










































































Study with the several resources on Docsity
Earn points by helping other students or get them with a premium plan
Prepare for your exams
Study with the several resources on Docsity
Earn points to download
Earn points by helping other students or get them with a premium plan
Community
Ask the community for help and clear up your study doubts
Discover the best universities in your country according to Docsity users
Free resources
Download our free guides on studying techniques, anxiety management strategies, and thesis advice from Docsity tutors
NUR 155 Foundations to Nursing EXAM 2
Typology: Exams
1 / 82
This page cannot be seen from the preview
Don't miss anything!
proving individualized care.
desired goal -Make value decisions -Time management decisions -Scheduling decisions -Priority decisions
menting a patient's health data
-collect data -organize data -validate data
"I have pain, nausea, fear"
vital signs, labs, drainage, etc.
-Interviewing
-Nurse controls the interview -Used to gather and give information when time is limited, e.g., in an emergency
-Client controls the purpose, subject matter, and pacing -Combination of directive and nondirective approaches usually appropriate during the information-gathering interview
"no" response, then you are answering a close-ended type of question. Examples of close-ended questions are:
Is the prime rib a special tonight? Should I date him? Will you please do me a favor?
one word answers. The answers could come in the form of a list, a few sentences or something longer such as a speech, paragraph or essay. Here are some examples of open-ended questions: What were the most important wars fought in the history of the United States? What are you planning to buy today at the supermarket? How exactly did the fight between the two of you start?
-Place -Seating -Distance -Language
-Avoiding jumping to conclusions
community responses to a actual or potential health problem/life processes. A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for
which the nurse is accountable."
-At-Risk -Health Promotion -Wellness Diagnoses -NANDA-I nursing diagnoses
addresses an issue pertaining to the human response within the patient, family or community to a disease, life situation, or other health condition -Examples: Pain or Hypothermia Must be followed by defining characteristics or factors that relate to the "actual" portion of the diagnosis
diagnosis encompasses potential or likely risk factors in which a patient is vulnerable to -Example: At risk of infection
pain" (NANDA International, n.d.)
family coping -A health promotion nursing diagnosis is a clinical judgment that encompasses a patient's desire and motivation for a readiness of enhanced state of health or factor that may lead to improved level -A health promotion nursing diagnosis does not require a current level of wellness -Example: Readiness for enhanced learning
patient's progress or potential progress towards healthier behaviors rather than on a problem. They were created to remedy a situation in which only negative issues were addressed, leaving out diagnoses for patients in a healthy setting. A wellness diagnosis indicates a readiness to advance from the current level of health to a higher level.
Describes the client's health problem or response Use of qualifiers
-Etiology (related factors and risk factors) Identifies one or more probable causes of the health problem Do not
presence of a particular diagnostic label Have signs and symptoms Constipation R/T medication use AEB infrequent passage of stool and hard, dry stool.
lems For risk for nursing diagnoses have no signs/symptoms Factors that cause the client to be more vulnerable to the problem form the etiology or a risk for nursing diagnoses Risk for Infection R/T break in skin integrity.
nosis Nursing judgment Describes human response Changes as client responds -Medical Diagnosis
Made by physician Disease process Stays the same
-AEB observed choking (Observed evidente of difficulty in swallowing
A newborn has a temp of 97.1 Ax.: - Hypothermia -R/T immature body system -AEB Ax temp of 97.
A client comes to the clinic and states he can't handle the stress anymore.: - -Ineffective coping -R/T inadequate coping -AEB verbalization of the inability to cope
An assessment on a post-operative client reveals rhonchi. The client refuses to cough due to pain.: -ineffective airway clearance -R/T ineffective cough -AEB abnormal breath sounds
client. The nurse identifies the client is at risk for developing infection. The client does not have symptoms of an infection at this time.: -Risk for infection -R/T surgical incision
Set priorities