Nursing Process Overview
43 Questions
0 Views

Choose a study mode

Play Quiz
Study Flashcards
Spaced Repetition
Chat to Lesson

Podcast

Play an AI-generated podcast conversation about this lesson

Questions and Answers

What is defined as the most likely cause or contributing factor of the nursing diagnosis?

  • Cluster
  • Priority
  • Etiology (correct)
  • Concept map
  • Which aspect should not be emphasized during the interview process?

  • Confidentiality
  • Personal biases of the interviewer (correct)
  • Social determinants of health
  • Building rapport and trust
  • What is a primary challenge of note-taking during patient interviews?

  • It impedes eye contact. (correct)
  • It ensures accurate documentation.
  • It helps maintain focus on the patient.
  • It enhances nonverbal observation.
  • Which of the following is not one of the 10 traps of interviewing?

    <p>Many open-ended questions (D)</p> Signup and view all the answers

    What purpose does a concept map serve in the context of nursing?

    <p>It organizes cues and problems for connection. (A)</p> Signup and view all the answers

    What is the primary purpose of the nursing process?

    <p>To establish a framework for identifying client health status and needs (C)</p> Signup and view all the answers

    Which of the following is NOT a characteristic of nursing assessment?

    <p>Primarily focuses on psychiatric evaluations (A)</p> Signup and view all the answers

    What type of data is considered primary in nursing assessment?

    <p>Subjective and objective data from the client (D)</p> Signup and view all the answers

    What is the first step in the nursing process?

    <p>Assessment (D)</p> Signup and view all the answers

    Which type of database consists of complete health history and a full physical examination?

    <p>Complete database (B)</p> Signup and view all the answers

    Which of the following best describes a follow-up database?

    <p>Evaluates identified problems at regular intervals (A)</p> Signup and view all the answers

    What is a critical aspect of nursing assessment?

    <p>It establishes a database for nursing interventions (A)</p> Signup and view all the answers

    Why is critical thinking important in nursing?

    <p>It enhances the ability to identify and prioritize patient needs (A)</p> Signup and view all the answers

    What is the primary focus of the Jarvis Health Assessment Framework?

    <p>Addressing both wellness and illness needs of the individual (C)</p> Signup and view all the answers

    Which of the following is NOT a focus area of clinical judgement in nursing?

    <p>Conducting surgical procedures (C)</p> Signup and view all the answers

    What should nurses avoid when recording data in a database?

    <p>Using vague generalities (D)</p> Signup and view all the answers

    In the diagnostic reasoning phase, which step follows the identification of cues?

    <p>Clustering cues and identifying data gaps (D)</p> Signup and view all the answers

    Which of the following models is included in non-nursing assessment frameworks?

    <p>Body systems review model (A)</p> Signup and view all the answers

    What role does the assessment phase play in the nursing process?

    <p>It provides quality data crucial for the diagnosis phase (B)</p> Signup and view all the answers

    Which of the following is a component of the clinical judgement process?

    <p>Taking actions (D)</p> Signup and view all the answers

    What is the purpose of diagnostic reasoning in nursing?

    <p>To analyze data and determine patient health status (A)</p> Signup and view all the answers

    What is a crucial step in the assessment phase after collecting data?

    <p>Organizing and recording data (D)</p> Signup and view all the answers

    Which of the following components is NOT part of a Nursing Health History?

    <p>Current medication list (B)</p> Signup and view all the answers

    What is a key aspect of critical thinking in assessment?

    <p>Analyzing and evaluating information (D)</p> Signup and view all the answers

    When should data be validated during the assessment process?

    <p>When subjective and objective data do not agree (A)</p> Signup and view all the answers

    Which assessment technique involves striking the body surface to create sound or vibration?

    <p>Percussion (D)</p> Signup and view all the answers

    What should be done first when organizing and recording data after collection?

    <p>Cluster related clues together (D)</p> Signup and view all the answers

    What is the main purpose of conducting a general survey?

