Rasmussen, NUR2092 Exam 1 Prep Questions and Answers
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Terms in this set (97)
Assessment
Diagnosis
Outcome identification
Nursing Process
Planning
Implementation
Evaluation
1. Collect data
Assessment 2. Use evidence-based assessment techniques
3. Document relevant data
1. Compare clinical findings with normal and abnormal variation
and developmental events
Diagnosis 2. Interpret data-- make & test hypotheses
3. Validate diagnoses
4. document diagnoses
Outcome Identification Definition (nursing process)
1. Identify expected outcomes
2. Individualize to the person
Outcome Identification
3. Culturally appropriate
4. realistic and measurable
5. include a timeline
1. ESTABLISH PRIORITIES
2. Develop Outcomes
3. Set timelines for outcomes
Planning Definition
4. IDENTIFY interventions
5. Integrate evidence-based trends and research
6. Document plan of care
1. Implement in a safe and timely manner
2. Use evidence-based interventions
3. Collaborate with colleagues
Implementation Definition 4. use community resources
5. coordinate care delivery
6. provide health teaching and health promotion
7. document implementation and any modifications.
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1. Progress toward outcomes
2. conduct systematic, ongoing, criterion-based evaluation.
Evaluation Definition 3. Include patient and significant others
4. use ongoing assessment to revise diagnoses, outcomes, plan
5. distribute results to patient and family
EBP is a systematic approach to practice that emphasizes the use
of best evidence in combination with the clinician's experience,
evidence-based practice
as well as the patient preferences and values, to make decisions
about care and treatment
Four factors: the best evidence from a critical review of research
Evidence based clinical decision literature; the patient's own preferences; the clinician's own
making experience and expertise; and finally physical examination and
assessment.
Includes complete health history and full physical examination
Complete (Total Health) Describes current and past health state and forms baseline to
Database measure all future changes
Yields first diagnoses
For limited or short term problem. Collect "mini" database,
Focused or Problem-Centered
smaller in scope, concerns mainly one problem, one cue
Database
complex, or one body system
The status of any identified problems should be evaluated at
regular and appropriate intervals. What change has occurred? Is
Follow-Up Database the problem getting better or worse? Which coping strategies
are used? This type of database is used in all settings to follow
up both short-term and chronic health problems.
Rapid collection of the database, often compiled concurrently
Emergency Database
with lifesaving measures Diagnosis must be swift and sure.
elicit a response that is more than one word
ex: what brings you in today? Tell me all about your headaches?
Open-ended questions Used for narrative information
Calls for long paragraph answers
Elicits feelings, opinions, ideas
Builds and enhances rapport
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require one or two word answers
ex: what is your age? Are your headaches on one side or both?
Used for specific information
Elicits cold facts
Limits rapport and leaves interaction neutral
Close-ended questions
Direct questions help you elicit specific information and are
useful to fill in any details that were initially left out after the
person's opening narrative. Direct questions are also useful when
you need specific facts such as past medical history or during
the review of systems. You need direct questions to speed up the
interview.
1. Ask only one direct question at a time. Avoid bombarding the
person with long lists: "Have you ever had pain, double vision,
watering, or redness in the eyes?" Avoid double-barreled
questions such as, "Do you exercise and follow a diet for your
weight?" The person will not know which question to answer. And
Follow these guidelines for
if the person answers "yes," you will not know which question the
open and closed/direct
person has answered.
questions:
2. Choose language the person understands. You may need to
use regional phrases or colloquial expressions. For example,
"running off" means running away in standard English, but it
means diarrhea to Appalachian mountain people.
CLARIFICATION (rephrase)
FACILITATION (nodding, Hmm,hmm)
Therapeutic communication
SILENCE (when to use)
techniques
SUMMARIZE (summarize what pt stated) EMPATHY (likening to
others, comfort, "I understand")
AVOIDANCE LANGUAGE (using other words)
CHANGING THE SUBJECT
DISTANCING (walking to the door, avoid eye contact)
Communication Barriers BLAMING (if you didn't smoke...)
FALSE REASSURANCE (you'll be fine)
FAILURE TO LISTEN
GIVING ADVICE
Pain that feels like it is coming from a body part that has been
Phantom Pain
amputated.
Severe pain that erupts while a patient is already medicated with
Breakthrough Pain
long-acting painkiller
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