Study Guide
subjective data - correct answer ✔✔what the person says about himself or herself during
history taking
objective data - correct answer ✔✔Observed when inspecting, percussing, palpating, and
auscultating patient during physical examination
-BP, vitals, temp, rash, etc
novice nurse - correct answer ✔✔task oriented
focus on rules and direction form telling style leader
proficient nurse - correct answer ✔✔significant amount of experience (2-3+ yrs)
expert nurse - correct answer ✔✔make decisions at an advanced level of intuition and
analytical ability
nursing process - correct answer ✔✔Assessment
Diagnosis
Planning
Implementation
Evaluation
elements of the assessment - correct answer ✔✔review of clinical record
interview
health history
, physical exam
functional assessment
cultural and spiritual assessment
consultation
review of the literature
direct source - correct answer ✔✔info coming from the patient himself
-can be subjective or objective
indirect source - correct answer ✔✔info from family members, health record etc
1st level priority - correct answer ✔✔Emergent, life threatening, and immediate
-airway, breathing, cardiac, "gas exchange"
2nd level priority - correct answer ✔✔requires attention such as abnormal labs, medication etc
3rd level priority - correct answer ✔✔patient education
patient outcomes must be SMART. what does the acronym mean? - correct answer ✔✔specific
measurable
attainable
relevant
time-bound
complete total health database - correct answer ✔✔-includes complete health history and full
physical examination