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NUR 245 / NUR245 EXAM 1. QUESTIONS WITH 100% CORRECT ANSWERS.

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What is neuropathic pain? pain caused by lesion or disease in somatosensory nervous system What are some examples of conditions that can cause neuropathic pain diabetes shingles HIV/AIDS chemotherapy stroke MS tumor Behavioral cues for pain assessment in older adults changes in functional status changes in dressing, walking, toileting, involvement in activities (ADLs and IADLs) slowness, rigidity, fatigue sudden onset of acute confusion ABCT / components of the mental status exam A-appearance B-behavior C-cognition T-thought processes Mini-cog quick easy screening for cognitive impairment in otherwise healthy older adults 3-item recall test, clock drawing test tests function, ability to plan, manage time, organize activities, working memory can be used w/ varied culture groups + literacy levels Timed Up and Go (TUG) rise from chair, walk 10 feet, turn, walk back to chair, sit down MMSE Mini mental state exam Tests cognitive function through orientation, registration, attention and calculation, recall language can help diagnose dementia MOCA (Montreal Cognitive Assessment) Screens for mild cognitive decline. 30-point questionnaire. or = 26 considered normal What does MOCA measure visuo-constructive ability language function memory auditory attention conceptual thinking working memory and calculations speech/language Palpation applies your sense of touch to assess the body, especially while perceiving/diagnosing a disease or illness Percussion tapping on the person's skin with shirt, sharp, strokes to assess underlying structures Auscultation listening to sounds produced by the body Vital signs include temperature, pulse oximetry and rate, respiration, blood pressure, pain

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NUR 245 EXAM 1
Phases of nursing process (ADPIE)
Assessment, Diagnosis, planning, Implementation, Evaluation




Nursing Process: assessment
-collect data
-review of clinical record
-health history
-physical exam
-function assessment
-risk assessment
-use EBP
-document relevant data




Nursing process: diagnosis
-compare clinical findings with normal and abnormal variation
-interpret data
-ID clusters of cues
-make hypothesis

,-test hypothesis
-derive dx
-validate dx
-document dx




Nursing process: planning
-establish priorities
-developmental outcomes/goals (SMART goals)
-identify nursing interventions
-document plan of care




SMART goals
Specific, Measurable, Attainable, Realistic, Timely




Nursing Process: Implementation
-implement the plan in a safe and timely manner
-use EBP interventions
-collaborate with colleagues
-coordinate care delivery
-provide teaching and health promotion

, -document implementation and modifications




Nursing process: Evaluate
-progress towards goals/outcomes
-conduct systematic, ongoing, criterion based evaluation
-include patient and significant others
-use ongoing assessment to revise diagnosis, outcome, plan
-disseminate results to patient and family




Close/direct questions
-elicit a one or two word response
-help you elicit specific information
-helpful in filling in any details originally left out
-highly stressed people and people with difficulty hearing will find these easier




Open-ended questions
-unbiased
-associated with non-directive interview
-invite clients to discover, explore, elaborate, clarify, or illustrate a thought or feeling

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