MedSurg 1 Exam 1

  1. What is the nursing process?
    A systematic method for nurses to plan and implement client care to achieve desired outcomes.
  2. What is assessment?
    The careful observation and evaluation of a client's health status.
  3. What is the client database?
    The client database includes all the information obtained from the medical and nursing history, physical examination, and diagnostic studies.
  4. What is the nursing diagnosis?
    The second phase of the nursing process, in which the nurse reports or analyzes data to identify and define health problems that independent or physician-prescribed nursing actions can prevent or solve.
  5. What are actual nursing diagnoses?
    They identify existing problems.
  6. What are health promotion nursing diagnoses?
    They reflect clinical judgment of a client's motivation to increase well-being and enhance health-seeking behaviors.
  7. What are the three parts of nursing diagnostic statements?
    • The name or label of the problem,
    • the cause of the problem,
    • the signs and symptoms, or data, that indicate the problem.
  8. What is risk nursing diagnosis?
    A problem that the client is at high risk for developing.
  9. What is wellness diagnosis?
    No problem exists; the client desires a higher level of wellness.
  10. What is syndrome diagnosis?
    Used when the diagnosis is associated with a cluster of other diagnosis.
  11. What are collaborative problems ?
    A problem that is monitored and managed by the nurse using physician prescribed and nursing prescribed interventions.
  12. Define planning in the nurses process.
    Setting priorities, defining expected outcomes, determining specific nursing interventions, and recording the plan of care.
  13. Name the levels of Maslow.
    • Physiologic needs (first level)
    • safety and security needs (second level)
    • love and belonging needs (third level)
    • esteem and self esteem needs (fourth level)
    • self actualization needs (fifth level)
  14. What are expected outcomes?
    Outcomes are specific and realistic, so the client can obtain them and not become frustrated, and measurable so the nurse can reliably determine to what extent the client is meeting the goals.
  15. What are interventions?
    Actions for achieving the outcome.
  16. What are nursing orders?
    They are specific nursing directions so that all healthcare team members understand exactly what to do for the client.
  17. What is implementation?
    Carrying out the written plan of care, performing the interventions, monitoring the client status, and assessing and reassessing the client before, during, and after treatments.
  18. What are the five functions of documentation?
    • Communicates care
    • shows trends and patterns in client status
    • creates a legal document
    • supplies validation for reimbursement
    • provides a foundation for evaluation, research, and quality improvement.
  19. What is the evaluation phase?
    The assessment and review of the quality and suitability of caregiving and the clients responses to that care.
  20. What is critical thinking?
    Intentional, contemplative, and outcome directed thinking.
  21. Define laws.
    Written rules for conduct and action.
  22. Define ethics
    Moral principles and values that guide the behavior of honorable people
  23. Define constitutional law
    Laws based on the Constitution that protect nurses basic rights
  24. Define statutory law
    A law that any local, state, or federal legislative body enacts
  25. What does the nurse practice act do?
    It defines nursing practice and sets standards for nurses in each state.
  26. Define administrative law
    The rules and regulations that concerned the health, welfare, and safety of federal and state citizens.
  27. Define board of nursing
    The administrative agency with the authority to regulate the nurse practice act
  28. Define common law
    Laws based on earlier court decisions, judgments and decrees
  29. Define criminal law
    Laws that concern offenses that violate the publics welfare
  30. Define civil law
    Laws that apply to disputes that arise between individual citizens
  31. Define liability
    Legal responsibility
  32. Define tort law
    The body of law that governs breaches of duty owed by one person to another
  33. Define duty
    An expected action based on moral or legal obligations
  34. Define tort
    An injury that occurred because of another person's intentional or unintentional actions, or failure to act
  35. Intentional tort
    A deliberate and willful act that infringes on another person's rights or property
  36. Assault
    An act that involves a threat or attempt to do bodily harm
  37. Battery
    Actual physical contact with another person without that person's consent
  38. False imprisonment
    Win healthcare workers physically or chemically restrain an individual from leaving a healthcare institution
  39. Defamation
    An act that harms a persons reputation and good name
  40. Unintentional tort
    Situations that resulted in injuries, although the person responsible did not mean to cause any harm
  41. Negligence
    The failure to act as a reasonable person would have acted in a similar situation
  42. Malpractice
    Defined as professional negligence. It refers to harm that results from a licensed person actions or lack of action
  43. Standards of practice
    Guidelines that the nursing profession establishes for clinical decision-making
  44. What are the essential elements of malpractice?
    • Harm to an individual
    • duty of a professional toward an individual
    • breach of duty by the professional
    • breach of duty as the cause of harm
  45. Good Samaritan law
    Provides legal immunity for rescuers who provide first aid in an emergency to accident victims. Nurses are still held to a higher standard of care.
