Term
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Definition
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Term
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Definition
| in in-patient setting, a handoff that occurs when a new shift starts |
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Term
| Charting By Exception (CBE) |
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Definition
| permits the nurse to document only those findings which fall outside the standards the nursing care and norms that have been developed by that institution |
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Term
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Definition
| way to guide the care of clients who have specific and generally predictable conditions |
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Term
| Computer Based Personal Reporting |
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Definition
| response to a federally initiated goal to have a single record for each citizen |
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Term
| Computer Based Personal Reporting |
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Definition
| response to a federally initiated goal to have a single record for each citizen |
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Term
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Definition
| When a specialist or health care member must give an expert opinion or specialized care for a client |
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Term
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Definition
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Term
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Definition
| designed to document routine nursing procedure and free nurses from writing out continuing processes repeatedly |
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Term
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Definition
| organizes data entry by (D) data (A)action and (R) response; system is broader in its view because a focus can be a problem area but does not have to be |
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Term
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Definition
| occurs anytime the responsibility for the care of a patient is transferred from one provider to another |
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Term
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Definition
| Health Insurance Portability and Accountability Act |
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Term
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Definition
| an unusual happening (i.e. fall, med error, equipment malfunction, etc.) |
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Term
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Definition
| a combinatio of coomputer science, information science, and nursing science designed to assist in the management and processing of nursing data, information and knowledge to support the practice of nursing and delivery of nursing care |
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Term
| Personal Helath Information (PHI) |
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Definition
| protected confidential information by HIPAA |
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Term
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Definition
| simplifies the documentation by incorporating the plan of care; stand for Problem (P), Intervention (I), and Evaluation (E) |
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Term
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Definition
| generated at admission and revised to reflect changes in client's condition; contains assessment data, nursing diagnosis, outcomes, nursing interventions, and evaluation criteria |
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Term
| Point of Care Documentation |
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Definition
| documentation that takes place as care occurs with the goal of promoting efficiency, accuracy, and timeliness |
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Term
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Definition
| reports are used to assess patterns of errors and the need to change the procedures involved |
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Term
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Definition
| takes place when two or more people share information about client care (i.e. face-to-face, voicemail, audio tape, etc.) |
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Term
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Definition
| Situation, Background, Asessment, Recommendation |
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Term
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Definition
| progress note that relates to only one health problem; stands for Subjective (S), Objective (O), Assessment (A), and Plan (P) |
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Term
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Definition
| occurs when the client does not proceed along the intended pathway |
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Term
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Definition
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Term
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Definition
| ongoing or constant physical or mental illness |
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Term
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Definition
| thinking and awareness, process by which sensory input, past experience, and emotions are integrated and made meaningful |
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Term
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Definition
| interchange of information |
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Term
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Definition
| Problem solving process a person uses to manage stress |
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Term
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Definition
| statistics dealing with the numbers and percentages of the population |
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Term
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Definition
| act of voiding or expelling waste from the bowels |
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Term
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Definition
| behaviors that a person in stable health uses to improve that state over time |
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Term
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Definition
| protection or exemption from an organism or disease |
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Term
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Definition
| states of contamination from disease-producing germs |
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Term
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Definition
| loss of important relationships or lack of company |
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Term
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Definition
| experience of parting with an object, person, belief, or relationship that one values and the sadness that follows; the loss requires a reorganization of one or more aspects of the person's life |
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Term
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Definition
| acts of movement such as walking driving, and exercise |
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Term
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Definition
| emotional state or outlook; disorders that are often unrecognized or misdiagnosed |
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Term
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Definition
| process by which living things take in and use food materials; study of diet |
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Term
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Definition
| Ability and strategy to deal with pain |
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Term
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Definition
| physical and emotional state of decreased muscle and cognitive activity |
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Term
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Definition
| expected function and behavior that define interaction with others |
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Term
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Definition
| a person's ability to perform primary care functions in the four areas of bathing, feeding, toileting, and dressing without the help of others |
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Term
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Definition
| a person's awareness or identification of self; the filtering process of evaluating events and entering them into the subconcious |
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Term
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Definition
| person's characteristics and perception's concerning sexual expression |
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Term
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Definition
| completeness or purity of the skin |
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Term
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Definition
| readily reversible state of altered consciousness in which awareness and responsiveness to the environment are decreased |
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Term
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Definition
| sacred or holy matters that belong to or related to god or church |
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Term
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Definition
| a group of symptoms that consistently occur together |
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Term
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Definition
| personal standards for decision making |
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Term
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Definition
| social grouop whose members may or may not share commmon geographic boundaries but who interact because of common interests or shared values to meet their needs within a larger society |
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Term
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Definition
