chapters for text 1 ( thy and lab )

What is the difference between a nursing diagnosis and medical diagnosis?

Nursing diagnosis = patient response; Medical diagnosis = disease

What is a SMART goal?

Specific, Measurable, Achievable, Relevant, Time-bound

What is a priority problem?

Life-threatening or urgent issue

What is clustering data?

Grouping related patient information

What happens if evaluation shows goal not met?

Revise care plan

What is a collaborative intervention?

Requires provider order

What is an independent intervention?

Nurse can perform without order

What is dependent intervention?

Requires physician/provider order

What is active listening?

Fully focusing, understanding, responding

What is nonverbal communication?

Body language, facial expressions

What is congruence?

Words match actions

What is an example of broad opening?

“Tell me what’s bothering you”

What is empathy vs sympathy?

Empathy = understand feelings; Sympathy = feel sorry

What should you do if patient is crying?

Stay present, allow expression

What is health literacy?

Ability to understand health info

What reading level should teaching be at?

~5th–6th grade

What is the best time to teach?

When patient is ready + stable

What is return demonstration?

Patient shows skill back

What is motivation in learning?

Willingness to learn

What is incident report used for?

Internal documentation of errors (NOT in chart)

Can incident reports be mentioned in patient chart?

No

What is late entry documentation?

Adding note after event (must label as late)

What is charting by exception?

Only abnormal findings documented

What is a sentinel event?

Serious unexpected event (death/injury)

What is root cause analysis?

Identify cause of error

What is restraint use rule?

Last resort only

What must be done if restraints used?

Frequent monitoring + documentation

What is a near miss?

Error caught before harm

What is tolerance?

Need more drug for same effect

What is dependence?

Withdrawal if stopped

What is addiction?

Psychological craving

What is PCA?

Patient-controlled analgesia

What should you monitor with opioids?

Respiratory rate

What is breakthrough pain?

Sudden pain despite meds

What is shear?

Skin moves in opposite direction of body

What is friction?

Skin rubbing

What is Braden scale?

Measures pressure ulcer risk

What is debridement?

Removal of dead tissue

What promotes wound healing?

Protein, oxygen, circulation

What is nosocomial infection?

Hospital-acquired infection

What is asepsis?

Absence of microorganisms

What is medical asepsis?

Clean technique

What is surgical asepsis?

Sterile technique

What is isolation?

Separation to prevent spread

What is vector transmission?

Insects/animals spread disease

What do you do FIRST if patient has pain 10/10 and low oxygen?

Treat oxygen (ABCs first)

Patient refuses medication — what do you do?

Educate + respect refusal + document

Patient asks question you don’t know — what do you do?

Say you will find out

Patient is falling risk and wants to walk alone — what do you do?

Assist or educate, don’t allow unsafe action

What is priority: teaching or safety?

Safety