed,
n n n n n n n n n n
nonjudgmental questions
n n
Paraphraseforunderstanding n n
Avoid stereotyping
n n
15. what are the four c's with cultural and spiritual assessment?:call, cope,
n n n n n n n n n n n
concerns, and causes
n n n
16. whataresome culturalandspiritualassessmentduringaninterview?:•To
n n n n n n n n n n
provide patient-centered culturally competent care, you must know how to collect
n n n n n n n n n n n
relevantculturaldataaboutapatient'spresentinghealthproblem(s)andhowtothen use it.
n n n n n n n n n n n n n n n
• The goal of a cultural assessment is to obtain accurate information from a patient that
n n n n n n n n n n n n n n
allows you to formulate a mutually acceptable and culturally relevant plan of care for
n n n n n n n n n n n n n n
each health problem of a patient.
n n n n n n
• Using a cultural assessment model will help you focus on the information that is most
n n n n n n n n n n n n n n
relevant to your patient's problems.
n n n n n
• You need to assess and interpret a patient's perspective during your assessment. Use
n n n n n n n n n n n n
open-ended, focused, and contrasted questions.
n n n n n
• One effective approach to assessment is to ask questions that will help you
n n n n n n n n n n n n
n n
, • Exam-Ready Client Centered Care Notes &
nn n n n n n
Guides – Grab Now!"
n n n n
understand• a patient's explanatory model—his or her views about health and illness and
nn
n n n n n n n n n n n n
its treatment.
n n
17. what is linguistic competence?: The ability of an organization of an organiza- tion
n n n n n n n n n n n n
and its staff to communicate effectively and convey information in a manner that is easily
n n n n n n n n n n n n n n n
understood by diverse audiences these audiences include people of limited English
n n n n n n n n n n n
proficiency, those who are deaf or hard of hearing.
n n n n n n n n n
Most health care providers and virtually all health care organizations nationwide are
n n n n n n n n n n n
subject to federal civil rights laws. These laws outline requirement for the provision of
n n n n n n n n n n n n n n
language access services
n n n
Do not use a patient's family members to interpret for you or other health care providers.
n n n n n n n n n n n n n n n
It's a federal civil rights issue to not provide translation services!
n n n n n n n n n n
Cultural dynamics, lackof interpreting skills,low health literacy,and bias could lead to
n n n n n n n n n n n n n
inaccurate interpretation.
n n
18. what is chief concern?: the reason the patient is seeking care.the chief con- cern
n n n n n n n n n n n n n n
isusuallyabrief,spontaneous statement,intheclient'sownwords,describing the
n n n n n n n n n n n n n
reason for their visit.
n n n n
19. temperature normal ranges: 96.8 to 100.4 F n n n n n n
20. average oral/tympanic normal range: 98.6 n n n n
21. average rectal normal temperature: 99.5 n n n n
22. normal range for axillary temperature: 97.7 n n n n n
23. underweight: <18.5 n
24. normal weight: 18.5-24.9 n n
25. overweight:25-29.9 n
26. obese: > 30 n n
27. extreme obesity: > 40 n n n
28. normal ranges for respiration: 12-20 bpm n n n n n
29. normal range for pulse: 60-100 bpm n n n n n
30. normal range for blood pressure:120/80 mmHg n n n n n n
systolic <120
n n
Diastolic <80 n
pulse pressure 30 to 50 mm hg n n n n n n
31. normal range SPO2: 95-100% n n n
32. whatare some guidelines for vitalsigns?:Whencollectingvitalsigndatathe RN is
n n n n n n n n n n n n n n
responsible for reviewing, interpreting and critically thinking about the data. Changes
n n n n n n n n n n n
in vital signs, acute or trending, may indicate changes in physiological function and
n n n n n n n n n n n n n
thus require intervention.
n n n
Vital signs are the first form of patient data after patient identifiers that you should report
n n n n n n n n n n n n n n n
n n
nn n n n n n
Guides – Grab Now!"
n n n n
1. •
whatis thenursingprocess?:assessment,diagnosis,planning,implementing,
nn
n n n n n n n n
evaluation
n
2. what is assessment in the nursing process?:gather information about the
n n n n n n n n n n
client's condition.
n n
- view data (lab tests) investigation reports is part of assessment
n n n n n n n n n
- collect pertinent data and information relative to the healthcare consumer's health or
n n n n n n n n n n n
the situation
n n
3. what is the nursing diagnosis in the nursing process?:identify the client's
n n n n n n n n n n n
problem
n
- analyze the assessment data to determine the actual or potential diagnosis,
n n n n n n n n n n
problems, and issues
n n n
4. what is planning in the nursing diagnosis?:set goals of care and desired
n n n n n n n n n n n n
outcomes and identify appropriate nursing actions
n n n n n n
- analyze the assessment data to determine the actual or potential diagnosis,
n n n n n n n n n n
problems, and issues
n n n
5. what is implementing in the nursing diagnosis?:perform the nursing actions
n n n n n n n n n n
identified in planning
n n n
- american nurses association standard implements the plan, which includes care
n n n n n n n n n
coordination,healthteaching,healthpromotion,consultation,prescriptiveauthority,
n n n n n n n n
and treatment
n n
- Coordination of care, using therapeutic procedures for patient care. n n n n n n n n
- Health teaching and health promotion - RNs employs strategies to teach and
n n n n n n n n n n n
promote health and wellness.
