and History Taking 13th Edition Latest Review
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Objective data - ANSWERSData that the health professional observes by inspecting, percussing,
palpating, and auscultating during the physical examination.
Subjective data - ANSWERSData that the person says about him or herself during history taking.
Data base - ANSWERSThe combination of the patient's record, laboratory studies, objective
data, and subjective data.
Validation of data - ANSWERSThe process of ensuring accuracy by asking a coworker to listen to
the breath sounds when unsure of a sound heard.
Novice nurses decision-making - ANSWERSNovice nurses are more likely to make their decisions
using a set of defined, structured rules.
Intuition in nursing - ANSWERSA response characterized by pattern recognition, where expert
nurses act without consciously labeling the data.
Cognitive Level: Understanding - ANSWERSA level of cognitive processing that involves
comprehension of the material.
Cognitive Level: Remembering - ANSWERSA level of cognitive processing that involves recalling
facts and basic concepts.
,Cognitive Level: Analyzing - ANSWERSA level of cognitive processing that involves breaking
information into parts to explore understandings and relationships.
Evidence-based practice (EBP) - ANSWERSA practice that integrates the best available evidence
with clinical expertise and patient values.
Eupneic respirations - ANSWERSNormal, unlabored breathing.
Pulse rate - ANSWERSThe number of beats per minute, with a normal range typically between
60 to 100 beats per minute.
Nausea - ANSWERSA sensation of unease and discomfort in the stomach associated with the
urge to vomit.
Clinical knowledge - ANSWERSKnowledge gained through experience and education that
informs clinical decision-making.
Pattern recognition - ANSWERSThe ability to identify patterns in assessment data that inform
clinical judgments.
Management of Care - ANSWERSA component of client needs focused on ensuring safe and
effective care.
Introspective data - ANSWERSData related to self-examination or reflection, not typically used
to describe patient data.
Reflective data - ANSWERSData that involves contemplation or consideration, not typically used
to describe patient data.
,Percussion - ANSWERSA technique used in physical examination to assess the condition of the
thorax or abdomen by tapping on the surface.
Auscultation - ANSWERSThe act of listening to sounds within the body, typically using a
stethoscope.
Palpation - ANSWERSThe examination of the body using the sense of touch to assess texture,
temperature, and moisture.
Inspection - ANSWERSThe visual examination of the body to assess physical condition.
Cognitive Level: Comprehension - ANSWERSA level of cognitive processing that involves
understanding and interpreting information.
First-level priority problems - ANSWERSEmergent, life-threatening, and immediate problems
that require immediate attention, such as establishing an airway, supporting breathing,
maintaining circulation, and monitoring abnormal vital signs.
Second-level priority problems - ANSWERSProblems that require prompt intervention to
prevent further deterioration, such as mental status changes, acute pain, abnormal laboratory
values, and risks to safety or security.
Clustering related cues - ANSWERSA critical thinking skill that helps the nurse see relationships
among the data.
Nursing diagnosis - ANSWERSAn accurate nursing diagnosis provides the basis for the selection
of nursing interventions to achieve outcomes for which the nurse is accountable.
, Nursing process - ANSWERSA sequential method of problem solving that includes assessment,
diagnosis, outcome identification, planning, implementation, and evaluation.
Best evidence - ANSWERSThe most reliable and relevant research findings that inform clinical
decision-making in EBP.
Patient preferences - ANSWERSThe individual choices and values of patients that should be
considered in the decision-making process of care.
Cognitive Level: Applying - ANSWERSA level of cognitive skill that involves using knowledge in
practical situations.
Emergent problems - ANSWERSHealth issues that require immediate action to prevent serious
consequences.
Acute pain - ANSWERSA type of pain that is severe and sudden in onset, often requiring
immediate intervention.
Abnormal laboratory values - ANSWERSTest results that fall outside the normal range and may
indicate a health issue requiring attention.
Critical thinking skills - ANSWERSCognitive processes that involve analyzing and evaluating
information to make informed decisions.
Patient education - ANSWERSThe process of teaching patients about their health conditions and
how to manage them.
Prioritization in nursing - ANSWERSThe process of determining the order in which patient
problems should be addressed based on urgency and importance.