Science Medicine Nursing
Intro to Nursing - Exam 1
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STAT 330 - Chapter 9 NCLEX Vocab Quiz 1 u.s
33 terms 127 terms 15 terms 50
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Terms in this set (149)
The foundation of the nursing profession; The Nursing Process
is the systematic approach to problem-
solving and providing individualized
care?
The phases of the nursing process? Assessment, Diagnosis, Planning (includes Outcome), Implementation, Evaluation
What is Assessment? Collection of data to help establish a goal of making a clinical nursing judgment.
Difference between subjective and Subjective, from the client; Objective, from the nurse's senses.
objective data?
Primary, can only be the patient; Secondary, info from families, medical records,
Difference between primary, secondary
or other health care professionals; Tertiary, info from textbooks, nurse's and other
and tertiary sources?
health care team responses to patient
What must be done by the nurse on In depth nursing history and physical assessment must be done and it identifies
admission to a health care facility? And the patient's strengths and weakness/health problems.
what does it identify?
Through observations, interviews, physical assessment, and interpreting lab and
When does data collection take place?
diagnostic results.
The clinical act of identifying problems using the assessment data collected. This
What is diagnosis? step identifies an individual, family or group response to an actual or potential
health problem.
What is the nursing diagnosis based on? The pathophysiology of the disease process.
Who established the list of nursing North American Nursing Diagnosis Association (NANDA)
diagnosis for classifying nursing
problems, standardizing language and
facilitating communication for nurses?
What is included in Outcome? Development of patient focused goals...included in the planning phase.
, Must be patient-focused, specific to the nursing diagnosis or patient problem,
What are the guidelines on making goals?
measurable, realistic and have time frame.
Preparing the nursing care plan with patient input in how to identify goals and
What is involved in the Planning phase?
interventions to help with the identified problems.
Patient goals/outcomes specific to the problem, assessment, specific treatments
What is included in the Planning phase?
(independent and dependent), medications, teaching, and community care.
What is a Joint Commission on The care plan is a written summary of the care that a patient is to receive.
Accreditation of Healthcare
Organizations (JACHO) requirement?
What is the action phase? Implementatio/Intervention
Why are nursing actions goal oriented? To help the patient reach maximum health potential
What is crucial in the implementation Documentation
phase?
What is determined in the Evaluation The patient's reactions to nursing interventions and judging whether the goals of
phase? the plan of care were achieved.
What is ongoing and continuous process Evaluation..."revised or reassessed"
performed throughout the process?
Vital signs are a __________ mechanism? Homeostatic
What is an important component of It yields info about underlying health status
assessment?
What is included in vital signs? Temperature, Pulse, Respiration, Blood Pressure, Pain, Pulse Oximetry
What are normal vital ranges, in adults? Pulse: 60-100; Respirations: 12-20; Temp: 97-99; Systolic: 90-120; Diastolic: 60-80
Upon admission, physician order, facility policy; before and after- surgery,
When do you assess vital signs? diagnostic procedure, medication administration, nursing interventions, patient
becomes symptomatic
What produces heat in the body? Basal metabolism, muscle activity, hormones and cells (fever)
What causes loss of heat in body? Radiation, conduction/convection, evaporation... 40% of heat is lost through head.
What is included in core body Temp of deep body tissue: abdominal, chest, pelvic cavities, and cranium
temperature?
What is included in surface body Temp of skin, subcutaneous tissue, and fat
temperature?
Age, environment, time of day, exercise, stress and hormones. (temp is lowest in
What factors affect temperature?
am)
What are the temperature sites? What is Mouth (frenulum), axilla, rectum, ear, forehead. Most inaccurate is the axilla, most
most inaccurate and most dangerous? dangerous is rectum.
Elevated body temperature? Hyperthermia
Fever? (exceeds 99.6F) Pyrexia
Decreased body temperature? Hypothermia
Fever or elevated body temperature? Febrile
No fever, normal range temperature Afebrile
What are critical signs of hypothermia? Decreased body temp, decreased bp and urinary output
3 stages: Onset (tachy-cardia & pnea, feeling cold, chills), Course (no chills,
What are clinical signs of pyrexia? glassy-eyed, warm skin, drowsy, delirium, possible convulsions), Defervescence
(warm, flushed skin, sweating, decreased shivering, watch for dehydration)
How do you report the temperature? In Farenheit.
