NUR 210 Exam 1 With 100% Correct Answers 2023
what makes up an assessment - Correct answer-subjective data
objective data
data base
subjective data - Correct answer-What patient says about himself or herself during history taking
objective data - Correct answer-Observed when inspecting, percussing, palpating, and auscultating patient during physical examination
data base - Correct answer-formed from subjective data, objective data, and a patient's record and diagnostic studies
what is the nursing process - Correct answer-Assessment
Diagnosis
Outcome identification
Planning
Implementation
Evaluation
First-level priority problems - Correct answer-- require immediate intervention
- ABCs (airway, breathing, circulation)
- vital signs
Second-level priority problems - Correct answer-Require prompt medical attention
ex:
- Mental status change
- Untreated medical problems requiring immediate attention
- Acute pain
- Acute urinary elimination problems
- Abnormal laboratory values
- Risks of infection, safety or security
Third-level priority problems - Correct answer-those that are important to the patient's health but can be addressed after more urgent health problems are addressed. - Knowledge deficit - altered family processes
- low self esteem
- activity
- rest
- family coping 4 types of data base collection - Correct answer-- complete total health data base
- focused or problem-centered data base (for limited or short-term problems) - follow up data base
- emergency data base
what makes up a complete total health data base? - Correct answer-- Complete health history - Head to Toe physical examination
- Describes current and past health state and forms baseline to measure all future changes
what makes up a focused or problem-centered data base - Correct answer-For limited or short-term problems
- Collect "mini" data base, smaller scope and more focused than complete data base
- Concerns mainly one problem, or one body system
- History and examination follow direction of presenting concern
what makes up a follow-up data base? - Correct answer-- Status of all identified problems should be evaluated at regular and appropriate intervals
- Note changes that have occurred - Evaluate whether problem is getting better or worse
- Identify coping strategies being used
what makes up an emergency data base? - Correct answer-- Rapid collection of data, often compiled concurrently with lifesaving measures
- Diagnosis must be swift and sure
- Person is questioned simultaneously while his or her airway, breathing, circulation, level of consciousness, and disability are being assessed
goals of the health interview - Correct answer-- Obtain and record complete health history
- Obtain subjective data
- Establish rapport
- Teach about health
- Begin health promotion teaching
the process of communication - Correct answer-- mutual understanding by sender and receiver
- Communication can be learned and polished - Communication is a tool, as basic to quality health care as tools of inspection or palpation
internal factors that influence communication - Correct answer-- Liking others - Empathy - Ability to listen
- Self-Awareness
eternal factors that influence communication - Correct answer-- Ensure Privacy
- Refuse Interruptions if possible
- Physical Environment - Quiet - 4 - 5 feet distance - Equal-Status Seating - Face-to-face position - Don't allow computer screen to be a barrier between you and patient
communication techniques - Correct answer-- Use surname
- Introduce yourself
- Shake hands - Sate purpose of interview
- Types of questions: - Open ended - Closed or direct
facilitation - Correct answer-encourages patients to say more and shows you are interested and will listen further
silence - Correct answer-- Gives patient time to think and organize what to say without interruption from you
- Gives you a chance to observe person unobtrusively and note nonverbal cues
reflection - Correct answer-Echoes patient's words, repeating what person has just said
- focuses further attention on a specific phrase;
- helps person continue in his or her own way
empathy - Correct answer-- Recognizes a feeling and puts it into words
- Names the feeling and allows expression of it - Patient feels accepted and can deal with feeling openly
clarification - Correct answer-- Use when person's words are ambiguous or confusing
- Used to summarize person's words and to simplify them to make them clearer
confrontation - Correct answer-- Frame of reference shifts from patient's perspective to yours
- May focus on discrepancy or inconsistency in person's narrative
- You have observed a certain action, feeling, or statement and now focus person's attention on it
- You give honest feedback about what you see or feel
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