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critical thinking five-step process that professional nurses use to apply the best available evidence to caregiving and promoting human functions and responses to health and illness - ANSWER nursing process a _______________________ care approach is holistic and essential when applying the nursing process - ANSWER patient-centered a nursing assessment must be what three things in order for the nurse to correctly identify a person's desire to improve their health or identify any health problem? - ANSWER 1) complete 2) relevant to a patient's condition 3) accurate the nursing process is a form of ________________________ reasoning - ANSWER scientific deliberate and systematic col
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critical thinking five-step process that professional nurses use to apply the best available evidence to caregiving and promoting human functions and responses to health and illness - ANSWER nursing process
a _______________________ care approach is holistic and essential when applying the nursing process - ANSWER patient-centered
a nursing assessment must be what three things in order for the nurse to correctly identify a person's desire to improve their health or identify any health problem? - ANSWER 1) complete
the nursing process is a form of ________________________ reasoning - ANSWER scientific
deliberate and systematic collection of information about a patient to determine the patient's current and past health and functional status and their present and past coping patterns - ANSWER assessment
two steps of nursing assessment - ANSWER 1) collection of information from a primary source (a patient) and secondary sources (family, friends, health professionals, and the medical record)
five sources of information in a nursing assessment - ANSWER 1) the patient through interview, observations, and physical examination
true or false: assessment is part of the working phase of a nurse-patient relationship - ANSWER true
assessment identifies what two things that help the nurse develop the nursing care plan? - ANSWER 1) functional (patient strengths) patterns
three examples of objective data - ANSWER 1) inspecting the condition of a surgical incision
best source of information (usually) - ANSWER the patient
describe how to communicate with a patient (five ways) - ANSWER 1) use short but not leading questions
when are family members and significant others primary sources of information? - ANSWER 1) for children
how are family members secondary sources of information? - ANSWER they confirm findings or identify patterns that a patient provides
an interactive process of passing patient-specific information from one caregiver to another for ensuring patient-centers care and patient safety - ANSWER hand-off
three types of records that often contain significant health care information - ANSWER
two main characteristics of a patient-centered interview - ANSWER 1) relationship based
technique used often in counseling that allows you to become a helper in the change process; a process that addresses a patient's ambivalence to medically indicated behavior change and supports patients in making health care decisions in cases in which there is more than one reasonable option - ANSWER motivational interviewing
four communication skills involved in effective communication in assessment - ANSWER 1) courtesy
three phases of an interview - ANSWER 1) orientation and setting an agenda
the nurse should start an assessment or nursing health history with what type of questions? - ANSWER open-ended
six types of interview techniques - ANSWER 1) observation
type of question that prompts a patient to describe a situation in more than one or two words - ANSWER open-ended
what is the goal of a patient-centered interview? - ANSWER to find out, in the patient's words, their health goals and any concerns or problems that exist and their probable cause
true or false: an open-ended question presupposes a specific answer - ANSWER false; an open-ended question does not presuppose a specific answer
why are leading questions risky? - ANSWER due to possibly limiting the information provided to that a patient thinks you want to know
examples of back channeling - ANSWER active listening prompts such as "all right", "go on", or "uh-huh."
observations or measurements of a patient's health status - ANSWER objective data
how does a nurse record a patient's response? - ANSWER in quotations to indicate the subjective response
what does the acronym PQRST stand for? - ANSWER 1) provokes
symptoms that accompany other symptoms - ANSWER concomitant symptoms
purpose of a health history - ANSWER 1) provides a holistic view of a patient's health are experiences and current health habits
two components of a health history - ANSWER 1) medical records
two components of family history - ANSWER 1) data about immediate and blood relatives
systematic approach for collecting subjective information from patients about the presence or absence of health-related issues in each body system - ANSWER review of systems
what does interpreting and validating assessment data ultimately lead the nurse to? - ANSWER the second step of the nursing process, in which you make clinical decisions in your patient's care
three things nurse does when critically interpreting assessment information - ANSWER
true or false: validation opens the door for gathering more assessment data because it involves clarifying vague or unclear data - ANSWER true
a health history includes a ________________________________________ - ANSWER wellness assessment
three examples of categories in a wellness assessment - ANSWER 1) nutrition
a nursing health history focuses on (functional/dysfunctional) assessment - ANSWER functional
what type of care is the goal of a nursing health history? - ANSWER patient-centered
describe the communication process in nursing - ANSWER sender ---> encode ---> message ---> decode ---> receiver ---> encode ---> response ---> decode ---> sender
two main communication skills in interviewing - ANSWER 1) listening
two components of effective listening - ANSWER 1) active
six types of interactional skills - ANSWER 1) attending
giving the client undivided attention - ANSWER attending
four techniques of attending - ANSWER 1) use direct eye contact if appropriate for the culture
example of questioning - ANSWER "What did you mean when you said your back was breaking?"
letting the client know that the nurse empathizes with the thoughts, feelings, or experiences expressed - ANSWER reflecting
set of signs and symptoms that you group together in a logical way - ANSWER data clusters
the comparison of data with another source to determine data accuracy - ANSWER validation
who most often validates your assessment information? - ANSWER family and friends of the patient
who else can participate in validation? - ANSWER 1) the patient
seven barriers to effective nurse-client communication - ANSWER 1) false reassurance
seven diversity factors that contribute to the influence of culture on nurse-client interactions - ANSWER 1) body language
how could the use of a family member as an interpreter cause potential problems? - ANSWER they could interpret or relay information wrongly
describe the three phases of the client interview - ANSWER 1) pre-interaction (record review)
purpose of the focused interview phase in the client interview - ANSWER to obtain clarification of previous assessment data and gather missing information
six main components of a nursing health history - ANSWER 1) biographical data
nine examples of biographical data - ANSWER 1) name
four components in the present health/illness portion of a nursing health history - ANSWER 1) reason for seeking care
the reason for seeking care may also be known as what? - ANSWER the chief complaint (why are you here?)
eleven components of a patient's past history - ANSWER 1) childhood illnesses
three techniques of summarizing - ANSWER 1) listen to verbal and nonverbal content throughout the interview
example of summarizing - ANSWER "Let's review the health problems you've identified today."