Types of Assessment - ANSWER-comprehensive, episodic or problem-focused,
emergency
comprehensive assessment - ANSWER-(initial) results in baseline data for problem
identification and care planning, time consuming, complete, all aspects of preventive
health/physical disease
episodic/problem-focused assessment - ANSWER-based on the patient's health issues,
involves one or two body systems. smaller scope, but more in depth
What is the nursing process? - ANSWER-systematic problem-solving approach to
identifying and treating human responses to actual or potential health difficulties. patient
centered and focuses on problem solving and inhaling strengths. uses ADPIE
emergency assessment - ANSWER-involves life threatening or unstable situation,
traumatic injury, uses ABCDE
ABCDE - ANSWER-airway, breathing, circulation, disability, and exposure
ADPIE - ANSWER-assessment of patient, nursing diagnosis, planning care,
implementing and then evaluating patients status
implementation - ANSWER-collaboration with other team members, involvement of
patient and family, actually doing the phase
evaluation - ANSWER-how effective is nursing care and each phases affects the other
nursing diagnosis vs medical diagnosis - ANSWER-medical focuses on diagnosis and
treatment of disease whereas nursing focuses on the human response to actual or
potential health problems
assessment - ANSWER-establish baseline, review history, physical assessment
diagnosis - ANSWER-clustering of data to make a judgement or statement about the
patient's difficulties or condition
, Nanda diagnosis for nursing - ANSWER-a clinical judgement about individual, family, or
community responses to actual or potential health difficulties/life processes. Provides
the basis for selection of nursing interventions to achieve outcomes for which the nurse
is accountable
Normal range of blood pressure - ANSWER-120/80
normal range of pulse - ANSWER-60-100 bpm
scale of pulse strength - ANSWER-0-4+
scale of 0 pulse - ANSWER-non palpable or absent
1+ of pulse - ANSWER-weak, diminished, and barely palpable
2+ of pulse - ANSWER-normal, expected
3+ of pulse - ANSWER-Full, increased
4+ of pulse - ANSWER-Bounding
normal oral temperature range - ANSWER-97.7-99.5 F
normal range for Temporal range - ANSWER-98.7-100.5 F
five ways to take temperature - ANSWER-oral, axillary, rectal, tympanic, and temporal
normal respirations - ANSWER-12-20
normal O2 saturation - ANSWER-95-100%
Pain scale - ANSWER-1-10
COLDERR - ANSWER-characteristic, onset, location, duration, exacerbation, relief,
radiation
6 stages of infection cycles - ANSWER-infectious agent, reservoir, portal of exit, means
of transmission, portal of entry, susceptible host
infectious agent - ANSWER-bacteria, viruses, and fungi
reservoir - ANSWER-place for growth and multiplication of microorganisms is the
natural habitat of the organism (other people, animals, soil, food, water, milk and
inanimate objects)
portal of exit - ANSWER-point of escape for the organism from the reservoir
(respiratory, gastrointestinal, and genitourinary tracts, as well as breaks in the skin and
blood and tissue
means of transmission - ANSWER-how an organism is transmitted from its reservoir,
through touching, kissing, sexual intercourse, contaminated instrument, blood, food,
water, or inanimate objects, vectors like mosquitos, ticks, and lice
portal of entry - ANSWER-point at which organisms enter a new host, same as exit
route... urinary, respiratory, and gastrointestinal tracts
susceptible host - ANSWER-source that is acceptable for microorganisms that
overcome any resistance mounted by the host's defenses
nursing interventions to break chain of infection between susceptible host and infectious
agent - ANSWER-immunizations and screen healthcare staff
nursing interventions to break chain of infection between infectious agent and reservoir -
ANSWER-hand hygiene, sterilization, antibiotic/antimicrobials
nursing interventions to break chain of infection between reservoir and portal of exit
from reservoir - ANSWER-transmission-based precautions, sterilization or use of
disposable supplies
nursing interventions to break chain of infection between portal of exit from reservoir
and means of transmission - ANSWER-dry intact dressing, hand hygiene, wear gloves if
