NUR309 Exam 1 Study guide
1. Name, room number, provider name, diagnosis, last VS, changes to client condition/interventions/client
response, important lab and diagnostic results, status toward discharge, pain level/interventions/response (last
dose of pain meds), current orders including any that have not been completed, client/fam- ily concerns.: Handoff
report should include
2. (A)DPIE: Assessment
3. Assessment: gathering information about a clients psychological, physiological, sociological, cultural, and spiritual
status.
4. Assess: You can never treat or plan until you first do this.
5. LPNs can assess a patient.: False: they can only collect data
6. Purpose of assessment: establish baseline information and recognize changes as they occur, determine clients
normal function, collect data for nursing dx, deter- mine what is wrong or what the client may be at risk for.
7. When to assess: every time you enter a room, after intervention (evaluation), new complaint, before discharge,
initial meeting, before/after labs.
8. Primary source: Always the client and always the best source
9. Secondary source: Anywhere we get information besides the client (family, significant other, medical record,
other healthcare practitioner).
10.Open ended questions: Questions a person is to answer in his or her own words, provide the most
information.
11.Closed ended questions: Questions that can be answered in short or single word responses, typically only asked
when patient is in acute distress.
12.Question guidelines: Practice therapeutic communication, no "why" questions.
13.Nursing history: biographical information (marital status, age, occupation, what patient wants to be referred to as),
means of communication, reason the patient is seeking healthcare, health history, physical assessment, advanced
directive.
14.Purulent: Containing pus.
15.Erythema: Redness of the skin.
16.Subjective data: (Symptoms) what the client tells you (nurse cannot see, hear, touch, smell, or feel this). These
claims may have to be validated.
17.Objective data: (Signs) can be observed using the 4 senses.
18.Initial assessment: Typically head-to-toe, performed on admission, usually within the first hour. Establishes a
reference baseline for future comparison.
19.Focused assessment: Only assessing the area of concern (problem that is already identified), typically used
throughout the shift, or to identify response to intervention.
20.Emergency assessment: Only done when patient is in acute crisis, assessing life threatening concerns.
21.A(D)PIE: Diagnosis (nursing)
, NUR309 Exam 1 Study guide
22. Nursing diagnosis: statement that describes the patient's response to an actual or potential health problem that
the RN is licensed and competent to treat indepen- dently. Goal is care. Identifies patient response to disease or pathology.
Can change multiple times a day.
23.Medical diagnosis: Identifies disease. Goal is cure.
24.Actual diagnosis: A patient problem that is present at the time of the assess- ment.
25.Potential diagnosis: (At risk for) identifies problems that may occur if the actual problem is not successfully
treated in a timely manner.
26.Components of nursing diagnosis: Problem statement, etiology, defining characteristics.
27.Problem statement: What is the actual problem identified, or what problem is the patient at risk for? What to
change or prevent.
28.Etiology: What is causing or contributing to the problem or potential problem? Cannot use medical diagnosis, but
can look up the pathology. Use R/T.
29.Defining characteristics: Signs and symptoms that indicate the existence of the patient problem. Only included
in an actual nursing dx. Use AEB.
30.2 parts: A potential diagnosis statement will only have .
31.AD(P)IE: Planning goals, expected outcomes, and intervention.
32.Planning: Designed to identify ways to manage the problems that the patient is having. Prioritize the nursing
diagnoses, formulate desired outcomes, select appropriate nursing interventions to help achieve goals.
33.Prioritizing diagnoses: unstable, unexpected, ABCsDEF, acute, and actual diagnoses are always priority.
34.(A)BCsDEF: Airway (choking, aspiration, trach suction).
35.A(B)CsDEF: Breathing (respirations, SOB, coughing).
36.AB(C)sDEF: Circulation (BP, heart rate, bleeding, pulse rate).
37.ABC(s)DEF: Safety (at risk for injury)
38.ABCs(D)EF: Discomfort
39.ABCsD(E)F: Education
40.ABCsDE(F): Feeling
41.During CPR when circulation is prioritized: What is the one exception to the ABCsDEF rule?
42.Maslow's hierarchy of needs: Physiological (breathing, food, water, sleep), safety (security of body, employment,
resources), love/belonging (friendship, family, sexual intimacy), esteem (self-esteem, confidence, achievement), self-
actualization (morality, creativity, problem solving).
43.SMART goal: Specific (no generalizations), measurable, attainable, realistic, timely for short and long term
goals.