    <p>To identify strengths and deficits objectively (B)</p> Signup and view all the answers

    Why is it essential to validate data during the assessment process?

    <p>To eliminate errors and biases (C)</p> Signup and view all the answers

    What does the PQRSTU acronym stand for in the context of assessing a patient's symptoms?

    <p>Provocation, Quality, Radiation, Severity, Timing, Understanding (A)</p> Signup and view all the answers

    Which of the following is not included in biographical data during a complete health history?

    <p>Allergies (C)</p> Signup and view all the answers

    Which symptom is characterized by 'excessive dryness' in the context of skin assessment?

    <p>Pruritus (B)</p> Signup and view all the answers

    What stage of edema would a patient with 'deep pitting' and swollen legs be classified as?

    <p>3+ (C)</p> Signup and view all the answers

    What does the term 'normocephalic' refer to during a head assessment?

    <p>Head in proportion to body size (B)</p> Signup and view all the answers

    Which of the following conditions is not considered a malignant skin cancer?

    <p>Actinic Keratosis (D)</p> Signup and view all the answers

    What do the 'ABCDE' principles in mole patrol help to identify?

    <p>Potentially malignant moles (B)</p> Signup and view all the answers

    Which of the following terms describes a swelling caused by fluid accumulation in the legs?

    <p>Edema (D)</p> Signup and view all the answers

    What is the normal angle for a healthy nail's shape and contour?

    <p>160 degrees or less (D)</p> Signup and view all the answers

    During an ear assessment, what is the primary concern if the tympanic membrane appears red?

    <p>Infection (B)</p> Signup and view all the answers

    What developmental consideration should be taken into account for older adults during a head and neck assessment?

    <p>Concave cervical curve (D)</p> Signup and view all the answers

    Which type of hearing loss is characterized by problems in the inner ear or auditory nerve?

    <p>Sensorineural hearing loss (A)</p> Signup and view all the answers

    Which of the following could be a sign of a serious condition when assessing lymph nodes?

    <p>Supraclavicular nodes are enlarged (A)</p> Signup and view all the answers

    What is the main purpose of the tympanic membrane in the ear?

    <p>Transmit sound vibrations (B)</p> Signup and view all the answers

    Flashcards

    Nursing Process

    A systematic method used to identify and address a patient's health needs. Includes assessment, diagnosis, planning, implementation, and evaluation.

    What is data in the nursing process?

    Information or facts about a patient used to identify health problems, plan care, and evaluate outcomes.

    Primary Data

    Information gathered directly from the patient, such as their statements or physical observations.

    Secondary Data

    Information gathered from sources other than the patient, like medical records or family members.

    Signup and view all the flashcards

    Complete Database

    A comprehensive assessment that includes a complete health history and physical exam.

    Signup and view all the flashcards

    Episodic/Problem-Centered Database

    Focuses on a specific problem or issue, gathering just enough information to address it.

    Signup and view all the flashcards

    Follow-up Database

    Ongoing assessment to monitor progress and evaluate the effectiveness of interventions.

    Signup and view all the flashcards

    Emergency Database

    Rapid assessment done concurrently with lifesaving measures in a critical situation.

    Signup and view all the flashcards

    Subjective Data

    Gathering information directly from the patient about their health and experiences. This includes their subjective feelings, symptoms, and perspectives.

    Signup and view all the flashcards

    Concept Map

    A tool used to organize and connect cues and problems in a patient's case. It helps to visualize the relationships between different factors.

    Signup and view all the flashcards

    Etiology

    The most likely cause or contributing factor to a nursing diagnosis. It helps in understanding why a patient is experiencing a particular problem.

    Signup and view all the flashcards

    Clustering

    A process of grouping significant cues or pieces of information together to identify patterns and potential problems.

    Signup and view all the flashcards

    Interview Process

    A systematic and structured approach to interviewing patients, which includes building rapport, gathering information, and providing education.

    Signup and view all the flashcards

    Assessment in Nursing

    The process of identifying and analyzing a patient's health needs.

