Rasmussen, NUR2092 Exam 1
prep-Health Assessment
Nursing Process - ANSThe following are components of ________________
Assessment
Diagnosis
Outcome identification
Planning
Implementation
Evaluation
Assessment - ANS_____________________ involves:-
1. Collect data
2. Use evidence-based assessment techniques
3. Document relevant data
Diagnosis - ANSA _________________________ involves: -
1. Comparing clinical findings with normal and abnormal variation and developmental events
2. Interpreting data-- make & test hypotheses
3. Validating diagnoses
4. documenting diagnoses
Outcome Identification - ANSThe nursing process or _____________________ is defined
as:-
1. Identify expected outcomes
2. Individualize to the person
3. Culturally appropriate
4. realistic and measurable
5. include a timeline
Planning - ANS_____________________ is defined as:-
1. ESTABLISH PRIORITIES
2. Develop Outcomes
3. Set timelines for outcomes
4. IDENTIFY interventions
5. Integrate evidence-based trends and research
6. Document plan of care
Implementation Definition - ANS____________________________ is defined as:-
1. Implement in a safe and timely manner
2. Use evidence-based interventions
3. Collaborate with colleagues
4. use community resources
5. coordinate care delivery
,6. provide health teaching and health promotion
7. document implementation and any modifications.
Evaluation - ANS____________________ is defined as:-
1. Progress toward outcomes
2. conduct systematic, ongoing, criterion-based evaluation.
3. Include patient and significant others
4. use ongoing assessment to revise diagnoses, outcomes, plan
5. distribute results to patient and family
evidence-based practice - ANS_____________________ is a systematic approach to
practice that emphasizes the use of best evidence in combination with the clinician's
experience, as well as the patient preferences and values, to make decisions about care and
treatment.
Evidence based clinical decision making - ANSFour factors: the best evidence from a critical
review of research literature; the patient's own preferences; the clinician's own experience
and expertise; and finally physical examination and assessment.
Complete (Total Health) Database - ANS_______________ Includes complete health history
and full physical examination. It describes current and past health state and forms a baseline
to measure all future changes. Yields first diagnoses
Focused or Problem-Centered Database - ANSFor limited or short term problem. Collect
"mini" database, smaller in scope, concerns mainly one problem, one cue complex, or one
body system
Follow-Up Database - ANSThe status of any identified problems should be evaluated at
regular and appropriate intervals. What change has occurred? Is the problem getting better
or worse? Which coping strategies are used? This type of database is used in all settings to
follow up both short-term and chronic health problems.
Emergency Database - ANSRapid collection of the database, often compiled concurrently
with lifesaving measures Diagnosis must be swift and sure.
Open-ended questions - ANSwhat kind of questions elicit a response that is more than one
word?
ex: what brings you in today? Tell me all about your headaches?
Close-ended questions - ANS_________________ questions require one or two word
answers
ex: what is your age? Are your headaches on one side or both?
Used for specific information
Elicits cold facts
Limits rapport and leaves interaction neutral.
, Follow these guidelines for open and closed/direct questions: - ANS1. Ask only one direct
question at a time. Avoid bombarding the person with long lists: "Have you ever had pain,
double vision, watering, or redness in the eyes?" Avoid double-barreled questions such as,
"Do you exercise and follow a diet for your weight?" The person will not know which question
to answer. And if the person answers "yes," you will not know which question the person has
answered.
2. Choose language the person understands. You may need to use regional phrases or
colloquial expressions. For example, "running off" means running away in standard English,
but it means diarrhea to Appalachian mountain people.
Therapeutic communication techniques - ANSWhat communication techniques
include:-CLARIFICATION (rephrase).
FACILITATION (nodding, Hmm,hmm).
SILENCE (when to use).
SUMMARIZE (summarize what pt stated) EMPATHY (likening to others, comfort, "I
understand")
Communication Barriers - ANSAVOIDANCE LANGUAGE (using other words)
CHANGING THE SUBJECT
DISTANCING (walking to the door, avoid eye contact)
BLAMING (if you didn't smoke...)
FALSE REASSURANCE (you'll be fine)
FAILURE TO LISTEN
GIVING ADVICE
Phantom Pain - ANSPain that feels like it is coming from a body part that has been
amputated is called _____________________
Breakthrough Pain - ANSSevere pain that erupts while a patient is already medicated with
long-acting painkiller
Somatic Pain - ANSNociceptive pain
Skin pain, tissue pain, or muscle pain
Nerves that detect pain in skin and deep tissues
Visceral Pain - ANSActivation of nociceptors of the thoracic, pelvic or abdominal viscera.
Structures are highly sensitive to distention, ischemia and inflammation
Radiating Pain - ANSPain that travels the length of a nerve
Sign that a nerve or nerve root along the spinal column is under pressure from injury or
inflammation
Referred Pain - ANSPain that is felt in a location other than where the pain originates
An example is the pain from the pancreas, which is felt in the back. Pain in internal organs is
often referred to sites distant from them.
