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Quiz 3&4: The Nursing Process/Vital Signs/Documentation/Admission, transfer, discharge (Unitek)
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Quiz 3&4: The Nursing Process/Vital Signs/Documentation/Admission, transfer, discharge (Unitek)
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Quiz 3&4: The Nursing Process/VitalSigns/Documentation/Admission,
transfer, discharge (Unitek)
Nursing Process (ADPIE) - Answer -five-step systematic method for giving patient care;
involves
assessing, diagnosing, planning, implementing, and evaluating
Nursing Diagnosis - Answer -describes a health problem that can be treated by nursing
measures; a step in the nursing process
medical diagnosis - Answer -the identification of a disease or condition by a doctor
medical diagnosis vs nursing diagnosis - Answer -Medical Diagnosis: is used to
evaluate the cause or etiology of disease
Nursing Diagnosis: clinical judements about a persons response to an actual or
potential health state
NANDA-I - Answer -North American Nursing Diagnosis Association International
a professional nursing organization that provides standardized language to identify
patient problems and plan customized care everywhere.
Basically puts everyone on the same page for continuity of care
direct care - Answer -Deals directly with the patients such as a hospital, nursing home,
physician practice, and assisted living facilities.
subjective - Answer -based on or influenced by personal feelings, tastes, or opinions
objective - Answer -Factual, related to reality or physical objects; not influenced by
emotions, unbiased
5 Purposes for Patient Records - Answer -1) Documented Communication
2) Permanent Record for Accountability
3) Legal Record of Care
4) Teaching
, 5) Research and Data Collection
OBRA - Answer -Omnibus Budget Reconciliation Act of 1987. Purpose is to improve the
quality of life of nursing center residents.
Nursing Care Plan - Answer -includes nursing diagnoses, goals and/or expected
outcomes, specific nursing interventions, and a section for evaluation findings so any
nurse is able to quickly identify a patient's clinical needs and situation.
What does data collection include? - Answer -
Two primary methods of collecting patient data? - Answer -Interview patient & physical
exam
focused assessment - Answer -assessment conducted to assess a specific problem;
focuses on pertinent history and body regions
During which phase of the nursing process does the nurse identify the problem? -
Answer -Assessment
What will a nurse do during the last phase of the nursing process.... - Answer -A nurse
will evaluate the desired outcomes vs the actual outcomes
How do you take temporal lobe Vital Signs differently for an adult and child? (Tympanic
Pulse) - Answer -Adult: lobe (pinna) pulled up and back
Child: lobe (pinna) pulled down and back
Factors that influence pulse rates - Answer -Age
Exercise
Fever, heat
Hemorrhage
Medications
Metabolism
Postural changes
Pulmonary Conditions
Unrelieved severe pain/ chronic pain
Factors that affect body temp - Answer -Exercise
Hormonal Influences
Daily Variations (diurnal)
Stress
Environment
Food ingestion and liquids (hot and cold)
Smoking
Celsius to Fahrenheit - Answer -(C x 1.8) + 32 = F
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