1. Name, room number, provider name, diagnosis, last VS, changes to client condition/interventions/client
response, important lab and diagnostic results, status toward discharge, pain level/interventions/response (last
dose of pain meds), current orders including any that have not been completed, client/fam- ily concerns.: Handoff
report should include
2. (A)DPIE: Assessment
3. Assessment: gathering information about a clients psychological, physiological, sociological, cultural, and spiritual
status.
4. Assess: You can never treat or plan until you first do this.
5. LPNs can assess a patient.: False: they can only collect data
6. Purpose of assessment: establish baseline information and recognize changes as they occur, determine clients
normal function, collect data for nursing dx, deter- mine what is wrong or what the client may be at risk for.
7. When to assess: every time you enter a room, after intervention (evaluation), new complaint, before discharge,
initial meeting, before/after labs.
8. Primary source: Always the client and always the best source
9. Secondary source: Anywhere we get information besides the client (family, significant other, medical record,
other healthcare practitioner).
10.Open ended questions: Questions a person is to answer in his or her own words, provide the most
information.
11.Closed ended questions: Questions that can be answered in short or single word responses, typically only asked
when patient is in acute distress.
12.Question guidelines: Practice therapeutic communication, no "why" questions.
13.Nursing history: biographical information (marital status, age, occupation, what patient wants to be referred to as),
means of communication, reason the patient is seeking healthcare, health history, physical assessment, advanced
directive.
14.Purulent: Containing pus.
15.Erythema: Redness of the skin.
16.Subjective data: (Symptoms) what the client tells you (nurse cannot see, hear, touch, smell, or feel this). These
claims may have to be validated.
17.Objective data: (Signs) can be observed using the 4 senses.
18.Initial assessment: Typically head-to-toe, performed on admission, usually within the first hour. Establishes a
reference baseline for future comparison.
19.Focused assessment: Only assessing the area of concern (problem that is already identified), typically used
throughout the shift, or to identify response to intervention.
20.Emergency assessment: Only done when patient is in acute crisis, assessing life threatening concerns.
21.A(D)PIE: Diagnosis (nursing)
, NUR309 Exam 1 Study guide
22. Nursing diagnosis: statement that describes the patient's response to an actual or potential health problem that
the RN is licensed and competent to treat indepen- dently. Goal is care. Identifies patient response to disease or pathology.
Can change multiple times a day.
23.Medical diagnosis: Identifies disease. Goal is cure.
24.Actual diagnosis: A patient problem that is present at the time of the assess- ment.
25.Potential diagnosis: (At risk for) identifies problems that may occur if the actual problem is not successfully
treated in a timely manner.
26.Components of nursing diagnosis: Problem statement, etiology, defining characteristics.
27.Problem statement: What is the actual problem identified, or what problem is the patient at risk for? What to
change or prevent.
28.Etiology: What is causing or contributing to the problem or potential problem? Cannot use medical diagnosis, but
can look up the pathology. Use R/T.
29.Defining characteristics: Signs and symptoms that indicate the existence of the patient problem. Only included
in an actual nursing dx. Use AEB.
30.2 parts: A potential diagnosis statement will only have .
31.AD(P)IE: Planning goals, expected outcomes, and intervention.
32.Planning: Designed to identify ways to manage the problems that the patient is having. Prioritize the nursing
diagnoses, formulate desired outcomes, select appropriate nursing interventions to help achieve goals.
33.Prioritizing diagnoses: unstable, unexpected, ABCsDEF, acute, and actual diagnoses are always priority.
34.(A)BCsDEF: Airway (choking, aspiration, trach suction).
35.A(B)CsDEF: Breathing (respirations, SOB, coughing).
36.AB(C)sDEF: Circulation (BP, heart rate, bleeding, pulse rate).
37.ABC(s)DEF: Safety (at risk for injury)
38.ABCs(D)EF: Discomfort
39.ABCsD(E)F: Education
40.ABCsDE(F): Feeling
41.During CPR when circulation is prioritized: What is the one exception to the ABCsDEF rule?
42.Maslow's hierarchy of needs: Physiological (breathing, food, water, sleep), safety (security of body, employment,
resources), love/belonging (friendship, family, sexual intimacy), esteem (self-esteem, confidence, achievement), self-
actualization (morality, creativity, problem solving).
43.SMART goal: Specific (no generalizations), measurable, attainable, realistic, timely for short and long term
goals.