    Signup and view all the flashcards

    Nursing Interview

    A structured conversation between a nurse and a patient to collect information about their health.

    Signup and view all the flashcards

    General Survey

    A systematic observation using your senses to gather data about a patient's physical appearance, behavior, and environment.

    Signup and view all the flashcards

    Palpation

    A physical examination technique that involves using your hands to feel for textures, shapes, sizes, and temperatures.

    Signup and view all the flashcards

    Percussion

    A physical examination technique that involves tapping on a patient's body to listen for sounds that indicate the density of underlying tissues.

    Signup and view all the flashcards

    Auscultation

    A physical examination technique that involves listening to sounds produced by the body using a stethoscope.

    Signup and view all the flashcards

    Validating Assessment Data

    Comparing and verifying information from different sources to ensure accuracy and completeness of patient data.

    Signup and view all the flashcards

    Organizing and Clustering Assessment Data

    Organizing and clustering collected data to identify patterns and relationships, helping to interpret the patient's condition.

    Signup and view all the flashcards

    Nursing Documentation

    Accurate, factual information about a patient's condition, recorded directly by the nurse.

    Signup and view all the flashcards

    Nursing Frameworks

    Specialized tools or models that guide nurses in systematically gathering patient data.

    Signup and view all the flashcards

    Body Systems Review

    A systematic approach to collecting data based on examining each body system, from head to toe.

    Signup and view all the flashcards

    Jarvis Health Assessment Framework

    A comprehensive framework by Jarvis, incorporating health history, physical exam, and nursing history.

    Signup and view all the flashcards

    Clinical Judgement

    Clinical Judgement: Recognizing cues, generating and weighing hypotheses, taking actions and evaluating

    Signup and view all the flashcards

    Diagnostic Reasoning

    The process of analyzing patient data to draw conclusions about their health status.

    Signup and view all the flashcards

    Interpretation of Data

    Interpreting data to identify patient needs and problems.

    Signup and view all the flashcards

    Cues

    Specific pieces of information about a patient, like vital signs or symptoms.

    Signup and view all the flashcards

    Reason for Seeking Care

    The patient's reason for seeking medical attention, expressed in their own words or specific symptoms. It can be followed by an assessment using the PQRSTU method to further understand the symptom.

    Signup and view all the flashcards

    Past Health History

    A detailed account of the patient's general health over the past 5-10 years. Includes information like major childhood illnesses, hospitalizations, surgical procedures, pregnancy history, immunizations, allergies, and current medications.

    Signup and view all the flashcards

    Family History

    Information about the health status of relatives, especially those with blood ties. Includes age, health condition, and cause of death for immediate family members.

    Signup and view all the flashcards

    Review of Systems

    A quick assessment of the patient's overall health, covering various body systems. It's subjective, meaning it relies on the patient's reports rather than physical findings.

    Signup and view all the flashcards

    Functional Assessment and ADLs

    A set of questions and observations focusing on how the patient performs daily activities, including aspects like self-esteem, sleep, stress management, and alcohol/substance use.

    Signup and view all the flashcards

    Skin

    The outer layer of skin, responsible for protection, preventing penetration, sensing touch, regulating temperature, and other functions. It's composed of the epidermis and dermis.

    Signup and view all the flashcards

    Skin Color Changes

    Abnormal changes in skin color, including paleness, redness, blueness, or yellowing. These changes can be indicative of underlying health conditions.

    Signup and view all the flashcards

    Edema

    A condition where excess fluid accumulates beneath the skin, causing swelling. It's assessed using a scale based on the depth and duration of the indentation formed after pressing on the skin.

    Signup and view all the flashcards

    Skin Lesions

    Any visible abnormality on the skin, characterized by features like color, elevation, shape, size, location, and the presence of any fluid discharge.

    Signup and view all the flashcards

    Common Skin Lesions in Children

    Skin conditions affecting children, including diaper dermatitis, eczema, impetigo, and measles.

    Signup and view all the flashcards

    Basal Cell Carcinoma

    A type of skin cancer developing in the basal layer of the epidermis. It's characterized by slow growth and is often treatable.