| points in life when old responsibilities are discarded and new ones are assumed |
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Term
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Definition
| basic human unit; membership is based on mutual commitment, hereditary, or legal arrangements |
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Term
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Definition
| Output is rerouted back to the system as input |
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Term
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Definition
| way of viewing the world or an organization in which the parts are seen in relationship to the whole |
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Term
| Certified Registered Nurse Anesthetist |
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Definition
| professional with specialized education and skills in the administration of anesthesia anesthetic agents and in monitering clients during surgical and others procedures |
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Term
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Definition
| nurse who manages client care in an operating room environment and protects the client's safety and health needs |
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Term
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Definition
| agent used to induce complete loss of sensation and consciousness |
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Term
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Definition
| legal document giving permission for surgical or diagnostic procedure signed by client or legal guardian, before signing, the physician has explained all aspects of procedure and risks |
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Term
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Definition
| the time that starts when the patient is transfered to the operating room bed and ends when the patient is transferred to the postanesthetic area |
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Term
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Definition
| depresses superficial peripheral nerves and blocks conduction of pain impulses from their site or origin |
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Term
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Definition
| Severe body temperature elevation after administration of certain anesthetics |
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Term
| Moderate dedation/analgesia |
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Definition
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Term
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Definition
| condition in which the bowel is temporarily paralyzed and distention occurs |
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Term
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Definition
| designated area in the hospital or ambulatory care facility where immediate postoperative care is provided |
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Term
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Definition
| phase that begins with the transfer to the surgical recovery area and ends with recovery |
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Term
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Definition
| area where the client remains until entering the operating room |
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Term
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Definition
| Phase that begins with the decision to have surgery and ends with the transfer to the operating room bed |
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Term
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Definition
| agent used to induce loss of sensation in a selected body area |
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Term
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Definition
| wears a sterile gown, mask, headgear, gloves, disposable shoe covers, and eye protection and provides the surgeon with the required instruments, sponges, drains, and other equipment, anticipating what will be needed throughout surgery |
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Term
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Definition
| type of wound healing device made of stainless steel that decreases the risk of infection and reduces tissue handlings because they allow for faster wound closure |
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Term
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Definition
| material used to stitch the ends of traumatic or surgical wounds |
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Term
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Definition
| lack of oxygen, leading to cell death |
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Term
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Definition
| injuries caused by exposure to thermal, chemical, electrical, or radioactive energy |
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Term
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Definition
| interruption of the body functions due to electric current |
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Term
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Definition
| collapse, dropping down, or toppling |
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Term
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Definition
| to connect electricity between an electrical conductor and the ground or earth |
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Term
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Definition
| Infection acquired during the receipt of healthcare |
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Term
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Definition
| ingesting, inhaling, or absorbing potentially hazardous substances |
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Term
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Definition
| substances in the air, water, or land that are potentially hazardous to health |
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Term
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Definition
| device that prevents a client from moving or gaining mobility |
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Term
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Definition
| safety error in which hospitals are required to report serious safety events to regulatory agencies and state health agencies |
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Term
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Definition
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Term
| Disease Prevention Activites |
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Definition
| avoidance behaviors that seek to prevent specific diseases or conditions |
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Term
| Health-Maintenance Activities |
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Definition
| Behaviors that a person in stable health uses to maintain or improve that state over time |
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Term
| Health Promotion Activites |
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Definition
| health behaviors that enhance a person's level of health |
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Term
| Health-protection activities |
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Definition
| environmental or regulatory measures that seek to protect the health of a community or large population |
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Term
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Definition
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Term
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Definition
| equipment that measures vascular volume |
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Term
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Definition
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Term
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Definition
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Term
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Definition
| portable chair with a toilet seat and a waste receptacle beneath that can be emptied so a client who cannot walk to the bathroom can manage toileting |
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Term
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Definition
| noninvasive urinary collection device for incontinent males that consists of a thin, flexible sheath placed over the penis and attached to tubing and a collection bag |
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Term
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Definition
| difficulty or painful swallowing |
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Term
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Definition
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Term
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Definition
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Term
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Definition
| observance of health rules as related to self-care activites (feeding, bathing, dressing, toileting) |
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Term
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Definition
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Term
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Definition
| a condition in which vascular fibrous tissue extends over an organ or other specialized structure (i.e. cornea) |
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Term
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Definition
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Term
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Definition
| substance that forms and hardens on the teeth and is mainly composed of bacteria and saliva |
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Term
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Definition
| awareness of the position and movement of body parts in space, sensed by sensory nerve terminals in the muscles, tendons, and the labyrinth of the inner ear |
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Term
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Definition
| plaque that remains on the and hardens on the teeth that cannot be removed by simple brushing |
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Term
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Definition
