Nursing Process
What is assessment?
When the heart rate is greater than 100 bpm.
What is tachycardia?
A questionnaire that assess the client's risk for being malnourished.
What is the Malnutrition Screening Tool (MST)?
The first technique used during a physical assessment.
What is inspection?
Asking about specific symptoms the client is experiencing in a particular body system.
What is review of symptoms (ROS)?
This step of the nursing process involves using evidence-based resources and clinical judgment to prioritize nursing interventions and create goals.
What is planning?
When the respiratory rate is less than 12 breaths per minute.
What is bradypnea?
Dizziness, irritability, and decreased urine output are symptoms of this condition.
What is dehydration?
This part of the stethoscope is used to listen to high frequency sounds such as lung sounds and bowel sounds.
What is the diaphragm?
This interview technique invites the client to share more information than a simple "yes or no" question.
What is open-ended questioning?
What is evaluation?
Blood pressure measuring 130-139/80-89 on 3 separate occasions.
What is stage 1 hypertension?
What is CBC, Vitamin B12, and albumin/prealbumin?
This technique is used to assess the temperature, texture, and moisture of the skin.
What is palpation?
A description of the patient's current concern and how it developed.
What is history of present illness (HPI)?
The step of the nursing process in which you would carry out the intervention.
Implementation
When the client's blood pressure is lower when standing than when lying down or sitting.
What is orthostatic (postural) hypotension?
A BMI of 25-29.9.
What is overweight?
This is a medium, drum-like sound that should occur when percussing the abdomen.
What is tympany?
A therapeutic communication technique used to validate the accuracy of the client's story.
What is summarizing?
What is objective data?
PQRST (list them!)
P- Provocation
Q- Quality
R- Region
S- Severity
T- Timing
The nurse recognizes that client's from other parts of the world may have different eating habits than in the United States. This is an example of ____.
What is culturally competent care?
This portion of the assessment involves assessing a client's physical appearance, posture, and personal hygiene.
What is the general survey?
The client states: "I have a sharp pain in my stomach every time I eat greasy food." This is an example of ___.
What is subjective data?