    Signup and view all the flashcards

    Mole Patrol: ABCDE

    An evaluation of moles using the ABCDE method to assess for potential melanoma, a serious type of skin cancer.

    Signup and view all the flashcards

    Pressure Wounds (Bedsores)

    Injuries to the skin that occur over bony prominences due to impaired circulation, usually in bedridden patients. These are categorized by stages (I-IV) indicating the depth of the wound.

    Signup and view all the flashcards

    Cranial Bones

    The bones of the skull, including frontal, parietal, occipital, and temporal bones. These form the protective structure for the brain.

    Signup and view all the flashcards

    Sutures

    The junction or seam where two cranial bones join together. Examples include the coronal, sagittal, and lambdoid sutures.

    Signup and view all the flashcards

    Sternocleidomastoid Muscles

    The prominent muscles located on either side of the neck, responsible for head movement and rotation. These muscles are commonly used for ROM testing.

    Signup and view all the flashcards

    Study Notes

    Nursing Process

    • Provides a framework for identifying client health status and helping them meet health needs
    • Guides planning, implementing, and evaluating care
    • Presented as a written nursing care plan
    • Characteristics: dynamic, cyclic, client-centered, flexible, universally applicable, and patient status-oriented
    • Consists of 5 steps: Assessment, Diagnosis, Planning, Implementation, and Evaluation

    Nursing Assessment (Critical Phase)

    • Aims to understand the patient's health
    • Identifies strengths promoting health
    • Identifies needs and creates nursing diagnoses for interventions
    • Evaluates the effects of plans
    • Establishes a database for nursing interventions
    • Characteristics: first phase in the nursing process, systematic data collection, clustering and validation of data, continuous process, and CNO outlines accountability for assessment

    Types of Data

    • Primary Data: Subjective/objective data from the client (posture, statements)
    • Secondary Data: Information obtained from sources other than the client (medical records, X-rays, family statements, verbal reports),
    • Types of Databases: Complete (full health history and physical exam), episodic/problem-centered (short-term problems), follow-up (evaluating identified problems), emergency (rapid collection for life-saving measures)

    Importance of Critical Thinking

    • Involves analyzing information, evaluating it, and forming conclusions
    • Requires recognizing issues, asking questions, being well-informed, and honestly considering biases
    • Crucial for making sound judgments, deciding on proper assessments, and evaluating actions

    Assessment Phase Steps

    • Data collection: observation, physical examination, and interviews
    • Validation: comparing collected data with objective data and resolving conflicting information
    • Organization and recording: initial and ongoing assessments, and special purpose assessments

    Components of Nursing Health History

    • Biographical Information
    • Reasons for visit
    • History of current illness
    • Past health status
    • Review of systems
    • Spiritual well-being
    • Social and family history
    • Lifestyles
    • Psychological data
    • Patient's perception of health status
    • Patient's expectations

    General Survey & Physical Exam

    • General Survey: systematic use of senses to collect data without missing important information
    • Physical Exam: identifying strengths and deficiencies in functional abilities; baseline for comparison

    Validating Data

    • Verifying data for completeness, accuracy, and eliminating errors and biases
    • Validating when subjective and objective data disagree or when client statements change or differ
    • Validating unusual or abnormal data

    Studying That Suits You

    Use AI to generate personalized quizzes and flashcards to suit your learning preferences.

    Quiz Team

    Related Documents

    Test 1 - Clinical II PDF

    Description

    This quiz covers the nursing process, including its framework for identifying client health status and its five essential steps: Assessment, Diagnosis, Planning, Implementation, and Evaluation. It emphasizes the importance of systematic data collection and the roles of primary and secondary data in nursing assessments. Test your understanding of these core concepts in nursing care.

    More Like This

    Medical Care Mastery
    60 questions
    The Nursing Process: Assessment
    12 questions
    Nursing Process: Assessment Quiz
    8 questions
    Use Quizgecko on...
    Browser
    Browser