GNUR 238 EXAM 1 STUDY GUIDE
CRITICAL THINKING AND INTRO TO THE NURSING PROCESS - Answers -
Critical Thinking - Answers - APPLICATION of knowledge
Experience to identify patient problems
Clinical Reasoning - Answers - uses critical thinking, knowledge, and experience, to
develop SOLUTIONS to problems and make decisions in a CLINICAL setting
Problem Solve - Answers - systematic, analytic approach to finding a solution to a
problem
Decision Making - Answers - choosing a SOLUTION or answer from among different
options, often considering a STEP in the problem solving process
Reasoning - Answers - LOGICAL thinking that links thoughts, ideas, and facts together
in a meaningful way
Judgement - Answers - RESULT or decision related to the processes of thinking and
reasoning
ATTITUDES FOR CRITICAL THINKING - Answers - Confidence, Fairness, Risk Taking,
Perseverance, Curiosity, thinking independently, humility, discipline, creativity, integrity,
responsibility
INTRO TO WAY NURSES THINK - Answers - Nursing Process- 1950 labeled by Lydia
Hall
How Nurses: - Answers - think, identify patient problems, determine patient
OUTCOMES, and PRIORITIZE patient care
STEPS OF NURSING PROCESS - Answers - 5 step process based on scientific
process
ADPIE
1) - Answers - A- Assessment
2) - Answers - D- (nursing) Diagnosis
3) - Answers - P- Plan
4) - Answers - I- Implementation
5) - Answers - E-Evaluation
,Critical Thinking and the Nursing Process - Answers - Critical thinking-power of the
nursing DIAGNOSIS and the nursing PROCESS
INTERVIEWING YOUR PATIENT TO OBTAIN A HEALTH HISTORY - Answers -
Sources of info for the Healthy History - Answers -
Primary Source - Answers - CLIENT-interview
Secondary Source - Answers - not conscious, too young, delusional, cognitive
impairment
-other individuals (family)
-client records and CHARTS
** secondary source if primary source NOT possible
2 Primary components of health assessment: - Answers - HEALTH HISTORY --
subjective data (cannot use senses, what a patient is TELLING you)
PHYSICAL EXAM - objective data (you assess, can see/sense
health history = subjective
-database used to create a PLAN, prevent disease, resolve problems, and minimize
limitations
-If patient cant verbalize, use OBJECTIVE data to determine pain
COMPONENTS OF COMPREHENSIVE HEALTH HISTORY - Answers - Biographic
data--initial visit
REASON for seeking care (CC)
History of PRESENT illness
Present health status
PAST medical history
Family history
Personal and psychosocial history
Review of all body systems
** most of health history is SUBJECTIVE DATA
HISTORY OF PRESENT ILLNESS - Answers - Should include the following data:
O= onset
L=Location
D=duration
C=characteristics
A=alleviating and aggravating factors
R=related symptoms
T=treatments
S=severity (0-10)
PRESENT HEALTH STATUS - Answers -
, Health Conditions - Answers - CHRONIC or recurring
-how does it affect their ADL's
Allergies - Answers - Food, environment, and meds
-what does reaction look like?
