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64 Cards in this Set

  • Front
  • Back
State factors that may influence prioritization of the client's basic needs
Maslow's Hierarchy of Needs:
1. Physiological
2. Safety and Security
3. Love and Belonging
4. Self Esteem
5. Self-Actualization
Describe the purpose of each of the five components of the Nursing Process.
ASSESSMENT: obtain enough data to allow you to be of help to the patient
Describe the purpose of each of the five components of the Nursing Process.
DIAGNOSIS AND ANALYSIS: identify patterns in the data and draw conclusions about the clients health status
Describe the purpose of each of the five components of the Nursing Process.
PLANNING: the end product of formal planning is a holistic plan of care that addresses the patient's unique problems and strengths
Describe the purpose of each of the five components of the Nursing Process.
IMPLEMENTATION: perform or delegate planned interventions
Describe the purpose of each of the five components of the Nursing Process.
EVALUATION: planned, ongoing, systematic activity on which you make judgments about the clients progress towards desired health outcomes, the effectiveness of the nursing care plan, the quality of nursing care in health care setting
Describe the essential component of the Nursing Assessment: health history
medical, surgical, medications, communicable diseases, allergies, injuries/accidents, diabetes/handicaps, childhood illnesses, immunizations
Describe the essential component of the Nursing Assessment: physical and psychosocial assessment
Psychosocial: dress, grooming, personal hygiene, mood and manner, speech and facial expressions
physical: gender and race, stated age vs. apparent age, body fat, stature, motor activity, body and breath odors
Describe the essential component of the Nursing Assessment: analysis of laboratory and diagnostic tests
Provide info about clients health status, help determine which nursing interventions are appropriate or inappropriate
Subjective data
Info given verbally by patient; what they report is stated
Objective data
Factual data observed by nurse
Describe methods of data collection
Nursing history, observation, inspection, palpation. percussion, auscultation
Identify sources for data collection
Patient, family, diagnostic tests, previous records
Compare and contrast a nursing diagnosis and a medical diagnosis.
Nursing diagnosis is a statement of a client problem within scope of nursing practice with a directive of nursing intervention
Medical Diagnosis: describes a disease, illness or injury
Describe the components in the development of a nursing diagnosis.
Identifying the health problem, formulation nursing diagnosis, stating whether its an actual or potential problem, writing the nursing diagnosis
Describe the steps in developing a client goal.
Be specific: realistic, observable, measurable
Action Verbs
Time Frames
Purpose of nursing interventions
Review diagnosis and outcomes, selects standardized interventions, individualized to meet patients needs
Three types of nursing interventions: dependent
One that is prescribed by a physician or advanced practive nurse but is carried out by the bedside nurse
ex: diagnostic tests, medications, treatments, IV therapy, diet and activity
Three types of nursing interventions: independent
One that nurses are licensed to prescribe, perform or delegate based on their knowledge and skills
Three types of nursing interventions: interdependent
One that is carried out in collaboration with other health team members
ex: physical therapists, dietitians, physicians
Discuss the method by which the nurse evaluates care
Evaluation of actions, goals, and care plan
Four basic techniques of physical assessment- Inspection
visual examination, inspect for: size, shape, color, symmetry, position and abnormalities
Four basic techniques of physical assessment- Palpation
touching patient with different parts of hand
light palp: 1/2-3/4 inch
deep palp: 1 1/2-2 inches
Four basic techniques of physical assessment- Auscultation
Listening for breath, heart or bowel sounds
*when assessing in abdomen, look, listen and feel in that order
Four basic techniques of physical assessment: Percussion
Tapping fingers rapidly against patients body, helps locate organ borders, shape and position
-can tell if is solid or filled with fluid or gas
Four basic techniques of physical assessment: Percussion
Tapping fingers rapidly against patients body, helps locate organ borders, shape and position
-can tell if is solid or filled with fluid or gas
Describe assessment activities designed to identify a client’s safety status.
Assess client on admission-age, blindness, confusion, disease consequences, emotional state, frequency of accidents, gait, habits/lifestyle, insufficient knowledge
The environment- room for lighting and equipment, unit for chemicals and infections, hospital for fire and mass causalities/codes
Examine a falls risk assessment that could be utilized in the clinical setting.
The Morse Falls Scale
Discuss the categories of risks inherent in a health care agency.
Falls, equipment related accidents, fires and electrical hazards, restraints, side rails, ambularm and bed alarms, mercury poisoning.
Identify factors to assess when it becomes necessary to physically restrain a client.
when they are in danger of harming themselves or others
Discuss how nurses can implement the National Patient Safety Goals.
Improve accuracy of patient identification, improve effectiveness of communication among caregivers, improve the safety of using medications, reduce the risk of health care associated infections, accurately and completely reconcile medications across the continuum of care, reduce the risk of patient harm resulting from falls, encourage patients active involvement in their own care as a patient safety strategy, recognition and response to changes in a patients condition
Define a sentinel event and give examples.
An unexpected occurrence involving death or serious physical or psychological injury, or the risk there of
ex: amputating wrong leg!
1 respiratory cycle= 1 inspiration + 1 expiration
normal range: 12-20
Respiration: rhythm
pattern of respiration and intervals between
- normal is regular
Pulse: 3 characteristics of a pulse
Rate: # of pulse beats in 1 min (60-100 bpm)
Rhythm: pattern of pulses and intervals between
Volume: pulse strength or amplitude (normal 2+)
Oral: 98.6
Rectal: 99.5
Axillary: 97.7
Tympanic: calibrated to oral or rectal
Blood pressure
Measurement of the force exerted by the flow of blood on large arteries
Normal: 120/80
Prehypertensive: 120-139/80-89
Hypertension: 140-159/90-99
Pitch: frequency of sound waves
Intensity: loudness
Duration: time
Quality: rumbling, blowing, musical
Percussion sounds
the less dense the tissue, the louder and longer the sound
tympany-least dense tissue
hyperresonance- heard if there is increased air in lung or pleural space
resonance- heard over normal lung tissue
dullness- found with areas of decreased air in lungs
flatness-most dense tissue
Light Palpation
assess for texture, tenderness, moisture, elasticity, pulsations, surface organs, masses
-dorsal surface:temp
-finger tips: texture, size, pulse, form
-palmar surface: vibrations
Deep Palpation
used to feel internal organs/masses for: size, shape, tenderness, symmetry, mobility
blue fingertips, lips or eyes
Red inflammation
extreme paleness, black people: loss of red tones
Assessing Pitting Edema
Trace: a minimal depression is noted with pressure
+1: creates a depression of 2mm, no visible distortion, rapid return of skin
+2: depression to 4mm, disappears in 10-15 sec
+3: depression 6mm in depth, 1-2 min, area appears swollen
+4: depression 8mm, 2-3 min, area grossly edematous
flat, ex: freckle
elevated, raised

ex: mole
papule > 1cm
solid, elevated, >1cm
macules >1 cm

ex: measles
superficial, raised

ex: mosquito bite
encapsulated, fluid filled cavity
elevated containing free fluid up to 1cm

ex: chicken pox
turbid fluid puss in cavity

water on the brain
Enlargement of bones in face
Normal size head
Smally head
Large head
wry neck; neck twisted to side
double vision
PE- pupils equal
R- round
R- react to
L-light and
A- accomodation
What is an early sign of deoxygenation?
Subcutaneous crepitus
Crackling noise