Nurs314 Test 1
Card Set Information
Nurs314 Test 1
health assessment of the individual, test 1
What are the 4 goals of the American Nurses Association (ANA)?
1. promote health
2. prevent illness
3. treat human responses to health or illness
4. advocate for individuals, families, communities, and populations
Each states ______ and ______ form the legal framework for practice.
Nursing Practice Act
Standards of Nursing Practice
What are the roles performed by the nurse that relate to legal accountability?
1. provider of direct and indirect care
2. forensic specialist
3. expert witness
4. reporting responsibilites related to cases of abuse, rape, and sexual assault
The nurse has a _____ obligation to take action to protect a client's privacy and confidentiality.
The concept of privacy includes:
right to be left alone
give or refuse consent for treatment
control of how personal information is shared
What are the 4 areas of legal risk with regards to maintaining a client's safety in practice?
failure to monitor client's status
use of restraints
Entails purposeful, outcome-directed (result oriented) thinking
What is critical thinking driven by? Based on? Guided by?
driven by patient, family, and community needs
based on nursing process, scientific method, evidence-based thinking
guided by professional standards and codes of ethics
What are the 5 steps of the nursing process?
2. nursing diagnosis/analysis
_____ functional health patterns is a _____ approach to human functional assessment.
How many functional health patterns does Gordon assess and what do these pattern's look at?
ability to perform ADL's
skills needed for independent living
social relationships, self-concept, & coping
What are Gordon's 11 functional health patterns?
______ is the process of reviewing a situation for the purpose of identifying the client's needs or problems
Assessment is a _______ process of gathering, verifying, and communicating data about a client's health status
The nursing process begins with what?
a complete and accurate health assessment
What are the components of a health assessment?
What kind of data is taken from a health history vs a physical examination?
health history-subjective data that a client or family member tells you
physical examination-objective data that is observable and measurable
What is a therapeutic dialogue?
used to enhance the subjective data we receive from a patient during a health history
What are the types of assessment data bases?
What is a comprehensive assessment and when is it taken? What does it provide?
complete health history and physical examination
provides baseline data to measure future changes
Whar is a focused assessment?
based on patient issues
usually contains only one problem, one cure complex, or one body system
What is an emergency assessment abd what does it involve?
life-threatening or unstable situation
rapid assessment of
: general appearance (color, skin perfusion, level of activity, level of consciousness, position of comfort), ABC's (airway/aeration/aggitation, breathing sounds/respiratory rate, circulation/color/capillary refill), pulses (central, peripheral), vital signs
What are Erikson's stages of psychosocial development?
: trust v. mistrust
: autonomy v. shame & doubt
: initiative v. guilt
early school years
: industry v. inferiority
: identity v. role confusion
: intimacy v. isolation
: generativity v. stagnation
: integrity v. despair
According to Erikson, which stage of psychosocial development is a person that requests assistance, shares time, and expresses belief in another person?
According to Erikson, which stage of psychosocial development is a person that refuses to provide information and is unable to accept assistance?
According to Erikson, which stage of psychosocial development is a person that expresses one's own opinion?
According to Erikson, which stage of psychosocial development is a person that fails to express their needs and is over-concerned about being clean?
toddler: shame & doubt
According to Erikson, which stage of psychosocial development is a person that expresses curiosity and demostrates original thoughts?
early childhood: initiative
According to Erikson, which stage of psychosocial development is a person that imitates others and is fearful of starting new projects.
early childhood: guilt
According to Erikson, which stage of psychosocial development is a person that completes a task, works well with others, and uses their time effecively?
early school years: industry
According to Erikson, which stage of psychosocial development is a person that does not complete tasks, not organized, and does not like to work with others?
early school years: inferiority
According to Erikson, which stage of psychosocial development is a person that independent and plans for the future?
According to Erikson, which stage of psychosocial development is a person that fails to set goals for the future.
adolescence: role confusion
According to Erikson, which stage of psychosocial development is a person that establishes a close, intense relationship with another person.
early adulthood: intimacy
According to Erikson, which stage of psychosocial development is a person that avoids close interpersonal relationships.
early adulthood: isolation
According to Erikson, which stage of psychosocial development is a person that guids others and is willing to share with another person?
middle age: generativity
According to Erikson, which stage of psychosocial development is a person that worries about their own needs and ignores the needs of others.
According to Erikson, which stage of psychosocial development is a person that uses past experiences to assit others and accepts their limitations.
According to Erikson, which stage of psychosocial development is a person that does not accept change very well and demands unnecessary assistance and attention.
What is a follow-up/ongoing assessment?
follow-up on a specific problem such as someone with a chronic problem, pregnant, receiving their test results, after surgery, pediatrics
What did Erikson integrate into the assessment?
age and physical development
cultural and environmental considerations
What did Erikson focus on and how many stages did he describe? What is each stage characterized by?
focused on societal and cultural influences as determinants of behavior
growth of the "ego"
described 8 stages of ego development to encompass the lifespan
each stage is characterized by a distinct conflict that can result in either negative or positive resolution
Why should we consider a patient's cultural and environmental backgrounds?
cultural factors influence the beliefs of patients about thier health status
illnesses that are more common among groups of patients
patient's environment might include safety in the home, transportation issues, or community involvement
What are psychosocial and lifestyle factors that we should consider when taking a health history?
social, cultural, and spiritual assessment
sexual history and orientation
What is a primary v. a seconday data source?
secondary-charts & family members
What considerations should you give to the setting when collecting a health history?
comfort (temperature, avoid interruptions)
______ provides information that is consistent with existing records and comprehensive in scope
_____ provides information that differs from past descriptions or changes details each visit.
What are the components of a health history?
reason for seeking care
history of present illness (symptom analysis, pain (scale 0-10)
past health history (current medications, allergies, family history)
functional health assessment (Gordon)
growth and development
review of systems
What is involved in a symptom analysis?
onset, location, duration, character, associated or aggrivating factors, relieving factors, timing, severity
provocative/palliative, quality, region, severity, timing, understanding patients perception
_____ is a series of questions about all the body systems that helps to reveal concerns/problems as part of a comprehensive health assessment
review of systems (ROS)
What systems are involved in the review of systems during a health assessment?
general health status
nutrition & hydration
skin, hair, nails
head & neck (eyes, ears, nose, mouth, throat)
thorax & lungs
heart & neck vessels
male and femal genitalia
anus, rectum, prostate
endocrine & hematologic systems
teaching opportunity/health promotion