| metal or plastic receptacle that the penis can be placed to facilitate urinating without spilling |
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Term
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Definition
| physical inability to withstand activity |
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Term
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Definition
| exercise that requires the use of oxygen for energy and involves elevation of the heart beat for an extended period of time |
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Term
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Definition
| direct visualization of a joint by insertion of a scope |
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Term
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Definition
| Wasting away of an organ, muscle, or body tissue |
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Term
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Definition
| positioning or moveming the body to prevent or correct problems related to activity or immobilization |
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Term
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Definition
| shortening of a muscle and loss of joint mobility from fibrotic changes in the tissue surrounding the joint |
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Term
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Definition
| preliminary step to ambulation, especially for clients who may be unable to ambulate initially, which involves sitting at the side of a bed with the legs dependent |
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Term
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Definition
| preliminary step to ambulation, especially for clients who may be unable to ambulate initially, which involves sitting at the side of a bed with the legs dependent |
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Term
| Deep Vein Thrombosis (DVT) |
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Definition
| a thrombosis originating in the large veins of the legs because of the relatively low velocity of the blood flow there |
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Term
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Definition
| without muscle tone or resistance; decreased muscle tone |
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Term
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Definition
| Temporary of permanent plantar flexion due to weakness or paralysis |
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Term
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Definition
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Term
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Definition
| exercise involving muscle contraction without a change in muscle length (usually against resistance) |
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Term
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Definition
| dynamic form of exercise in which there is constant muscle tension, muscle contraction, and active movement |
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Term
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Definition
| Extent to which a person can move joints and muscle |
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Term
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Definition
| sudden, involuntary muscle tone or contractions due to CNS lesions |
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Term
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Definition
| spherical, saclike, epithelial structures in the lungs through which gas exchange occurs |
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Term
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Definition
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Term
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Definition
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Term
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Definition
| Narrow airways that conduct air into aveolar ducts and aveoli |
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Term
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Definition
| Narrowing of the bronchioles caused by tightening of the smooth muscles in the airway |
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Term
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Definition
| grayish, bluish, or purplish skin tone |
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Term
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Definition
| movement of molecules from an area of higher concentration to an area of lower concentration |
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Term
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Definition
| Breathing that requires marked effort |
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Term
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Definition
| breathing in excess of metabolic demands, resulting in removal of too much Carbon Dioxide from the blood; indicated by PaCO2 |
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Term
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Definition
| decreased amount of oxygen available for tissues |
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Term
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Definition
| amount of oxygen in the blood |
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Term
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Definition
| noninvasive means for approximating oxygenation that uses light and a sensor attached to the client's finger or earlobe to determine the percentage of hemoglobin that has combined with oxygen |
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Term
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Definition
| exchange in carbon dioxide for oxygen in lungs and tissues |
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Term
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Definition
| permanent or temporary opening into the trachea though the neck |
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Term
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Definition
| movement of air in and out of the lungs; breathing |
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Term
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Definition
| pain and discomfort felt about the heart, characterstic of myocardial ischemia; severe pain felt in anterior chest, shoulder, left arm, neck, and jaw |
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Term
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Definition
| heart's capability of generating its own electrical impulse, wich is then conducting through specialized conduction fibers |
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Term
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Definition
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Term
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Definition
| period of rest in the cardiac cycle, when the ventricles are not contracting and the coronary arteries are filling with blood |
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Term
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Definition
| abnormality in the heart's rhythm |
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Term
| Intermittent Claudication |
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Definition
| limb pain caused by poor blood flow |
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Term
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Definition
| insufficient blood supply to a body part due to obstruction of circulation |
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Term
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Definition
| hypoxicity of heart muscle and death of portions of the heart muscle from decreased blood flow through the coronary artery |
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Term
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Definition
| layer of cardiac muscle that forms the walls of the heart |
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Term
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Definition
| passing of blood through an area |
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Term
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Definition
| severe circulatory insufficiency |
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Term
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Definition
| cerebrovascular accident (CVA); involves a sudden onset of hemorrhage, blood clots, or other vascular lesions causing damage to the brain |
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Term
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Definition
| period of contraction of the ventricles |
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Term
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Definition
| Blood clot in the blood vessel |
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Term
| Transient Ischemic Attack |
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Definition
| temporary cerebral ischemia due to transient interruption in blood supply |
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Term
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Definition
| the process by which a medication enters the bloodstream |
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Term
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Definition
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Term
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Definition
| eating disorder in which the person refuses to eat from fear of becoming overweight even with normal or less than ideal body weight |
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Term
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Definition
| amount of energy the body uses during absolute rest in an awake state |
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Term
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Definition
| unit of heat, commonly used to describe energy value of food |
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Term
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Definition
| food grouop containing simple and complex sugars containg carbon, hydrogen, and oxygen |
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Term
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Definition
| protein that contains sufficient amount of essential amino acids to maintain body tissue and promote body growth |
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Term
