Let’s be nosey
information provided by a patient to a nurse from the patient's viewpoint
What is subjective data.
when a patient has an unsteady gate
risk for Falling
this step of the nursing process, you prioritize the diagnosis in order of importance and figure out what nursing interventions need to take place
What is planning
A patient admitted to the medical unit with HF is exhibiting signs and symptoms of pulmonary edema. The nurse is aware that positioning will promote circulation. How should the nurse best position the patient?
In High Fowler Position
temperature or blood pressure, or something observed with the senses, such as a rash or a cough.
What is objective data
This is the step of the nursing process where you do the PES (Problem, Etiology, and Signs/Symptoms)
What is Diagnosis
Specific, Measurable, Achievable, Relevant, and Time-Bound.
What are SMART goals
A nurse is caring for a patient who is exhibiting ventricular tachycardia (VT). Because the patient is pulseless, the nurse should prepare for what intervention?
Defibrillation
this type of assessment Detailed nursing assessment of specific body system(s) relating to the presenting problem or current concern(s) of the patient.
What is a focused assessment
A patient has a blood clot or dvt
What is Impaired tissue integrity
the nurse should do this step during the evaluation step of the nursing process?
Evaluate the plan
A nurses should expecta a patient who takes Keppra, Valporic Acid, or Phenytoin should be placed on what?
Seizure precautions
This involves collecting, organizing, validating, and documenting the clients’ health status.
What is health assessment
Labs K: 7, Na: 128, Mg:1.9 are signs of what?
What is electrolyte imbalance
Individualize a nursing plan of care based on the assessment findings by establishing what?
priorities
The physician states to the nurse that the patient has fluid noted in the pleural space. The nurse should expect the patient and prepare the patient for a…
thoracentesis
This is performed to identify a life-threatening problem (choking, stab wound, heart attack).
Emergency assessment
Maladaptive coping responses include avoidance of the stressful condition, withdrawal from a stressful environment, disengagement from stressful relationships, and misuse of drugs and/or alcohol.
What is Ineffective Coping
This type of planning is initiated during the admission of the patient into the hospital.
what is discharge planning
The nurse is caring for a client whose respiratory status has declined since shift report. The client has tachypnea, is restless, and displays cyanosis. Which noninvasive diagnostic test should be assessed first?
Pulse oximetry