Trust the process
This is when you collect subjective and objective data
Nursing assessment
What type of data is collected in the interview portion of a health assessment?
Subjective
While the nurse is collecting data on the client's gastrointestinal system during the review of systems portion of the health interview, the nurse's findings are unremarkable and the client denies any complications. How would the nurse best document the subjective portion of the assessment?
a."Gastrointestinal problems are not present at this time."
b. "Client denies gastrointestinal signs and symptoms."
c. "Client's gastrointestinal health is within normal limits. "
d. "Client denies recent constipation, diarrhea, bowel incontinence, or abdominal pain."
d. "Client denies recent constipation, diarrhea, bowel incontinence, or abdominal pain."
What is the definition of culture
Shared norms for behaviors, values, and beliefs
This pain is from damage or dysfunction at any level of the nervous system
Neuropathic
This is when you analyzing subjective and objective data to make a professional nursing judgement
Nursing diagnostic phase
Before meeting a new client for a comprehensive exam, the lvn would first...
Review the chart
General non-descriptive terms, such as normal, abnormal, or poor should be used when documenting. True or False
FALSE
A nurse's personal reflection reveals that the nurse tends to see their own culture as the "gold standard" to which all other cultures should aspire. This nurse should create learning goals to address what phenomenon?
Ethnocentrism
This sensation of pain distant from the actual source
Referred
This is the clinical judgement about actual or potential health problems and life processes. This includes potential risks
Nursing Diagnosis
In the introductory phase of the assessment, what is the most important thing for the nurse to do?
Establish a trusting relationship
The nurse is collecting data from a client about his nutrition. Which finding would the nurse document as objective data?
a. reports nausea
b. Reports poor intake
c. frequent voiding
d. Emesis of 300 ml
A woman has accompanied her 80-year-old husband to a scheduled clinic visit and expresses concern about subtle declines in his cognition. Which principles would guide the nurse's assessment of the client's mental status?
The nurse must differentiate between age-related changes and the signs and symptoms of dementia
Emotional or Mental Pain
Psychological
The way in which one processes information using knowledge, past experience, intuition and cognitive abilities
Critical Thinking
A nurse is taking complete health histories on all of the patients attending a wellness workshop. On the history form, one of the written questions asks, “You don’t smoke, drink, or take drugs, do you?” This question is an example of:
Using biased or leading questions
Assessment of a client who has suffered a recent stroke reveals that he is unresponsive to all stimuli and his eyes remain closed. The nurse documents the client's level of consciousness as which of the following?
COMA
A woman who has lived in the United States for a year after moving from Europe has learned to speak English and is almost finished with her college studies. She now dresses like her peers and says that her family in Europe would hardly recognize her. This nurse recognizes that this situation illustrates which concept?
assimilation
This is psychologic pain becomes physical
Psychosomatic
identify which phase as being foundational to all other phases in the nursing process?
Assessment
The nurse is conducting an interview. Which of these statements is true regarding open-ended questions? SATA
a. Elicit hard facts.
b. Allow for self-expression.
c. Build and enhance rapport.
d. Call for short one to two word answers.
b. Allow for self-expression.
c. Build and enhance rapport.
A nurse will be performing frequent assessment and reassessment of a client. Which form would be most appropriate for the nurse to use?
a. An assessment flow chart
b. A screening tool that assesses specific risks
c. An integrated cued checklist
d. An abbreviated admission data sheet
a. An assessment flow chart
A nurse is caring for a client according to the five constructs of the cultural competence process. What will the nurse demonstrate while caring for the client? (select all that apply)
a. Cultural awareness
b. Cultural knowledge
c. Cultural encounters
d. Cultural ethnocentrism
e. Cultural desire
f. Cultural differences
a. Cultural awareness
b. Cultural knowledge
c. Cultural encounters
e. Cultural desire
This pain stimuli at a nerve root at its connection to the spinal nerve
Radicular