What are pulse characteristics? Rate: # per min; Rhythm: regularity; Quality: strength of pulsation
Intro to Nursing - Exam 1
10 studiers today 4.7 (9 reviews)
Save
Students also studied
Flashcard sets Practice tests
STAT 330 - Chapter 9 NCLEX Vocab Quiz 1 u.s
33 terms 127 terms 15 terms 50
dylmann15 Preview ssutherland11 Preview kaylabayazitoglu Preview
Terms in this set (149)
The foundation of the nursing profession; The Nursing Process
is the systematic approach to problem-
solving and providing individualized
care?
The phases of the nursing process? Assessment, Diagnosis, Planning (includes Outcome), Implementation, Evaluation
What is Assessment? Collection of data to help establish a goal of making a clinical nursing judgment.
Difference between subjective and Subjective, from the client; Objective, from the nurse's senses.
objective data?
Primary, can only be the patient; Secondary, info from families, medical records,
Difference between primary, secondary
or other health care professionals; Tertiary, info from textbooks, nurse's and other
and tertiary sources?
health care team responses to patient
What must be done by the nurse on In depth nursing history and physical assessment must be done and it identifies
admission to a health care facility? And the patient's strengths and weakness/health problems.
what does it identify?
Through observations, interviews, physical assessment, and interpreting lab and
When does data collection take place?
diagnostic results.
The clinical act of identifying problems using the assessment data collected. This
What is diagnosis? step identifies an individual, family or group response to an actual or potential
health problem.
What is the nursing diagnosis based on? The pathophysiology of the disease process.
Who established the list of nursing North American Nursing Diagnosis Association (NANDA)
diagnosis for classifying nursing
problems, standardizing language and
facilitating communication for nurses?
What is included in Outcome? Development of patient focused goals...included in the planning phase.
, Must be patient-focused, specific to the nursing diagnosis or patient problem,
What are the guidelines on making goals?
measurable, realistic and have time frame.
Preparing the nursing care plan with patient input in how to identify goals and
What is involved in the Planning phase?
interventions to help with the identified problems.
Patient goals/outcomes specific to the problem, assessment, specific treatments
What is included in the Planning phase?
(independent and dependent), medications, teaching, and community care.
What is a Joint Commission on The care plan is a written summary of the care that a patient is to receive.
Accreditation of Healthcare
Organizations (JACHO) requirement?
What is the action phase? Implementatio/Intervention
Why are nursing actions goal oriented? To help the patient reach maximum health potential
What is crucial in the implementation Documentation
phase?
What is determined in the Evaluation The patient's reactions to nursing interventions and judging whether the goals of
phase? the plan of care were achieved.
What is ongoing and continuous process Evaluation..."revised or reassessed"
performed throughout the process?
Vital signs are a __________ mechanism? Homeostatic
What is an important component of It yields info about underlying health status
assessment?
What is included in vital signs? Temperature, Pulse, Respiration, Blood Pressure, Pain, Pulse Oximetry
What are normal vital ranges, in adults? Pulse: 60-100; Respirations: 12-20; Temp: 97-99; Systolic: 90-120; Diastolic: 60-80
Upon admission, physician order, facility policy; before and after- surgery,
When do you assess vital signs? diagnostic procedure, medication administration, nursing interventions, patient
becomes symptomatic
What produces heat in the body? Basal metabolism, muscle activity, hormones and cells (fever)
What causes loss of heat in body? Radiation, conduction/convection, evaporation... 40% of heat is lost through head.
What is included in core body Temp of deep body tissue: abdominal, chest, pelvic cavities, and cranium
temperature?
What is included in surface body Temp of skin, subcutaneous tissue, and fat
temperature?
Age, environment, time of day, exercise, stress and hormones. (temp is lowest in
What factors affect temperature?
am)
What are the temperature sites? What is Mouth (frenulum), axilla, rectum, ear, forehead. Most inaccurate is the axilla, most
most inaccurate and most dangerous? dangerous is rectum.
Elevated body temperature? Hyperthermia
Fever? (exceeds 99.6F) Pyrexia
Decreased body temperature? Hypothermia
Fever or elevated body temperature? Febrile
No fever, normal range temperature Afebrile
What are critical signs of hypothermia? Decreased body temp, decreased bp and urinary output
3 stages: Onset (tachy-cardia & pnea, feeling cold, chills), Course (no chills,
What are clinical signs of pyrexia? glassy-eyed, warm skin, drowsy, delirium, possible convulsions), Defervescence
(warm, flushed skin, sweating, decreased shivering, watch for dehydration)
How do you report the temperature? In Farenheit.
What are pulse characteristics? Rate: # per min; Rhythm: regularity; Quality: strength of pulsation
