NURS 261 Exam 1

A systematic approach to practice that emphasizes the use of
1. the best evidence from a critical review of the current research literature
2. the patient's own preferences and values
3. the clinician's experience and expertise
4. the physical exam and assessment

medical

nursing

1. Assessment
2. Diagnosis
3. Outcome Identification
4. Planning
5. Implemantation
6. Evaluation

Collection of data, review of the clinical record and other examinations and assessment, use of evidence-based techniques, and documentation of relevant data

Comparison of clinical findings with what's "normal", interpretation of data including making and testing hypothesis, validating diagnoses, and documenting the diagnosis

Identify expected outcomes, individualize to the person, identifying culturally appropriate outcomes, establishing realistic and measurable outcomes, and including a timeline

Establishing priorities, developing and setting timelines for outcomes, identifying interventions, and integrating evidence-based research

Done in a safe and timely manner using evidence-based interventions, in collaboration with other providers and resources, providing health teaching and promotion, and documentation

Progression towards outcomes, use of ongoing evaluations and assessments, and revising diagnoses, outcomes, and plans as needed

any deviation from normal

relevant, irrelevant

identifying and prioritizing

actual, potential, collaborative

First level priority setting

Phase of the nursing process that involves setting goals and outcomes through an individualized care plan

The implementation phase of the nursing process

Phase of the nursing process that involves determine how effect your plan was

The best method for problem-solving for nurses

The process of analyzing health data and drawing conclusions to identify diagnoses

False

A piece of information, a sign or symptom, or a piece of laboratory data

A tentative explanation for a cue or set of cues that can be used as a basis for further investigation

Nurses who don't have experience and use "rules" to guide their practice

Nurses after 2-3 years of experience

Nurses that understand the patient as a whole rather than a set of individual systems/tasks to complete

Nurses that use excellent clinical judgement to create accurate solutions

Caregivers apply knowledge of culture to improve health outcomes

Caregivers apply a universal concept of understanding of culture to all contextual aspects of care

Provision of health care across cultural boundaries in consideration of context

self understanding

cultural

heritage and health practices
spirituality and religion
family and social roles

Types of things are compared between groups

exceed

True

Status of immigrants, minimal understanding of the US health care system and medical interventions, and difficulty with communication including the possible need for an interpreter

personal, social, economic, environmental

15

Shared patterns, beliefs, self-definitions, norms, and values that can occur among those who speak a particular language or live in a defined geographic region
Learned from birth through language and socialization, shared by all members, adapts, and dynamic and ever changing

Social group with shared traits with which someone can self-identify

Process of adopting culture and behavior of the majority culture

Unidirectional acculturation in a linear fashion

Acculturation that allows for reciprocal change and maintaining ethnic identity

May promote health, social networks and social support systems that buffer stress and illness, and lead to thoughts of hope and optimism

increased

66%

31%

Assessment of someone's religious or spiritual beliefs using open-ended questions

Faith, Influence, Community, Address/Action

Tool to examine a patient's coping mechanisms

A balance of the person, both within one's being and in the outside world

True

cultural context

personal

False

Force resulting in injury or death

Attempted or completed acts without permission

Repeated unwanted attention through various methods

Emotional abuse of agressive nature

Everyone

False

women of childbearing age

mandatory reporters

Significan issue where victims are at risk for trauma, however no standard screening tool exists

Heal protocol and Adult human trafficking tool and guide

Failure to provide for children's basic needs

Nonaccidental injury that leads to harm of a child

Fondling, sexual acts, exploitation, and trafficking

Pattern of behavior that harms a child's sense of self-worth or development

Involves both overt and covert behaviors, failure to act by a caregiver or a trusted person. Takes the forms of sexual abuse, neglect, financial abuse, etc.

Provides subjective data for your assessment

Directed with clues from the health history and provides you with objective data

1. Provides subjective data
2. Identifies patient strengths
3. Identifies actual and potential health problems
4. Identifies support systems
5. Identifies teaching and discharge needs

Name, Age, Gender, Birth, Date and Place, Marital Satus, Race, Religion, Education, and Occupation

Patient's experience directly from them

Written documentation that specifies medical treatment for a competent patient should the patient become unable to make decisions

Reason for seeking health care, "always a quote"

Includes childhood illnesses, surgeries, injuries, hospitalizations, adult medical problems, medications, allergies and their reactions, immunizations, travel, and military service

Used to identify familial or genetically linked disorders

A visual representation of a person's family tree that can provide information about family medical history

Focuses on health promotion, protective patterns, roles, and relationships. Includes healthcare practices, typical days, nutrition assessments, activity and exercise patterns, recreation, habits, occupational risks, ad stress.