ex. swelling, hives, rash
NK(no known) E=environmental
F=food D=med A=allergy
Medications - Answers - Name, route, dosage, WHY do they take this medication
PAST HISTORY - Answers - Childhood diseases
Immunizations
Blood Transfusions - reactions? blood type
Major ILLNESSES
SURGERIES
Injuries
Hospitalizations
CHILDBIRTHS (Gravity= how many times preg) (Perity=how many deliveries)
PSYCHOSOCIAL HISTORY - Answers - Personal status
Family and social
Education
FINANCES
Roles and Relationships
ETHNICITY and culture
Environment/safety issues
Access to care
Health Promotion activities
Spirituality relationsips
MENTAL health
Use of alcohol, tobacco, and illicit drug use
DIET/nutrition
Functional ability
SUMMARY OF HEALTH HISTORY -contains: - Answers - Primarily SUBJECTIVE data,
from verbal interaction w/ patient/fam
OBJECTIVE data from OBSERVATION and review of past records, and the EHR
(electronic health record)
-organized to make essential data AVAILABLE to all health care team members
-last phase of history is REVIEW of systems
INTERVIEW - Answers - Usually begins in the ORIENTATION of nurse patient helping
relationship
-clarifying/re-iterating
-compassion, empathy
CRITICAL THINKING AND INTRO TO THE NURSING PROCESS - Answers -
Critical Thinking - Answers - APPLICATION of knowledge
Experience to identify patient problems
Clinical Reasoning - Answers - uses critical thinking, knowledge, and experience, to
develop SOLUTIONS to problems and make decisions in a CLINICAL setting
Problem Solve - Answers - systematic, analytic approach to finding a solution to a
problem
Decision Making - Answers - choosing a SOLUTION or answer from among different
options, often considering a STEP in the problem solving process
Reasoning - Answers - LOGICAL thinking that links thoughts, ideas, and facts together
in a meaningful way
Judgement - Answers - RESULT or decision related to the processes of thinking and
reasoning
ATTITUDES FOR CRITICAL THINKING - Answers - Confidence, Fairness, Risk Taking,
Perseverance, Curiosity, thinking independently, humility, discipline, creativity, integrity,
responsibility
INTRO TO WAY NURSES THINK - Answers - Nursing Process- 1950 labeled by Lydia
Hall
How Nurses: - Answers - think, identify patient problems, determine patient
OUTCOMES, and PRIORITIZE patient care
STEPS OF NURSING PROCESS - Answers - 5 step process based on scientific
process
ADPIE
1) - Answers - A- Assessment
2) - Answers - D- (nursing) Diagnosis
3) - Answers - P- Plan
4) - Answers - I- Implementation
5) - Answers - E-Evaluation
,Critical Thinking and the Nursing Process - Answers - Critical thinking-power of the
nursing DIAGNOSIS and the nursing PROCESS
INTERVIEWING YOUR PATIENT TO OBTAIN A HEALTH HISTORY - Answers -
Sources of info for the Healthy History - Answers -
Primary Source - Answers - CLIENT-interview
Secondary Source - Answers - not conscious, too young, delusional, cognitive
impairment
-other individuals (family)
-client records and CHARTS
** secondary source if primary source NOT possible
2 Primary components of health assessment: - Answers - HEALTH HISTORY --
subjective data (cannot use senses, what a patient is TELLING you)
PHYSICAL EXAM - objective data (you assess, can see/sense
health history = subjective
-database used to create a PLAN, prevent disease, resolve problems, and minimize
limitations
-If patient cant verbalize, use OBJECTIVE data to determine pain
COMPONENTS OF COMPREHENSIVE HEALTH HISTORY - Answers - Biographic
data--initial visit
REASON for seeking care (CC)
History of PRESENT illness
Present health status
PAST medical history
Family history
Personal and psychosocial history
Review of all body systems
** most of health history is SUBJECTIVE DATA
HISTORY OF PRESENT ILLNESS - Answers - Should include the following data:
O= onset
L=Location
D=duration
C=characteristics
A=alleviating and aggravating factors
R=related symptoms
T=treatments
S=severity (0-10)
PRESENT HEALTH STATUS - Answers -
, Health Conditions - Answers - CHRONIC or recurring
-how does it affect their ADL's
Allergies - Answers - Food, environment, and meds
-what does reaction look like?
ex. swelling, hives, rash
NK(no known) E=environmental
F=food D=med A=allergy
Medications - Answers - Name, route, dosage, WHY do they take this medication
PAST HISTORY - Answers - Childhood diseases
Immunizations
Blood Transfusions - reactions? blood type
Major ILLNESSES
SURGERIES
Injuries
Hospitalizations
CHILDBIRTHS (Gravity= how many times preg) (Perity=how many deliveries)
PSYCHOSOCIAL HISTORY - Answers - Personal status
Family and social
Education
FINANCES
Roles and Relationships
ETHNICITY and culture
Environment/safety issues
Access to care
Health Promotion activities
Spirituality relationsips
MENTAL health
Use of alcohol, tobacco, and illicit drug use
DIET/nutrition
Functional ability
SUMMARY OF HEALTH HISTORY -contains: - Answers - Primarily SUBJECTIVE data,
from verbal interaction w/ patient/fam
OBJECTIVE data from OBSERVATION and review of past records, and the EHR
(electronic health record)
-organized to make essential data AVAILABLE to all health care team members
-last phase of history is REVIEW of systems
INTERVIEW - Answers - Usually begins in the ORIENTATION of nurse patient helping
relationship
-clarifying/re-iterating
-compassion, empathy