  46. Statute of limitations
    The designated time in which a person can file a lawsuit
  47. Risk management
    The process of identifying and then reducing the cost of anticipated losses
  48. Incident report
    Identifies the nature of an incident (who, what, where, and when), witnesses, what actions were taken at the time, and the client's condition
  49. Anecdotal record
    A handwritten, personal account of an incident made at the time of occurrence and updated as needed
  50. Informed consent
    The voluntary permission granted by a client, or the clients assigned medical proxy
  51. Advance directives
    Legal documents that allow for clients to determine in advance their wishes regarding life-sustaining treatment and other medical care
  52. Living will
    A document that states the clients wishes regarding healthcare if he or she is terminally ill
  53. Medical durable power of attorney
    A person designated by the client to make healthcare decisions for their client if he or she is no longer competent or able to make these decisions.
  54. Utilitarianism
    And outcome oriented approach for decision-making, i.e. "The end justifies the means"
  55. Deontology
    An approach that states that duty is equally important as the consequences
  56. Define rights
    Freedoms or actions to which individuals have a just moral or legal claim
  57. Define values
    The belief that individuals find most meaningful
  58. Advocacy
    Safeguarding clients rights and supporting their interests
  59. Veracity
    The duty to tell the truth
  60. Non-maleficence
    And the duty to do no harm to the client
  61. Define verbal communication
    Communication that uses words. It includes speaking, reading, and writing.
  62. Define hearing
    Perceiving sounds
  63. Define listening
    An activity that includes attending to and becoming fully involved and what the client says
  64. Define para-language
    It refers to vocals sounds (not actually words) that communicate a message
  65. Define proxemics
    • The use of space when communicating
    • intimate -- -- within 6 inches
    • personal -- -- 6 inches to 4 feet
    • social -- -- 4 to 12 feet
    • public -- -- 12 or more feet
  66. Define comfort zone
    The area that when intruded on does not create anxiety
  67. Therapeutic communication
    Refers to using verbal and nonverbal communication to promote a person's physical and emotional well-being.
  68. Direct questioning
    Acquire specific information
  69. Open ended question
    Encourages the client to elaborate
  70. Expressive aphasia
    An inability to utilize verbal language skills
  71. Learning style
    The manner in which a person best comprehends new information
  72. Cognitive learner
    Processes information best by listening to or reading facts and descriptions
  73. Affective learner
    Learns best when presented with information that appeals to his or her feelings, beliefs, and values
  74. Psycho motor learner
    Prefers to learn by doing
  75. Learning needs
    The skills and concepts that the client and family must acquire to restore, maintain, or promote health
  76. Learning capacity
    A person's intellectual ability to understand, remember, and apply new information
  77. Motivation
    The desire to acquire new information
  78. Learning readiness
    Refers to the optimal time for learning
  79. CAM
    Complementary and alternative medicine
  80. Complementary therapy
    Therapy used in addition to conventional medical treatment
  81. Alternative therapy
    Therapy used instead of conventional medical treatment
  82. Integrative medicine
    Combining conventional medicine with complimentary or alternative therapy
  83. Ayurvedic medicine
    Based on spiritual practices that developed among Tibetan monks using nature to develop a strong body, clear mind, and tranquil spirit.
  84. Chinese medicine
    Proposes that health is the outcome of balancing Yin and Yang that must remain equalize to maintain life's energy force
  85. Native American medicine
    Views disease as resulting from this harmony with mother Earth, possession by an evil spirit, or violation of a taboo.
  86. Mind-body medicine
    Techniques that rely on the power of the brain, emotions, social interactions, and spiritual factors to alter body functions or symptoms
  87. Biologically-based practices
    Use natural products such as dietary supplements, aromatherapy, and animal derived extracts like bee venom
  88. Probiotics
    Micro organisms that exert beneficial health effects which can lower the frequency or duration of diarrhea
  89. Prebiotics
    Non-digestible food ingredients such as dietary fiber that beneficially stimulate or inhibit bacteria in the colon
  90. Apitherapy
    The medicinal use of bee venom
  91. Reflexology
    Manual pressure is applied to the feet and hands
  92. Yoga
    Exercises to integrate body and mind
  93. Electromagnetic therapy
    Promotes healing using electricity, magnets, or both
  94. Palliative treatment
    Treatment that reduces physical disk comfort but does not alter a disease's progression
  95. respite care
    Care for the caregiver, to provide for periodic relief, during periods of extended home health care
  96. Hospice
    A facility for the care of terminally ill clients, who can live out their final days with comfort, dignity, and meaningfulness
  97. Waiting for permission phenomenon
    Some clients seem to forestall dying when they feel that their loved ones are not yet prepared to deal with their death.
  98. Near-death experience
    The situation in which a person almost dies but is resuscitated.
  99. Nearing death awareness
    A phenomenon characterized by a dying clients premonition of the approximate time or date of death.
  100. Anticipatory grieving
    This occurs before death often when the dying client and family begin to consider the impact of their potential loss.
Card Set
MedSurg 1 Exam 1
medsurg 1 exam 1