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NUR |/ 216 |/Exam |/ 1 |/WITH |/CORRECT |/ANSWERS
comprehensive |/assessment |/- |/CORRECT |/ANSWERS |/✔✔An |/assessment |/that |/includes |/a |/complete |/health |/history |/and |/physical |/assessment; |/Usually |/brand |/new |/patients focused |/assessment |/- |/CORRECT |/ANSWERS |/✔✔assessment |/conducted |/to |/assess |/a |/specific |/problem; |/focuses |/on |/pertinent |/history |/and |/body |/regions HIPAA |/- |/CORRECT |/ANSWERS |/✔✔Health |/Insurance |/Portability |/and |/Accountability |/Act The |/nursing |/process |/- |/CORRECT |/ANSWERS |/✔✔Assessment Diagnosis |/ Planning Implementation Evaluation Assessment |/(ADPIE) |/- |/CORRECT |/ANSWERS |/✔✔Data |/collection |/(objective/subjective)
Prioritize |/Data: |/Primary |/(life |/threatening), |/Secondary |/(requires |/prompt |/attention), |/Tertiary |/(not |/urgent) Planning |/(ADPIE) |/- |/CORRECT |/ANSWERS |/✔✔Develop |/SMART |/goals, |/plan |/nursing |/interventions Implementation |/(ADPIE) |/- |/CORRECT |/ANSWERS |/✔✔Perform |/planned |/nursing |/interventions Evaluation |/(ADPIE) |/- |/CORRECT |/ANSWERS |/✔✔Were |/the |/goals |/met? |/If |/not, |/re-assess assessment |/skills |/- |/CORRECT |/ANSWERS |/✔✔Inspection Palpation Percussion |/ Auscultation (Bowels: |/Inspection, |/Auscultation, |/Percussion. |/Auscultation) |/Do |/not |/want |/to |/alter |/the |/bowel |/sounds Inspection |/- |/CORRECT |/ANSWERS |/✔✔Observe |/for |/Symmetry, |/size, |/color, |/shape
Ausculation |/- |/CORRECT |/ANSWERS |/✔✔listening |/to |/sounds |/within |/the |/body Bell |/- |/CORRECT |/ANSWERS |/✔✔low |/pitched |/sounds (mummers) Diaphragm |/- |/CORRECT |/ANSWERS |/✔✔high |/pitched |/sounds (bowel |/and |/lung |/sounds) What |/should |/we |/do |/before |/leaving |/the |/patients |/room? |/- |/CORRECT |/ANSWERS |/✔✔Patients |/safety Bed |/to |/lowest |/position Side |/Rails Call |/button |/and |/personal |/belongings |/in |/reach Contextual |/awareness |/- |/CORRECT |/ANSWERS |/✔✔Understanding |/the |/status |/of |/the |/client |/and |/the |/events |/that |/led |/to |/their |/interaction Analyzing |/assumptions |/- |/CORRECT |/ANSWERS |/✔✔Evaluating |/the |/client's |/clinical |/situation
Exploring |/alternatives |/- |/CORRECT |/ANSWERS |/✔✔The |/use |/of |/holistic |/approaches |/for |/treating |/the |/whole |/person (physical |/health, |/lifestyle |/choices, |/culture, |/living |/environment, |/life |/experiences) Reflecting |/and |/deciding |/- |/CORRECT |/ANSWERS |/✔✔Reflect |/on |/the |/client's |/goals |/and |/decide |/on |/the |/intervention |/with |/client |/input Steps |/for |/communicating |/with |/members |/of |/the |/health |/care |/team |/- |/CORRECT |/ANSWERS |/✔✔1.Identify |/the |/member |/by |/name |/and |/title 2.Provide |/info |/regarding |/the |/current |/situation 3.Provide |/info |/regarding |/the |/background |/situation 4.Give |/the |/most |/recent |/set |/of |/vital |/signs 5.Provide |/suggestions |/that |/may |/be |/helpful |/to |/the |/situation 6.Repeat |/the |/orders |/back |/that |/are |/given |/to |/you |/by |/the |/provider Nonmaleficence |/- |/CORRECT |/ANSWERS |/✔✔Do |/no |/harm Beneficence |/- |/CORRECT |/ANSWERS |/✔✔Promote |/good Autonomy |/- |/CORRECT |/ANSWERS |/✔✔the |/right |/to |/make |/own |/choice Justice |/- |/CORRECT |/ANSWERS |/✔✔Fairness