PQRST Method of Pain Assessment - ANSP = Provocation/Palliation
prep-Health Assessment
Nursing Process - ANSThe following are components of ________________
Assessment
Diagnosis
Outcome identification
Planning
Implementation
Evaluation
Assessment - ANS_____________________ involves:-
1. Collect data
2. Use evidence-based assessment techniques
3. Document relevant data
Diagnosis - ANSA _________________________ involves: -
1. Comparing clinical findings with normal and abnormal variation and developmental events
2. Interpreting data-- make & test hypotheses
3. Validating diagnoses
4. documenting diagnoses
Outcome Identification - ANSThe nursing process or _____________________ is defined
as:-
1. Identify expected outcomes
2. Individualize to the person
3. Culturally appropriate
4. realistic and measurable
5. include a timeline
Planning - ANS_____________________ is defined as:-
1. ESTABLISH PRIORITIES
2. Develop Outcomes
3. Set timelines for outcomes
4. IDENTIFY interventions
5. Integrate evidence-based trends and research
6. Document plan of care
Implementation Definition - ANS____________________________ is defined as:-
1. Implement in a safe and timely manner
2. Use evidence-based interventions
3. Collaborate with colleagues
4. use community resources
5. coordinate care delivery
,6. provide health teaching and health promotion
7. document implementation and any modifications.
Evaluation - ANS____________________ is defined as:-
1. Progress toward outcomes
2. conduct systematic, ongoing, criterion-based evaluation.
3. Include patient and significant others
4. use ongoing assessment to revise diagnoses, outcomes, plan
5. distribute results to patient and family
evidence-based practice - ANS_____________________ is a systematic approach to
practice that emphasizes the use of best evidence in combination with the clinician's
experience, as well as the patient preferences and values, to make decisions about care and
treatment.
Evidence based clinical decision making - ANSFour factors: the best evidence from a critical
review of research literature; the patient's own preferences; the clinician's own experience
and expertise; and finally physical examination and assessment.
Complete (Total Health) Database - ANS_______________ Includes complete health history
and full physical examination. It describes current and past health state and forms a baseline
to measure all future changes. Yields first diagnoses
Focused or Problem-Centered Database - ANSFor limited or short term problem. Collect
"mini" database, smaller in scope, concerns mainly one problem, one cue complex, or one
body system
Follow-Up Database - ANSThe status of any identified problems should be evaluated at
regular and appropriate intervals. What change has occurred? Is the problem getting better
or worse? Which coping strategies are used? This type of database is used in all settings to
follow up both short-term and chronic health problems.
Emergency Database - ANSRapid collection of the database, often compiled concurrently
with lifesaving measures Diagnosis must be swift and sure.
Open-ended questions - ANSwhat kind of questions elicit a response that is more than one
word?
ex: what brings you in today? Tell me all about your headaches?
Close-ended questions - ANS_________________ questions require one or two word
answers
ex: what is your age? Are your headaches on one side or both?
Used for specific information
Elicits cold facts
Limits rapport and leaves interaction neutral.
, Follow these guidelines for open and closed/direct questions: - ANS1. Ask only one direct
question at a time. Avoid bombarding the person with long lists: "Have you ever had pain,
double vision, watering, or redness in the eyes?" Avoid double-barreled questions such as,
"Do you exercise and follow a diet for your weight?" The person will not know which question
to answer. And if the person answers "yes," you will not know which question the person has
answered.
2. Choose language the person understands. You may need to use regional phrases or
colloquial expressions. For example, "running off" means running away in standard English,
but it means diarrhea to Appalachian mountain people.
Therapeutic communication techniques - ANSWhat communication techniques
include:-CLARIFICATION (rephrase).
FACILITATION (nodding, Hmm,hmm).
SILENCE (when to use).
SUMMARIZE (summarize what pt stated) EMPATHY (likening to others, comfort, "I
understand")
Communication Barriers - ANSAVOIDANCE LANGUAGE (using other words)
CHANGING THE SUBJECT
DISTANCING (walking to the door, avoid eye contact)
BLAMING (if you didn't smoke...)
FALSE REASSURANCE (you'll be fine)
FAILURE TO LISTEN
GIVING ADVICE
Phantom Pain - ANSPain that feels like it is coming from a body part that has been
amputated is called _____________________
Breakthrough Pain - ANSSevere pain that erupts while a patient is already medicated with
long-acting painkiller
Somatic Pain - ANSNociceptive pain
Skin pain, tissue pain, or muscle pain
Nerves that detect pain in skin and deep tissues
Visceral Pain - ANSActivation of nociceptors of the thoracic, pelvic or abdominal viscera.
Structures are highly sensitive to distention, ischemia and inflammation
Radiating Pain - ANSPain that travels the length of a nerve
Sign that a nerve or nerve root along the spinal column is under pressure from injury or
inflammation
Referred Pain - ANSPain that is felt in a location other than where the pain originates
An example is the pain from the pancreas, which is felt in the back. Pain in internal organs is
often referred to sites distant from them.
PQRST Method of Pain Assessment - ANSP = Provocation/Palliation
