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34 Cards in this Set
- Front
- Back
open ended or closed question?
"what brought you to the hospital" |
open ended
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best position when talking with patient?
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two chairs placed at right angles / patient in bed chair placed at 45 degree angle
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group chair setting?
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horseshoe or circular chair arrangement
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acceptable personal space
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18" in US / 24" in Britian / 36" in Japan
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Validation
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the act of dbl checking or verifying data to confirm that it is accurate and factual
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what are Cues?
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sub or obj data that can be directly observed by the nurse ; hear, feel smell or measure, or seen
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Inferences?
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R.N. interpretation or conclusion made based on cues (nurse observes the cues that incision is red, hot and swollen)
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nursing assessment must be complete and
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accurate because nursing diagnoses and interventions are based on this information
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data must recorded in factual manner w/o ?
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interpretation or inferences
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Diagnosing
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analyze data, identify health problems, risks and strengths, formulate diagnostic statements
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taxonomy?
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system or set of categories arranged on the basis of a single principle or set of priciples
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diagnosing refers to ?
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the reasoning process
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diagnosis?
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a statement or conclusion regarding the nature of phenomenom
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what are the five types of nursing diagnosis?
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accutal, wellness, risk, possible and syndrome.
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risk diagnosis?
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problem does not exist, but risk factors are present
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wellness diagnosis?
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human response to levels of wellness in person, family or community that have readiness for enhancement
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possible nursing diagnosis
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evidence about a health problem is incomplete or unclear
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syndrome diagnosis
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diagnosis associated with acluster of diagnoses
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what three components of NANDA nursing diag?
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1. problem and definition
2. etiology 3. defining characteristics |
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what are qualifiers?
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words added to NANDA labels to give additional meaning
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independent functions?
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areas of healthcare unique to nursing and seperate from medical management
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dependent functions
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nurse is obligated to carry out therapies and tx written by MD
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three steps of diagnosing process
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analyzing data
identifying health problems, risks and strengths formulating diagnostic statements |
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two parts of nursing diagnosis are joined by?
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related to / why? due to implies that one part causes or is responsible for the other
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basic format of nursing diagnosis
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problem related to etiology
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planning
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prioritze problems/diagnosis/
formulate goals/desired outcomes/select nursing interventions/write nursing orders. |
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nursing intervention
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any treatment based on clinical judgement and knowledge a nurse performs to enhance client outcomes
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when does effective discharge planning begin?
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at first client contact / involves comprehensive and ongoing assessment to obtain information
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formal nursing care plan
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written or computerized guide that organizes information about the client's care
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standardized care plan
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formal plan that specifies nursing care for groups of clients with common needs (ie...MI)
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individulized care plan
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tailed to meet unique needs of a specific client
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rationale
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scientific principle given as the reason for selecting a particular nursing intervention
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multidisciplinary care plan
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standardized plan outlining care required for common predictable medical conditions
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indicator
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is concrete observable patient state, behavior, or self reported perception or evaluation
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