Fundamentals Test 2:nursing Process

Front 1

State factors that may influence prioritization of the client's basic needs

Back 1

Maslow's Hierarchy of Needs:
1. Physiological
2. Safety and Security
3. Love and Belonging
4. Self Esteem
5. Self-Actualization

Front 2

Describe the purpose of each of the five components of the Nursing Process.

Back 2

ASSESSMENT: obtain enough data to allow you to be of help to the patient

Front 3

Describe the purpose of each of the five components of the Nursing Process.

Back 3

DIAGNOSIS AND ANALYSIS: identify patterns in the data and draw conclusions about the clients health status

Front 4

Describe the purpose of each of the five components of the Nursing Process.

Back 4

PLANNING: the end product of formal planning is a holistic plan of care that addresses the patient's unique problems and strengths

Front 5

Describe the purpose of each of the five components of the Nursing Process.

Back 5

IMPLEMENTATION: perform or delegate planned interventions

Front 6

Describe the purpose of each of the five components of the Nursing Process.

Back 6

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

Front 7

Describe the essential component of the Nursing Assessment: health history

Back 7

medical, surgical, medications, communicable diseases, allergies, injuries/accidents, diabetes/handicaps, childhood illnesses, immunizations

Front 8

Describe the essential component of the Nursing Assessment: physical and psychosocial assessment

Back 8

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

Front 9

Describe the essential component of the Nursing Assessment: analysis of laboratory and diagnostic tests

Back 9

Provide info about clients health status, help determine which nursing interventions are appropriate or inappropriate

Front 10

Subjective data

Back 10

Info given verbally by patient; what they report is stated

Front 11

Objective data

Back 11

Factual data observed by nurse

Front 12

Describe methods of data collection

Back 12

Nursing history, observation, inspection, palpation. percussion, auscultation

Front 13

Identify sources for data collection

Back 13

Patient, family, diagnostic tests, previous records

Front 14

Compare and contrast a nursing diagnosis and a medical diagnosis.

Back 14

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

Front 15

Describe the components in the development of a nursing diagnosis.

Back 15

Identifying the health problem, formulation nursing diagnosis, stating whether its an actual or potential problem, writing the nursing diagnosis

Front 16

Describe the steps in developing a client goal.

Back 16

Be specific: realistic, observable, measurable
Action Verbs
Time Frames

Front 17

Purpose of nursing interventions

Back 17

Review diagnosis and outcomes, selects standardized interventions, individualized to meet patients needs

Front 18

Three types of nursing interventions: dependent

Back 18

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

Front 19

Three types of nursing interventions: independent

Back 19

One that nurses are licensed to prescribe, perform or delegate based on their knowledge and skills

Front 20

Three types of nursing interventions: interdependent

Back 20

One that is carried out in collaboration with other health team members
ex: physical therapists, dietitians, physicians

Front 21

Discuss the method by which the nurse evaluates care

Back 21

Evaluation of actions, goals, and care plan

Front 22

Four basic techniques of physical assessment- Inspection

Back 22

visual examination, inspect for: size, shape, color, symmetry, position and abnormalities

Front 23

Four basic techniques of physical assessment- Palpation

Back 23

touching patient with different parts of hand
light palp: 1/2-3/4 inch
deep palp: 1 1/2-2 inches

Front 24

Four basic techniques of physical assessment- Auscultation

Back 24

Listening for breath, heart or bowel sounds
*when assessing in abdomen, look, listen and feel in that order

Front 25

Four basic techniques of physical assessment: Percussion

Back 25

Tapping fingers rapidly against patients body, helps locate organ borders, shape and position
-can tell if is solid or filled with fluid or gas

Front 26

Four basic techniques of physical assessment: Percussion

Back 26

Tapping fingers rapidly against patients body, helps locate organ borders, shape and position
-can tell if is solid or filled with fluid or gas

Front 27

Describe assessment activities designed to identify a client’s safety status.

Back 27

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

Front 28

Examine a falls risk assessment that could be utilized in the clinical setting.

Back 28

The Morse Falls Scale

Front 29

Discuss the categories of risks inherent in a health care agency.

Back 29

Falls, equipment related accidents, fires and electrical hazards, restraints, side rails, ambularm and bed alarms, mercury poisoning.

Front 30

Identify factors to assess when it becomes necessary to physically restrain a client.

Back 30

when they are in danger of harming themselves or others

Front 31

Discuss how nurses can implement the National Patient Safety Goals.

Back 31

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

Front 32

Define a sentinel event and give examples.

Back 32

An unexpected occurrence involving death or serious physical or psychological injury, or the risk there of
ex: amputating wrong leg!

Front 33

Respiration

Back 33

1 respiratory cycle= 1 inspiration + 1 expiration
normal range: 12-20

Front 34

Respiration: rhythm

Back 34

pattern of respiration and intervals between
- normal is regular

Front 35

Pulse: 3 characteristics of a pulse

Back 35

Rate: # of pulse beats in 1 min (60-100 bpm)
Rhythm: pattern of pulses and intervals between
Volume: pulse strength or amplitude (normal 2+)

Front 36

Temperatures

Back 36

Oral: 98.6
Rectal: 99.5
Axillary: 97.7
Tympanic: calibrated to oral or rectal

Front 37

Blood pressure

Back 37

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

Front 38

Auscultation

Back 38

Pitch: frequency of sound waves
Intensity: loudness
Duration: time
Quality: rumbling, blowing, musical

Front 39

Percussion sounds

Back 39

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

Front 40

Light Palpation

Back 40

assess for texture, tenderness, moisture, elasticity, pulsations, surface organs, masses
-dorsal surface:temp
-finger tips: texture, size, pulse, form
-palmar surface: vibrations

Front 41

Deep Palpation

Back 41

used to feel internal organs/masses for: size, shape, tenderness, symmetry, mobility

Front 42

Cyanosis

Back 42

blue fingertips, lips or eyes

Front 43

Erythema

Back 43

Red inflammation

Front 44

Pallor

Back 44

extreme paleness, black people: loss of red tones

Front 45

Assessing Pitting Edema

Back 45

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

Front 46

Macule

Back 46

flat, ex: freckle

Front 47

Papule

Back 47

elevated, raised

ex: mole

Front 48

Plaque

Back 48

papule > 1cm

Front 49

Nodule

Back 49

solid, elevated, >1cm

Front 50

Patch

Back 50

macules >1 cm

ex: measles

Front 51

Wheal

Back 51

superficial, raised

ex: mosquito bite

Front 52

Cyst

Back 52

encapsulated, fluid filled cavity

Front 53

Vesicle

Back 53

elevated containing free fluid up to 1cm

ex: chicken pox

Front 54

Pusturle

Back 54

turbid fluid puss in cavity

ex:acne

Front 55

Hydrocephalus

Back 55

water on the brain

Front 56

Acromegaly

Back 56

Enlargement of bones in face

Front 57

Normocephalic

Back 57

Normal size head

Front 58

Microcephaly

Back 58

Smally head

Front 59

Macrocephaly

Back 59

Large head

Front 60

Torticollis

Back 60

wry neck; neck twisted to side

Front 61

Diplopia

Back 61

double vision

Front 62

PERRLA

Back 62

PE- pupils equal
R- round
R- react to
L-light and
A- accomodation

Front 63

What is an early sign of deoxygenation?

Back 63

restlessness

Front 64

Subcutaneous crepitus

Back 64

Crackling noise