Used in many countries to prevent TB and causes someone to have a positive TB skin test. Further diagnostic procedures including a sputum test and chest x-ray must be done.

Comprehensive (head to toe) verbal or survey assessment to determine your patient's status.

Identify why the patient is seeking care, followed by a complete symptom analysis

Pneumonic used in your review of systems to ask questions that are pertinent to your focused problem

Proactive/Palliative
Quantity
Region/Radiation
Severity/Scale
Timing
Understanding

open

Interview that is structured with specific questions

Interview that is controlled by the patient and helps to see what is important to them

Closed

Open

Don't rush, use active listening skills, don't focus on documentation, avoid "why" questions, and provide encouragement

Reassuring the patient that you are paying attention

Resisting the urge to talk all of the time

"let me see if I have this right," "I'm not sure what you meant"

Paying attention and maintaining eye contact

Asking what the patient wants to talk about

Like a mirror, repeating back what the patient said as a statement

Communication technique that can be very effective as long as it's used in the right context

Getting the conversation back on track

standard precautions

abdominal, bowel

Inspection directly using eyes

Inspection using a tool

Allows you to assess surface characteristics. It is most often used to assess for tenderness and deformaties

light

dorsal

What you are looking for when assessing the lymph nodes and TMJ

Temple Mandibular Joint

Applying pressure with your fingertips or pads over an area to a depth greater than 1/2 inch. Can be done with one or both hands.

Palpation technique commonly used to assess a partially free-floating object. Most commonly used in pregnancies.

Tapping on a surface, the sound determines the density of the underlying tissue and whether it is solid tissue or filled with air or fluid.

duller

Assessed using the flat side of a reflex hammer

Used for assessing CVA tenderness, specifically use when looking for a kidney infection

Costo Vertebral Angle

Percussion sounds associated with normal lung sounds: a hollow sound

Percussion sound associated with a gastric air bubble over the stomach: a drum like sound

Percussion sound associated with the liver: thud sound

Percussion sound associated with a hyper-inflated lung: booming sound

Lack of or very little percussion sound associated with muscle

Pneumonic for the areas you can auscultate

Cardiac, Lungs, Abdominal, Vessels

Listening with a stethoscope for characteristics of sounds

Larger side, high frequency sounds like breath and heart sounds, firm pressure agianst skin

Smaller side, low frequency sounds like heart murmurs and vascular bruits, light pressure

Omitting, misinterpreting, or hasty interpretation

Process in which you use your senses to collect objective data

health history

General survey, vital signs, height and weight, PE of all structures, organs, and body systems. Used to establish a baseline

Zeroes in on an acute problem. You assess only the parts of the body that relate to that problem

First impression of your client; begins as soon as you meet them

distress

general survey

Becoming Responsible Engaged in the World

Someone who is unrelated to the patient

They can identify person, place, time, and situation

Used to test a patient's eyesight. Test each eye separately, then both eyes together.

Used to assess patient's eyes, with the hope of seeing PERRLA. Always used in a darkened room

Left

Pupils are Equal
Round (and)
Reactive to Light (and)
Accommodation

Used to assess a patient's ears

1/4

1/2

tympanic membrane

Used to assess hearing and vibratory sensations

Low frequency tuning forks are best for vibration

High frequency tuning forks are best for hearing

Used in a darkened room to assess the sinuses, the fontanels or the newborns, and the male scrotum

Used to measure lengths and circumferences of extremities and abdominal girth, fundal height in pregnancies, and head circumference in newborns

Used during a musculoskeletal exam to assess range of motion of a joint

99

97

ovulation

0.5-1

Tool used for auscultation

anteriorly

Blood pressure cuff

Blood Pressure = Cardiac Output + Peripheral Vascular Resistance

120/70

130/80

high

low

The difference between the systolic and diastolic numbers

50 mmHg

Reflects the force of the heart contracting. This force creates a wave of pressure as blood circulates throughout the system. It reflects the stroke volume

The amount of blood ejected with each contraction

Taken on the wrist just under the thumb. Assess rate and rhythm and varies with age.

100-180

55-100

60-100

Lower

Taken just lateral to the thyroid

palpated, massaged

Cardiac Output = Stroke Volume x Heart Rate

Pulse taken right on the heart

Tachycardia

Bradycardia

Radial

1 minute

sinus arrhythmia

A device for measuring blood flow that transmits and reflects sound waves. It can be used to find where to measure a pulse. If you find the stop, you should always mark it with an X.

30-40

Respiration rates that are normal

Respiration rates that are higher than normal

Respiration rates that are lower than normal

absent of breathing

Difficulty breathing

Device used to measure both arterial oxygen saturation and pulse.

97-100

normal