contact with body fluids, cover nose and mouth when sneezing
emergency
comprehensive assessment - ANSWER-(initial) results in baseline data for problem
identification and care planning, time consuming, complete, all aspects of preventive
health/physical disease
episodic/problem-focused assessment - ANSWER-based on the patient's health issues,
involves one or two body systems. smaller scope, but more in depth
What is the nursing process? - ANSWER-systematic problem-solving approach to
identifying and treating human responses to actual or potential health difficulties. patient
centered and focuses on problem solving and inhaling strengths. uses ADPIE
emergency assessment - ANSWER-involves life threatening or unstable situation,
traumatic injury, uses ABCDE
ABCDE - ANSWER-airway, breathing, circulation, disability, and exposure
ADPIE - ANSWER-assessment of patient, nursing diagnosis, planning care,
implementing and then evaluating patients status
implementation - ANSWER-collaboration with other team members, involvement of
patient and family, actually doing the phase
evaluation - ANSWER-how effective is nursing care and each phases affects the other
nursing diagnosis vs medical diagnosis - ANSWER-medical focuses on diagnosis and
treatment of disease whereas nursing focuses on the human response to actual or
potential health problems
assessment - ANSWER-establish baseline, review history, physical assessment
diagnosis - ANSWER-clustering of data to make a judgement or statement about the
patient's difficulties or condition
, Nanda diagnosis for nursing - ANSWER-a clinical judgement about individual, family, or
community responses to actual or potential health difficulties/life processes. Provides
the basis for selection of nursing interventions to achieve outcomes for which the nurse
is accountable
Normal range of blood pressure - ANSWER-120/80
normal range of pulse - ANSWER-60-100 bpm
scale of pulse strength - ANSWER-0-4+
scale of 0 pulse - ANSWER-non palpable or absent
1+ of pulse - ANSWER-weak, diminished, and barely palpable
2+ of pulse - ANSWER-normal, expected
3+ of pulse - ANSWER-Full, increased
4+ of pulse - ANSWER-Bounding
normal oral temperature range - ANSWER-97.7-99.5 F
normal range for Temporal range - ANSWER-98.7-100.5 F
five ways to take temperature - ANSWER-oral, axillary, rectal, tympanic, and temporal
normal respirations - ANSWER-12-20
normal O2 saturation - ANSWER-95-100%
Pain scale - ANSWER-1-10
COLDERR - ANSWER-characteristic, onset, location, duration, exacerbation, relief,
radiation
6 stages of infection cycles - ANSWER-infectious agent, reservoir, portal of exit, means
of transmission, portal of entry, susceptible host
infectious agent - ANSWER-bacteria, viruses, and fungi
reservoir - ANSWER-place for growth and multiplication of microorganisms is the
natural habitat of the organism (other people, animals, soil, food, water, milk and
inanimate objects)
portal of exit - ANSWER-point of escape for the organism from the reservoir
(respiratory, gastrointestinal, and genitourinary tracts, as well as breaks in the skin and
blood and tissue
means of transmission - ANSWER-how an organism is transmitted from its reservoir,
through touching, kissing, sexual intercourse, contaminated instrument, blood, food,
water, or inanimate objects, vectors like mosquitos, ticks, and lice
portal of entry - ANSWER-point at which organisms enter a new host, same as exit
route... urinary, respiratory, and gastrointestinal tracts
susceptible host - ANSWER-source that is acceptable for microorganisms that
overcome any resistance mounted by the host's defenses
nursing interventions to break chain of infection between susceptible host and infectious
agent - ANSWER-immunizations and screen healthcare staff
nursing interventions to break chain of infection between infectious agent and reservoir -
ANSWER-hand hygiene, sterilization, antibiotic/antimicrobials
nursing interventions to break chain of infection between reservoir and portal of exit
from reservoir - ANSWER-transmission-based precautions, sterilization or use of
disposable supplies
nursing interventions to break chain of infection between portal of exit from reservoir
and means of transmission - ANSWER-dry intact dressing, hand hygiene, wear gloves if
contact with body fluids, cover nose and mouth when sneezing
