Nurs 2313 Ny's Quiz 2 Review Save
Questions and Answers
Terms in this set (604)
Subjective (what the patient reports) vs. Objective
Data Types
(measurable, observable signs)
Initial assessment Performed on admission
Focused assessment Addresses a specific issue or complaint
Ongoing assessment Conducted throughout care
Emergency assessment Quick evaluation in urgent situations
Temperature, Pulse, Respiration, Blood Pressure
Vital Signs
(BP), Oxygen Saturation
Pain as the 5th vital sign Assessing and managing pain levels
Types of Pain Acute vs. Chronic
Pain Scales Numeric rating, Wong-Baker Faces Scale
Non-pharmacological vs. Pharmacological
Pain Management
interventions
Physiological Needs: Food, water, shelter; Safety
Maslow's Hierarchy of Needs: Protection, security; Love & Belonging:
Needs Relationships, friendships; Esteem Needs: Respect,
self-confidence; Self-Actualization: Personal growth
Information from the patient's perspective (e.g.,
Subjective Data
pain, nausea)
Observable and measurable facts (e.g., vital signs,
Objective Data
lab results)
Patient safety initiatives Fall prevention, infection control
, Problem (NANDA diagnosis) + Etiology (cause) +
NANDA-I Format
Signs/Symptoms (evidence)
Risk Diagnosis Patient is at risk but does not yet show symptoms
Actual Diagnosis Condition is present with signs and symptoms
Evidence-Based Practice Using current research to guide clinical decisions
(EBP)
Steps of EBP Ask, Acquire, Appraise, Apply, Assess
Nursing Scope of What nurses are legally allowed to do, defined by
Practice state Nurse Practice Acts (NPAs)
Grouping related patient data to identify patterns
Clustering Data
and formulate nursing diagnoses
Purpose of Nursing Guides patient care and interventions; Helps
Diagnoses prioritize treatment plans
Medical Diagnosis Identifies a disease (e.g., Diabetes)
Focuses on patient responses to conditions (e.g.,
Nursing Diagnosis
Risk for unstable blood glucose)
Carrying out nursing interventions based on the
Implementation Phase
care plan
Includes medication orders, treatments, and
How to Write Orders
diagnostic tests; Ensuring accuracy and following
from Providers
legal documentation rules
Subjective: What the patient states; Objective:
SOAP Notes Measurable/observed data; Assessment: Nurse's
interpretation; Plan: Next steps in care
Legal Issues in Nursing HIPAA (confidentiality), Informed consent,
Practice Malpractice and negligence
Use factual, concise, objective language; Avoid
How to Document
assumptions or opinions; Use proper abbreviations
Correctly
and time stamps
How to Sign Your Name Includes first initial, last name, and credentials (e.g.,
as a Nurse J. Doe, RN)
Questions and Answers
Terms in this set (604)
Subjective (what the patient reports) vs. Objective
Data Types
(measurable, observable signs)
Initial assessment Performed on admission
Focused assessment Addresses a specific issue or complaint
Ongoing assessment Conducted throughout care
Emergency assessment Quick evaluation in urgent situations
Temperature, Pulse, Respiration, Blood Pressure
Vital Signs
(BP), Oxygen Saturation
Pain as the 5th vital sign Assessing and managing pain levels
Types of Pain Acute vs. Chronic
Pain Scales Numeric rating, Wong-Baker Faces Scale
Non-pharmacological vs. Pharmacological
Pain Management
interventions
Physiological Needs: Food, water, shelter; Safety
Maslow's Hierarchy of Needs: Protection, security; Love & Belonging:
Needs Relationships, friendships; Esteem Needs: Respect,
self-confidence; Self-Actualization: Personal growth
Information from the patient's perspective (e.g.,
Subjective Data
pain, nausea)
Observable and measurable facts (e.g., vital signs,
Objective Data
lab results)
Patient safety initiatives Fall prevention, infection control
, Problem (NANDA diagnosis) + Etiology (cause) +
NANDA-I Format
Signs/Symptoms (evidence)
Risk Diagnosis Patient is at risk but does not yet show symptoms
Actual Diagnosis Condition is present with signs and symptoms
Evidence-Based Practice Using current research to guide clinical decisions
(EBP)
Steps of EBP Ask, Acquire, Appraise, Apply, Assess
Nursing Scope of What nurses are legally allowed to do, defined by
Practice state Nurse Practice Acts (NPAs)
Grouping related patient data to identify patterns
Clustering Data
and formulate nursing diagnoses
Purpose of Nursing Guides patient care and interventions; Helps
Diagnoses prioritize treatment plans
Medical Diagnosis Identifies a disease (e.g., Diabetes)
Focuses on patient responses to conditions (e.g.,
Nursing Diagnosis
Risk for unstable blood glucose)
Carrying out nursing interventions based on the
Implementation Phase
care plan
Includes medication orders, treatments, and
How to Write Orders
diagnostic tests; Ensuring accuracy and following
from Providers
legal documentation rules
Subjective: What the patient states; Objective:
SOAP Notes Measurable/observed data; Assessment: Nurse's
interpretation; Plan: Next steps in care
Legal Issues in Nursing HIPAA (confidentiality), Informed consent,
Practice Malpractice and negligence
Use factual, concise, objective language; Avoid
How to Document
assumptions or opinions; Use proper abbreviations
Correctly
and time stamps
How to Sign Your Name Includes first initial, last name, and credentials (e.g.,
as a Nurse J. Doe, RN)
