Clinical Judgement
When determining patient priorities, I will remember that this concept from my CPR training with help me.
What is ABC's
Airway
Breathing
Circulation
The patient would have what type of assessment when coming in for a specific problem?
What is a focused assessment; for example a patient makes an appointment at the PCP office for a respiratory infection. The assessment will only pertain to the current complaint.
If the patient states " I had a headache all day, and I had a temperature of 102.4 last night", this is an example of what type of data?
What is subjective data?
Leading questions are not appropriate for use in healthcare settings. Give an example of this type of question and why it is not used.
What is " you must be very unhappy about having surgery today'?
This question tells the patient what answer is expected.
What does -Megaly mean?
What is enlargement of
Ex- Hepatomegaly (enlarged liver)
The nurse will use intuition as it relates to clinical judgment. The benefit to this is that the nurse will be able to do what?
What is recognize patterns immediately?
How would you describe an Emergency assessment?
An emergency assessment is a rapid collection of data, used to stabilize or offer life-sustaining measures.
When the nurse collects assessment data, the data will be organized in what manner?
What is by relevance, disease process, and priority?
What is using short, simple, concrete sentences?
Define -Sclerosis
Hardening of
If the nurse is working in the ED when a patient comes in with an OD, what data is the most important to collect?
What did they take, when was it taken, how much was taken, ect.
This information is most important, other questions such as history, and allergies can be obtained when the patient is more stable.
A complete assessment would be done for what circumstance?
A patient admitted to the hospital, a yearly physical or new patient office exam, ect.
The nurse observes edema on the BLE of a patient. This person also has abnormal lung sounds, the nurse knows that this is what type of data?
What is Objective?
When a patient comes in for a routine health check, the nurse will introduce themselves and give the purpose of the interview. What else is the nurse expected to review?
In order to complete the interview contract, the nurse must provide information about costs, explain the purpose and length of the interview, and provide a statement of confidentiality and the expectations of each person
Define -centesis
What is a surgical puncture to remove fluid
IE- Paracentesis- removal of fluid in the abdomen
Another framework for decision-making is ADPIE, is this fixed, or unchangeable or can the patient be reassessed?
ADPIE
Assessment, diagnosis (nurse), planning, implementation, evaluation
You can always reassess and start over with a new plan, but you do not medicate a patient before you assess. Assessment is always first.
What is a second visit for additional assessment of a previous illness or post-op condition?
The nurse has determined that the patient is alert and oriented, this is what type of data?
What is Objective?
What should be documented when describing a historical source?
The reliability of the informant is included when documenting a history source. If an interpreter is used, the interpreter's name, but not credentials, needs to be documented. The primary language is only documented if an interpreter is used for communication. The literacy level does not need to be documented. The patient's support systems are not documented under the history source.
What does -oma mean?
Give an example of modifiable and non-modifiable health risk factors
Modifiable- Smoking, healthy diet and weight, exercise
Non- family history, race, genderDescribe Primary, secondary, and Tertiary prevention.
Primary- prevention of illness or disease, example is vaccinations and healthy lifestyle
Secondary- prevention of getting a second person sickTertiary- prevention of progression of the disease or illness to other body parts or systems
What is an example of a close-ended question and what is the purpose of this type of question?
What is " What is your pain level on a scale of 1-10"?
Closed-ended/direct questions call for short one- to two-word answers, elicit cold facts, limit rapport, and leave interactions neutral.
When washing your hands, the nurse should wash for 30-60 seconds and turn the water off using a paper towel, T/F?
What is true
What does -emia mean?
What is Blood