CH 16-20

Question 1

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| Assessment</p>

Answer 1

<p>
first step of the nursing process. Activities required in the first step are data collection, validation, sorting, and documentation. The purpose is to gather information for health problem identification</p>

Question 2

Nursing health history

Answer 2

Data collected about a patient’s present level of wellness, changes in life patterns, sociocultural role, and mental and emotional reactions to illness

Question 3

Nursing process

Answer 3

systematic problem-solving method by which nurses individualize care for each patient. ADPIE

Question 4

Objective data

Answer 4

Information that can be observed by others; free of feelings, perceptions, prejudices

Question 5

Standards

Answer 5

actions that ensure safe nursing practice

Question 6

Subjective data

Answer 6

information gathered from patient statements; the patient’s feelings and perceptions. Not verfiable by another except by inference

Question 7

Nursing diagnosis

Answer 7

judgement that is clinically validated by the presence of major defining characteristics

Question 8

Client-centered problems

Answer 8

problems involving the client

Question 9

Defining characteristics

Answer 9

Related signs and symptoms or clusters of data that support the nursing diagnosis

Question 10

Diagnostic label

Answer 10

the name of the nursing diagnosis

Question 11

Etiology

Answer 11

study of all factors that may be involved in the development of a disease

Question 12

Medical diagnosis

Answer 12

formal statement of the disease entity or illness made by the physician or health care provider

Question 13

NANDA International

Answer 13

North American Nursing Diagnosis Association International

Question 14

Related factor

Answer 14

any condition or event that accompanies or is linked with the patient’s health care problem

Question 15

Risk for nursing diagnosis

Answer 15

Describes human responses to health conditions/life processes that may develop in a vulnerable individual, family, or community

Question 16

Client-centered goal

Answer 16

reflects a patient’s highest possible level of wellness and independence in function

Question 17

Collaborative intervention

Answer 17

Therapies that require the knowledge, skill, and expertise of multiple health care professionals

Question 18

Critical pathway

Answer 18

tools used in managed care that incorporate the treatment interventions of caregivers from all disciplines who normally care for a patient. Designed for a specific care type, a pathway is used to manage the care of a patient throughout a projected length of stay

Question 19

Dependent nursing intervention

Answer 19

aka physician-initiated interventions

Question 20

Expected outcome

Answer 20

measurable criterion to evaluate goal achievement

Question 21

Independent nursing intervention

Answer 21

aka nurse-initiated interventions or actions that a nurse initiates

Question 22

Kardex

Answer 22

trade name for card-filing system that allows quick reference to the particular need of the patient for certain aspects of nursing care

Question 23

Long-term goal

Answer 23

objective behavior or response that you expect to achieve over a longer period, usually over several days, weeks, or months

Question 24

Nursing care plan

Answer 24

a guideline for for coordinating nursing care

Question 25

Priority setting

Answer 25

ordering of nursing diagnoses or patient problems using determinations of urgency and/or importance to establish a preferential order for nursing actions

Question 26

Clinical guideline

Answer 26

a systematically developed set of statements that helps nurses, physicians, and other health care providers make decisions about appropriate health care for specific clinical situations

Question 27

Direct care

Answer 27

treatments performed through interactions with patients

Question 28

Indirect care

Answer 28

treatments performed away from the patient but on behalf of the patient or group of patients

Question 29

Implementation

Answer 29

initiation and completion of the nursing actions necessary to help the patient achieve health care goals

Question 30

Interdisciplinary care plan

Answer 30

plans representing the contributions of all disciplines caring for a patient

Question 31

Nursing intervention

Answer 31

any treatment based on clinical judgement and knowledge that a nurse performs to enhance patient outcomes

Question 32

Standing order

Answer 32

written and approved documents containing rules, policies, procedures, regulations, and orders for the conduct of patient care in various stipulated clinical settings

Question 33

Outcome

Answer 33

an end result that is measurable, desirable, and observable and translates into observable patient behaviors

Question 34

Outcome management

Answer 34

making sure that the proper steps are taken to ensure the outcome

Question 35

Performance improvement

Answer 35

an organization analyzes and evaluates current performance and uses the results to develop focused improvements actions

Question 36

Quality improvement

Answer 36

an approach to the continuous study and improvement for the processes of providing health care services to meet the needs of patients and others and inform health care policy

Question 37

Standard of care

Answer 37

minimum level of care accepted to ensure high-quality care to patients. standards of care define the types of therapies typically administered to patients with defined problems or needs