QUESTIONS & ANSWERS 100%
CORRECT
Checking accuracy and reliability - ANSWERrealizing that something doesn't seem
quite right and taking action to determine if it is accurate or not, sounds suspicious
and looking further into it
Nursing Process - ANSWERstep by step approach directed at planning and
providing pt care.
Data collection(assessment), Planning, Implementation, Evaluation
Step 1 Noticing - ANSWER-Identifying signs and symptoms
-gathering complete and accurate data
-assessing systematically and comprehensivly
-predicting and (managing) potential complications
-identifying assumptions
Identifying signs and symptoms - ANSWERIndicates when a situation is normal,
abnormal, or has changed, something is different than expected
Gathering complete and accurate data - ANSWERData collected from all available
sources is used as the basis for identifying issues, problems, concerns. Must verify
that data is complete and accurate
Assessing systematically and comprehensively - ANSWERA method of assessing
information or data so nothing is omitted or forgotten. Focused, head to toe, body
systems
focused assessment - ANSWERex. pt walks in with chest pain
bloody stools
body system assessment - ANSWERwhen the nurse examines one specific body
system, clusters the data related to the specific body system to identify issues
ex. GI- comes in throwing up, stomach pains. Head- pt complains of headache,
dizziness
head to toe assessment - ANSWERA complete assessment of the patient, one that
includes all systems
ex. admissions assessment
Predicting (and managing) potential complications - ANSWERLook at the big picture
to prepare for potential future complications for an individual pt, you are predicting
, complications which means you are identifying possible problems. What will put our
pt at risk
ex.recognize that all pt have risk for atelectasis after surgery
Identifying assumptions - ANSWERRecognize information taken for granted, hastily
arriving at a conclusion without supporting evidence, a misconception. EVIDENCE
ex. all thin people are healthy
Step 2- Interpreting - ANSWER-clustering related information
-recognizing inconsistencies
-checking accuracy and reliability
-Distinguishing relevant from irrelevant
-determining the importance of information
-comparing and contrasting
-(predicting) and managing potential complications
-judging how much ambiguity is acceptable
-using legal, ethical and professional
HERE WE- PLANNING, PRIORITIZE, DESICIONS
WHAT ARE YOU GOING DO WITH THE DATA YOU RECIEVE, MAKE SENCE OF
THE DATA*
Clustering related information - ANSWERGrouping together information with a
common theme. A method of organizing data so that you put .things together in
order to understand the situation, what is alike
ex. headache-clustering orther related sx-sleepy, hit head, dizziness
Recognizing inconsistencies - ANSWERdoes the objective data match the subjective
data
ex. pt says they aren't in pain but face is telling you diff. they are grimacing, clinching
fists, tearful, holding their side
Distinguishing relevant from irrelevant - ANSWERdecidingco what information is
pertinent or connects to the matter at hand, sort out what info relates to the current
problem
ex. pt tells cardiologist my back hurts
may be important to pt overall care but not the current problem
Comparing and contrasting - ANSWERlooking at 2 similar cases, identifying the
subtle differences, and acting on them
ex. pts both have arthritis
look at similarities and subtle differences
(Predicting) and managing potential complications - ANSWERlook at big picture
figure our possible complications for and individual pt. must know common
complications and consider individual differences.
Interpreting- you are planning interventions to help manage or reduce the risk of
complications
ex. plan interventions to reduce atelectasis and pneumonia- encourage use of
incentive spirometer, ambulation schedule.