Electronic |/Records |/(EHR) |/- |/CORRECT |/ANSWERS |/✔✔Communication |/tools |/for |/documenting |/progress, |/treatments, |/interventions, |/and |/client |/responses |/to |/care. Paper |/Records |/- |/CORRECT |/ANSWERS |/✔✔Maintain |/integrity. |/Properly |/date |/and |/time |/each |/entry |/followed |/by |/a |/full signature |/and |/title. 9 |/Types |/of |/Nursing |/Documentation |/Errors |/- |/CORRECT |/ANSWERS |/✔✔- Sloppy |/or |/illegible |/handwriting |/ -Failure |/to |/date, |/time |/and |/sign |/a |/medical |/entry -Lack |/of |/documentation |/ -Incomplete |/or |/missing |/documentation -Adding |/entries |/later |/on |/ -Documenting |/Subjective |/data -Not |/questioning |/incomprehensive |/orders -Using |/wrong |/abbreviations |/ -Entering |/info |/into |/the |/wrong |/chart steps |/to |/performing |/general |/survey |/- |/CORRECT |/ANSWERS |/✔✔1.General |/appearance |/ 2.Behavior
3.Body |/structure |/ 4.Mobility 5.Measurement |/ 6.Vital |/signs 7.Pain approach |/of |/the |/initial |/survey |/and |/assessment |/- |/CORRECT |/ANSWERS |/✔✔The |/initial |/survey |/and |/assessment |/will |/help |/determine |/a |/client's |/health |/status. |/The |/observation |/begins |/right |/when |/you |/step |/into |/the |/room. |/While |/performing |/the |/initial survey |/be |/sure |/to |/establish |/trust |/and |/build |/a |/rapport |/with |/the |/client |/through |/therapeutic communication. Glasgow |/Coma |/Scale |/- |/CORRECT |/ANSWERS |/✔✔Eyes |/ 4 |/Voice |/ 5 |/Motor |/ 6 Cyanosis |/- |/CORRECT |/ANSWERS |/✔✔bluish |/discoloration |/of |/the |/skin Erythema |/- |/CORRECT |/ANSWERS |/✔✔redness |/of |/the |/skin Pallor |/- |/CORRECT |/ANSWERS |/✔✔Extreme |/or |/unnatural |/paleness
Myoclonus |/- |/CORRECT |/ANSWERS |/✔✔Alteration |/in |/muscle |/movement |/that |/is |/seen |/as |/a |/sudden |/jerking |/of |/muscle. Ex: |/hiccups, |/seizure |/activity, |/and |/a |/single |/myoclonic |/jerk |/of |/the |/arm |/or |/leg |/when |/falling |/asleep Tic |/- |/CORRECT |/ANSWERS |/✔✔Alteration |/in |/muscle |/movement |/characterized |/by |/involuntary, |/repetitive |/movement. Neurologic |/or |/psychogenic |/cause. Tremors |/- |/CORRECT |/ANSWERS |/✔✔A |/rhythmic |/movement |/of |/one |/or |/more |/joints Height |/- |/CORRECT |/ANSWERS |/✔✔Stadiometer |/is |/used |/to |/measure |/height. |/Height |/is |/measured |/in |/feet |/and |/inches. Weight |/- |/CORRECT |/ANSWERS |/✔✔Use |/a |/standing |/scale |/or |/an |/electronic |/scale. |/Weight |/is |/measured |/in |/pound |/or |/kilograms. |/ Body |/weight |/is |/influenced |/by |/genetics, |/exercise, |/diet, |/and |/fluid |/volume. Remove |/shoes. |/ Repeated |/weights |/should |/be |/performed |/at |/the |/same |/time. An |/unintentional |/weight |/change |/alerts |/you |/to |/an |/underlying |/condition.
-Unintentional |/weight |/gain |/(5IB |/in |/a |/day) |/could |/indicate |/fluid |/retention, |/such |/as heart |/failure -Unintentional |/weight |/loss |/(5% |/of |/body |/weight |/in |/a |/month |/or |/10% |/in |/ 6 |/months) could |/indicate |/a |/disease |/process, |/such |/as |/a |/fever, |/infection, |/malignancy, |/or |/endocrine disease BMI |/- |/CORRECT |/ANSWERS |/✔✔assess |/for |/healthy |/weight |/and |/is |/the |/preferred |/method |/for |/identifying |/total |/body |/fat Underweight |/BMI |/- |/CORRECT |/ANSWERS |/✔✔less |/than |/18. Normal |/BMI |/- |/CORRECT |/ANSWERS |/✔✔18.5-24. Overweight |/BMI |/- |/CORRECT |/ANSWERS |/✔✔25-29. Obese |/BMI |/- |/CORRECT |/ANSWERS |/✔✔over |/ 30 Factors |/influencing |/temperature |/- |/CORRECT |/ANSWERS |/✔✔Increase- |/hormones, |/exercise, |/dehydration, |/illness, |/stress |/environment Decrease- |/surgery |/environment |/(older |/adults |/have |/lower |/core |/temp.)
