NUR 155 EXAM 1 with complete solutions...
NUR 155 EXAM 1!
Study online at https://quizlet.com/_jr43am
1. What are the fac- Assess
tors of ADPIE Diagnose
Plan
Implementation
Evaluate
2. Assess Data collection with a holistic approach (physical, psychological, emotional,
environmental, cultural, and spiritual) through observation, interviews, physi-
cal assessment, and cues.
3. Diagnoses Description of what a nurse observes. Identifies a problem, potential prob-
lems, and opportunity for improvement.
4. Planning Identifies nursing diagnoses, establishes short/long term goals, chooses out-
come indicators, and identifies interventions
5. How long are short A week or less
term goals?
6. Long term goals No clear end time
7. Implementation Evidence based practice, independent intervention
8. Evaluation Were the desired outcomes/ goals met? Were interventions successful?
9. Observation what you can see, hear, smell to gather patient information
10. Orientation phase -Nurse should recognize patients preferred name
-Demographic data collection
-Privacy
-Eye level with patient
-good nonverbal cues
11. Working phase
Page 1
, NUR 155 EXAM 1 with complete solutions...
NUR 155 EXAM 1!
Study online at https://quizlet.com/_jr43am
-health history
-review of systems
-health promotion
12. Health History -demographic data
-reason for seeking care
-allergies, medications
*family and social history
13. Termination Phase Interview is finalized
14. Physical assess- Inspection
ment Palpation
Percussion
Auscultation
15. inspection -see, hear, smell
16. Palpation uses touch to assess body organs, skin texture, temperature, moisture, turgor
(hydration), tenderness, and thickness.
Can determine organ location. size, distention or masses.
17. Percussion tapping the patients skin with short, sharp strokes that cause a vibration to
travel through the skin and to the upper layers of the underlying structures.
18. Auscultation Listening with the assistance of a stethoscope to hear sounds made by organs
or systems Breath sounds, heart sounds, and bowel sounds.
19. Comprehensive as- head to toe assessment
sessment
20. Focsused assess- Certain body system (edema, peripheral pulses, capillary refill, skin turgor,
ment muscle strength.
Page 2
, NUR 155 EXAM 1 with complete solutions...
NUR 155 EXAM 1!
Study online at https://quizlet.com/_jr43am
21. Emergency Assess- rapid, focused assessment.
ment *ABC's
*Severe trauma
*Cardiac arrest
*Respitory
*Seizure
22. Primary Data Directly from patient
23. Subjective data Symptoms
*Pain is subjective
"It feels like"
24. Objective data Signs
- can be measured or observed
*do not make interpretations
25. Gordons functional Activity/exercise
health patterns diet
elimination
Sleep/rest
Cognitive
self perception
role/relationshio
sexuality
stress tolerance
values/beliefs
Page 3
NUR 155 EXAM 1!
Study online at https://quizlet.com/_jr43am
1. What are the fac- Assess
tors of ADPIE Diagnose
Plan
Implementation
Evaluate
2. Assess Data collection with a holistic approach (physical, psychological, emotional,
environmental, cultural, and spiritual) through observation, interviews, physi-
cal assessment, and cues.
3. Diagnoses Description of what a nurse observes. Identifies a problem, potential prob-
lems, and opportunity for improvement.
4. Planning Identifies nursing diagnoses, establishes short/long term goals, chooses out-
come indicators, and identifies interventions
5. How long are short A week or less
term goals?
6. Long term goals No clear end time
7. Implementation Evidence based practice, independent intervention
8. Evaluation Were the desired outcomes/ goals met? Were interventions successful?
9. Observation what you can see, hear, smell to gather patient information
10. Orientation phase -Nurse should recognize patients preferred name
-Demographic data collection
-Privacy
-Eye level with patient
-good nonverbal cues
11. Working phase
Page 1
, NUR 155 EXAM 1 with complete solutions...
NUR 155 EXAM 1!
Study online at https://quizlet.com/_jr43am
-health history
-review of systems
-health promotion
12. Health History -demographic data
-reason for seeking care
-allergies, medications
*family and social history
13. Termination Phase Interview is finalized
14. Physical assess- Inspection
ment Palpation
Percussion
Auscultation
15. inspection -see, hear, smell
16. Palpation uses touch to assess body organs, skin texture, temperature, moisture, turgor
(hydration), tenderness, and thickness.
Can determine organ location. size, distention or masses.
17. Percussion tapping the patients skin with short, sharp strokes that cause a vibration to
travel through the skin and to the upper layers of the underlying structures.
18. Auscultation Listening with the assistance of a stethoscope to hear sounds made by organs
or systems Breath sounds, heart sounds, and bowel sounds.
19. Comprehensive as- head to toe assessment
sessment
20. Focsused assess- Certain body system (edema, peripheral pulses, capillary refill, skin turgor,
ment muscle strength.
Page 2
, NUR 155 EXAM 1 with complete solutions...
NUR 155 EXAM 1!
Study online at https://quizlet.com/_jr43am
21. Emergency Assess- rapid, focused assessment.
ment *ABC's
*Severe trauma
*Cardiac arrest
*Respitory
*Seizure
22. Primary Data Directly from patient
23. Subjective data Symptoms
*Pain is subjective
"It feels like"
24. Objective data Signs
- can be measured or observed
*do not make interpretations
25. Gordons functional Activity/exercise
health patterns diet
elimination
Sleep/rest
Cognitive
self perception
role/relationshio
sexuality
stress tolerance
values/beliefs
Page 3