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Definition
| mechanical and chemical processes necessary to convert food to an absorbable state |
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Term
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Definition
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Term
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Definition
| lipid organic substances composed of carbon hydrogen and oxygen |
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Term
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Definition
| component of food that adds bulk to the diet and is not digested |
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Term
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Definition
| anabolic process or glycogen storage; formation of glycogen from glucose |
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Term
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Definition
| protein that does not contain enough amino acids to independently maintain life, build tissue, and promote growth |
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Term
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Definition
| chemical reaction in the cells that produce heat as a byproduct; breakdown of drug (usually by liver) to an inactive form |
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Term
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Definition
| simple sugars monounsaturated fatty acids (MUFA); "unsaturated" double bond that forms between two side-by-side carbon atoms when an unsaturated fat has a single hydrogen atom missing from each of two carbon atoms |
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Term
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Definition
| food containing elements for normal body functioning |
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Term
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Definition
| more than 20% over ideal body weight |
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Term
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Definition
| body mass index (BMI) between 25 and 29.9 kg/m2 |
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Term
| Partially Complete Proteins |
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Definition
| proteins that contain sufficient amounts of essential amino acids to maintain life but not promote growth |
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Term
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Definition
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Term
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Definition
| organic compound composed of polymers of amino acids connected by peptide bonds |
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Term
| Polyunsaturated fatty acids (PUFA) |
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Definition
| two or more carbon to carbon double bonds when an unsaturated fat has a single hydrogen missing from each of the two carbon atoms |
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Term
|
Definition
| chemically, two hydrogen atoms attached to each of the two carbon atoms |
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Term
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Definition
| unsaturated fat molecules with an unusual configuration around the double carbon bonds |
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Term
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Definition
| Subgroup of minerals in small amounts found in food |
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Term
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Definition
| fat with a single hydrogem atom missing from each of two side by side carbon atoms |
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Term
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Definition
| organic compounds that do not supply energy but are necessary to the body in small amounts for growth, development, maintenance, and reproduction |
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Term
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Definition
| problems with word retrieval |
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Term
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Definition
| communication defect that may affect speach, reading, and writing |
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Term
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Definition
| enunciation of words and sentences |
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Term
|
Definition
| ability to concentrate on and take in specfic sensory stimuli |
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Term
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Definition
| thinking and awareness; system by which sensory input, past experiences, and emotions are integrated and made meaningful |
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Term
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Definition
| abnormally deep stupor occuring in illness or as a result of injury; external stimuli fail to arouse the client |
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Term
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Definition
| capacity for understanding and reasoning |
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Term
|
Definition
| state of awareness and full responsiveness to stimuli |
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Term
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Definition
| reversible disorder of cognition; confusion |
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Term
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Definition
| belief that is not based in reality and reflects an unconscious need or fear |
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Term
|
Definition
| cognitive impairment as a result of organic changes in brain cell function |
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Term
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Definition
| disorders affecting either single or combined motor control of the muscles of speech |
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Term
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Definition
| false sensory perception; seeing, hearing, tasting, smelling, feeling, objects that are not there |
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Term
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Definition
| process of reasoning; ability to process incoming stimuli and to determine meanings that encompass many aspects of the situation |
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Term
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Definition
| multidimensional process of acquiring knowledge that depends on symbols, language, classifications, concepts, and other concrete operations along with abstract functions |
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Term
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Definition
| ability to recall a thought at least once and usually again |
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Term
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Definition
| process of retrieving and interpreting sensory stimuli that function as a basis for understanding, knowing, or learning |
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Term
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Definition
| process by which humans create vocal sounds |
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Term
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Definition
| nursing technique to help restore the client's awareness of reality |
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Term
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Definition
| echoing of sounds through passages |
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Term
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Definition
| serious, persistent brain disease that is characterized by distortion of reality and difficulty processing information |
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Term
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Definition
| state of disorientation and agitation that occurs at night in institutionalized clients that are oriented during the day |
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Term
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Definition
| feelings about one's body |
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Term
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Definition
| awareness of self as separate and distinct from others |
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Term
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Definition
| Expected Behavior and Function |
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Term
|
Definition
| occurs when the person lack's knowledge of role expectations and fosters anxiety and confusion |
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Term
|
Definition
| occurs when a person's expectations concerning his or her role differ from reality |
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Term
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Definition
| occurs when the person perceives himself or herself as inadequate or unsuited for a role |
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Term
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Definition
| a person's unique dimensions, potentials, and purposes |
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Term
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Definition
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Term
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Definition
| evaluation and judment of one's worth |
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Term
|
Definition
| conscious assessment of the self |
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Term
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Definition
| the self a person wants to be |
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Term
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Definition
| Basic understanding of oneself |
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Term
|
Definition
| a person's awareness or identification of self; the filtering process of evaluating events and entering them into the subconscious |
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Term
|
Definition
| one's behavior and interaction with others in social situations |
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