Lecture Exam 3 for accelerated nursing program at LCC
Dementia
Delerium
Implementation
Evaluation
Diagnosis
Planning
Awareness
Attention
Memory
Learning
Label
Related factors
Defining Characteristics
All the above
Risk for fluid volume deficit
Fluid volume deficit
Delirium
Dementia
Planning
Diagnosis
Evaluation
Implementation
Diagnose if the pt is at risk for falls
Ensure that the pts skin is intact
Establish a therapeutic relationship
Identify important data
Autopsy
Check medication
I just went to the urinal and it needs to be emptied
My pain fells like a 5 on a scale of 1 to 5
The dr said I can go home today
I only ate half my breakfast
Affect
Aphasia
Apraxia
Agnosia
Awareness
Orientation
Memory
Learning
Awareness
Attention
Orientation
Judgment
Plan
Evaluate
Diagnose
Implement
Observing
Inspecting
Auscultation
Interviewing
Assessment, Outcome Identification, Nursing Diagnosis, Planning, Implementation, Evaluation, Interventions
Assessment, Nursing Diagnosis, Outcome Identification, Planning, Implementation, Evaluation
Assessment, Planning, Nursing Diagnosis, Outcome Identification, Implementation, Evaluation
Teacher
Advocate
Surrogate
Counselor
Male
Female
Pain of 5 on a 1 to 1 scale
Irregular radial pulse of 50 bpm
Shortness of breath
Dizziness
Dementia
Delerium
Implementation
Assessment
Diagnosis
Planning
Absent bowel sounds
Felling "bloated"
Abd distention
Surgical manipulation of the bowel
High cholesterol
Tau tangles
HTN
Build trust and rapport
Collect and cluster data
Establish goals and outcomes
Identify and validate the medical diag
Affect
Aphasia
Apraxia
Agnosia
Signs and symptoms
Subjective and objective
Etiology
A and B
All the above
Signs and symptoms
Etiology
"I'm not sure that I am going to be able to manage at home by myself"
"I can call a home-care agency if I feel I need help at home"
"What should I do if I have uncontrollable pain at home"
"Will a home helath aide help me with my care at home"
Physicians history and physical
Social service record
Admission sheet
Progress notes
Acute confusion
Impaired memory
Risk for acute confusion
Disturbed thought processes
Formulating a plan of care
Identifying the pts potential risks
Designing ways to minimize a pts stressors
Making decisions about the effectiveness of pt care
C/o sharp discomfort to RLQ of abd
Tissue trauma from abd surgery
Tylenol #3 eases pain from 7/10-1/10
Grimacing when getting out of bed
Judgment
Awareness
Attention
Orientation
Have a lower temp
Be give apirin every 8 hours prn
Be taught how to take an accurate temp
Maintain fluid intake sufficient to prevent dehydration
Data
Problem
Rationale
Evaluation
Affect
Aphasia
Apraxia
Agnosia
I am hungry
I feel very warm
I ate half my lunch
I have the urge to urinate
Plan
Analyze
Diagnose
Implement
Is dynamic rather than static
Focuses on the role of the nurse
Moves from the simple to the complex
Is based on the pts medical problem
DC
Outcome criteria
Etiology
Goal
Male
Female
Equal
Diagnosis
Clustering
Collection
Assessment
Implementaion
Assessment
Evaluation
Diagnosis
Be taught how to use a urinal when on bed rest
Experience fewer incontinence episodes at night
Be assisted to the toilet every two hours and when necessary
Transfer independently and safely to a commode before discharge
R/t
Diagnostic label
Secondary factors
Medical diagnosis
Establish outcomes
Determine priorities
Take corrective action
Set the time frames for goals
Sign
Symptom
Syndrome
Rate this question:
Reassess the pt
Examine the r/t
Analyze the secondary to factors
Review the DC
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