-Client |/movements -Impaired |/circulation |/(peripheral |/vascular |/disease, |/hypothermia, |/vasoconstriction, hypotension, |/and |/peripheral |/edema) Respirations |/- |/CORRECT |/ANSWERS |/✔✔Teens: |/16-20 |/depths |/ Adults: |/12-20 |/breaths |/(semi |/Flowers |/Position) Recognize |/factors |/influencing |/respirations |/- |/CORRECT |/ANSWERS |/✔✔- Exercise: |/faster |/and |/deeper -Anxiety: |/Breathing |/rate |/increase -Pain |/ -Body |/position |/ -Medications -Smoking: |/Changes |/lining |/of |/the |/airways. |/Inhibiting |/airflow. |/Breathe |/faster -Neurological |/injury |/and |/alterations |/in |/hemoglobin Blood |/pressure |/- |/CORRECT |/ANSWERS |/✔✔the |/force |/of |/blood |/against |/the |/walls |/of |/the |/artery |/during |/systole |/and |/diastole Normal |/is |/120/
Hypertension |/with |/ 3 |/separate |/visits |/over |/weeks. Hypotension |/- |/CORRECT |/ANSWERS |/✔✔Systolic |/blood |/pressure |/of |/less |/than |/ 90 |/mmHg Prehypertension |/- |/CORRECT |/ANSWERS |/✔✔120-139/80- Stage |/ 1 |/hypertension |/- |/CORRECT |/ANSWERS |/✔✔140-159/90- Stage |/ 2 |/hypertension |/- |/CORRECT |/ANSWERS |/✔✔160/ Recognize |/factors |/that |/affect |/BP |/- |/CORRECT |/ANSWERS |/✔✔-Smoking |/ -Sex |/ -Medication -Ethnicity |/(African) |/ -Diurnal |/Variations |/ -Obesity -History |/of |/hypertension |/or |/hypotension |/ -Birth |/control -Cuff |/to |/small |/ -Deflate |/to |/slow |/ -Clothing
answer |/Do |/you |/have |/any |/abdominal |/pain |/right |/now? |/How |/old |/are |/you |/Have |/you |/ever |/smoked |/cigarettes |/or |/other |/tobacco |/products? |/What |/time |/do |/you |/usually |/get |/up |/in |/the |/morning? Open-ended |/questions |/- |/CORRECT |/ANSWERS |/✔✔lets |/your |/client |/elaborate |/on |/their |/answers |/Describe |/how |/you |/are |/feeling? |/What |/symptoms |/brought |/you |/to |/the |/emergency |/department? |/What |/kind |/of |/outcome |/would |/you |/want |/to |/achieve |/from |/you |/plastic surgery |/operation? Identify |/components |/of |/a |/current |/health |/history |/- |/CORRECT |/ANSWERS |/✔✔-Biographic |/data -Reason |/for |/seeking |/care -History |/of |/present |/illness
-Social |/determinants |/of |/health OLDCARTS |/- |/CORRECT |/ANSWERS |/✔✔Onset, |/Location, |/Duration, |/Character, |/Aggravating |/factors, |/Relieving |/Factors, |/Treatment, |/Severity Obstetrical |/- |/CORRECT |/ANSWERS |/✔✔for |/female |/clients |/of |/childbearing |/age USE |/GTPAL |/format GTPAL |/- |/CORRECT |/ANSWERS |/✔✔gravida, |/term |/births, |/preterm |/births, |/abortions, |/living |/children Recognize |/the |/order |/in |/which |/the |/review |/of |/systems |/is |/conducted |/- |/CORRECT |/ANSWERS |/✔✔1.Skin 2.Head |/and |/Neck
- |/Head
- |/Eyes
- |/Ears
- |/Nose |/and |/sinuses
- |/Mouth |/and |/throat
- |/Neck
|/Substance |/use External |/factors |/- |/CORRECT |/ANSWERS |/✔✔Occupational |/health |/Living |/environment |/Relationships |/Abuse
