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NUR 216 Exam 1/84 Complete Questions with Answers
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NUR 216 Exam 1/84 Complete Questions with Answers
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NUR 216 Exam 1/84 Complete Questionswith Answers
comprehensive assessment - -An assessment that includes a complete
health history and physical assessment; Usually brand new patients
-focused assessment - -assessment conducted to assess a specific problem;
focuses on pertinent history and body regions
-HIPAA - -Health Insurance Portability and Accountability Act
-The nursing process - -Assessment
Diagnosis
Planning
Implementation
Evaluation
-Assessment (ADPIE) - -Data collection (objective/subjective)
Prioritize Data: Primary (life threatening), Secondary (requires prompt
attention), Tertiary (not urgent)
-Planning (ADPIE) - -Develop SMART goals, plan nursing interventions
-Implementation (ADPIE) - -Perform planned nursing interventions
-Evaluation (ADPIE) - -Were the goals met? If not, re-assess
-assessment skills - -Inspection
Palpation
Percussion
Auscultation
(Bowels: Inspection, Auscultation, Percussion. Auscultation) Do not want to
alter the bowel sounds
-Inspection - -Observe for Symmetry, size, color, shape
Direct: Visualize with our eyes
Indirect: Use and instrument
-Fingertips/pads: Palpation - -Fine sensation (texture, swelling, pulsation.
lumps)
, -Dorsa of hands: Palpation - -Best for determining temperature
-Base of fingers or ulnar surface: - -vibrations
-Palpation - -Light: surface characteristics
Deep: Organs, masses, tenderness (use intermittent pressure)
Ballpottement: Size/Shape of free floating objects
- Always palpate tender areas last
-Percussion - -tapping on a surface to determine the difference in the
density of the underlying structure
-Ausculation - -listening to sounds within the body
-Bell - -low pitched sounds
(mummers)
-Diaphragm - -high pitched sounds
(bowel and lung sounds)
-What should we do before leaving the patients room? - -Patients safety
Bed to lowest position
Side Rails
Call button and personal belongings in reach
-Contextual awareness - -Understanding the status of the client and the
events that led to their interaction
-Analyzing assumptions - -Evaluating the client's clinical situation
-Exploring alternatives - -The use of holistic approaches for treating the
whole person
(physical health, lifestyle choices, culture, living environment, life
experiences)
-Reflecting and deciding - -Reflect on the client's goals and decide on the
intervention with client input
-Steps for communicating with members of the health care team - -
1.Identify the member by name and title
2.Provide info regarding the current situation
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