Holistic Assessment Exam 1 Questions and Answers

Holistic Assessment Exam 1 Questions and Answers What are the steps in the nursing process? assessment, diagnosis, outcome & planning, implementation, evaluation What is the correct way to assess the abdomen? inspection, auscultation, palpation, (percussion?) What is done in assessment? cluster data, gathering data from subjective and objective data. What assessments are done when gathering objective data? Inspection, palpation, percussion, Auscultation What is the highest priority in assessment? Airway, breathing, circulation, vital signs What is the secondary priority when assessing a patient? safety, security, mental status, unrelated emergent, acute pain, infection What is the third priority when assessing a patient? non urgent, long term intervention What is orthostatic hypotension? taking the blood pressure at different positions (laying, sitting, standing). decrease in 20 or greater btw each bp. If the blood pressure continues to drop until last phase, it is a positive test. if negative, may mean the symptoms are from a different cause like vertigo. What happens during a nursing diagnosis? assessment of data- organization and prioritizing. -actual vs potential risk -collaborative medical and nursing interventions What happens during outcome identification? identify expected outcomes. goal related, broad statements regarding to patient. realistic and measurable. a SMART goal What happens during the orientation phase of the nurse client relationship? introduction & purpose, set the contract; time and duration, confidentiality. the goal is to develop trust and security What happens during the working phase of the nurse client relationship client begins identifying problems to work on. development of strategies to help What happens during the termination phase? gives client the time to talk about the therapeutic work. summarize goals and achievements. What are the phases in a nurse client relationship? orientation, working, termination What is a SMART goal? Specific, Measurable, Achievable, Realistic, Timed What happens during the planning stage? -setting goals and measurable outcomes -identify nursing interventions needed to meet the goals. How long are should a short term goal be? a week, unless in acute care a few hours How long are long term goals?