n n n n
6. what is evaluating in the nursing process?:determine if goals met and out-
n n n n n n n n n n n n
comes achieved
n n
- nursing goals and outcomes should be individualized
n n n n n n
- evaluates progress towards attainment of goals and outcomes n n n n n n n
7. what is culture competence skills?:- Respecting a patient's health beliefsand
n n n n n n n n n n n
understanding the effect of the patient's beliefs on health care delivery
n n n n n n n n n n n
- Shiftingamodelof understandingapatient'sexperiencefromadiseasehappening in the
n n n n n n n n n n n n n
patient's organ systems to that of an illness occurring in the context of culture
n n n n n n n n n n n n n n
- Ability to elicit a patient's explanation of an illness and it causes
n n n n n n n n n n n
-Ability to explain to a patient the health care provider's perspective on the illness and its
n n n n n n n n n n n n n n n
perceived causes
n n
- Being able to negotiate a mutually agreeable, safe, and effective treatment plan
n n n n n n n n n n n
8. what are the tools of physical assessment?:Inspection
n n n n n n n
Palpation
n
Percussion
Auscultation
n
n n
, • Exam-Ready Client Centered Care Notes &
nn n n n n n
Guides – Grab Now!"
n n n n
9. what•are the tools of a abdominal assessment?:inspect, auscultate,percuss,
n
nn
n n n n n n n n n
palpate
n
10. what is the general survey of the assessment?: physical appearance, body
n n n n n n n n n n
structure and position, body movement, and emotional mental status and behavior
n n n n n n n n n n n
11. what are three phases of the interview?: orientation + setting an agenda,
n n n n n n n n n n n
working phase, and terminating interview
n n n n n
12. what are the four c's with patient centered techniques?:Courtesy
n n n n n n n n n
Comfort
n
Connection
Confirmation
n
13. What are the ten traps of interviewing?:False assurance
n n n n n n n n
Unwanted advice
n n
Using authority Avoidance
n n
language Engaging in
n n n
distancing Using
n n
professional jargon
n n
Leading/biasedquestions
n n
Talking too much
n n n
Interruption
n
Why question
n
14. what are some communication skill for interviewing a patient?:Open-end- ed,
n n n n n n n n n n
nonjudgmental questions
n n
Paraphraseforunderstanding n n
Avoid stereotyping
n n
15. what are the four c's with cultural and spiritual assessment?:call, cope,
n n n n n n n n n n n
concerns, and causes
n n n
16. whataresome culturalandspiritualassessmentduringaninterview?:•To
n n n n n n n n n n
provide patient-centered culturally competent care, you must know how to collect
n n n n n n n n n n n
relevantculturaldataaboutapatient'spresentinghealthproblem(s)andhowtothen use it.
n n n n n n n n n n n n n n n
• The goal of a cultural assessment is to obtain accurate information from a patient that
n n n n n n n n n n n n n n
allows you to formulate a mutually acceptable and culturally relevant plan of care for
n n n n n n n n n n n n n n
each health problem of a patient.
n n n n n n
• Using a cultural assessment model will help you focus on the information that is most
n n n n n n n n n n n n n n
relevant to your patient's problems.
n n n n n
• You need to assess and interpret a patient's perspective during your assessment. Use
n n n n n n n n n n n n
open-ended, focused, and contrasted questions.
n n n n n
• One effective approach to assessment is to ask questions that will help you
n n n n n n n n n n n n
n n
, • Exam-Ready Client Centered Care Notes &
nn n n n n n
Guides – Grab Now!"
n n n n
understand• a patient's explanatory model—his or her views about health and illness and
nn
n n n n n n n n n n n n
its treatment.
n n
17. what is linguistic competence?: The ability of an organization of an organiza- tion
n n n n n n n n n n n n
and its staff to communicate effectively and convey information in a manner that is easily
n n n n n n n n n n n n n n n
understood by diverse audiences these audiences include people of limited English
n n n n n n n n n n n
proficiency, those who are deaf or hard of hearing.
n n n n n n n n n
Most health care providers and virtually all health care organizations nationwide are
n n n n n n n n n n n
subject to federal civil rights laws. These laws outline requirement for the provision of
n n n n n n n n n n n n n n
language access services
n n n
Do not use a patient's family members to interpret for you or other health care providers.
n n n n n n n n n n n n n n n
It's a federal civil rights issue to not provide translation services!
n n n n n n n n n n
Cultural dynamics, lackof interpreting skills,low health literacy,and bias could lead to
n n n n n n n n n n n n n
inaccurate interpretation.
n n
18. what is chief concern?: the reason the patient is seeking care.the chief con- cern
n n n n n n n n n n n n n n
isusuallyabrief,spontaneous statement,intheclient'sownwords,describing the
n n n n n n n n n n n n n
reason for their visit.
n n n n
19. temperature normal ranges: 96.8 to 100.4 F n n n n n n
20. average oral/tympanic normal range: 98.6 n n n n
21. average rectal normal temperature: 99.5 n n n n
22. normal range for axillary temperature: 97.7 n n n n n
23. underweight: <18.5 n
24. normal weight: 18.5-24.9 n n
25. overweight:25-29.9 n
26. obese: > 30 n n
27. extreme obesity: > 40 n n n
28. normal ranges for respiration: 12-20 bpm n n n n n
29. normal range for pulse: 60-100 bpm n n n n n
30. normal range for blood pressure:120/80 mmHg n n n n n n
systolic <120
n n
Diastolic <80 n
pulse pressure 30 to 50 mm hg n n n n n n
31. normal range SPO2: 95-100% n n n
32. whatare some guidelines for vitalsigns?:Whencollectingvitalsigndatathe RN is
n n n n n n n n n n n n n n
responsible for reviewing, interpreting and critically thinking about the data. Changes
n n n n n n n n n n n
in vital signs, acute or trending, may indicate changes in physiological function and
n n n n n n n n n n n n n
thus require intervention.
n n n
Vital signs are the first form of patient data after patient identifiers that you should report
n n n n n n n n n n n n n n n
n n
