CH 4: Nursing Process: Critical thinking, Decision making and Clinical Judgment

Question 1

objective data

Answer 1

data that can be assessed through senses

Question 2

primary data

Answer 2

data provided by the patient

Question 3

secondary data

Answer 3

data obtained from a source than the patient

Question 4

subjective data

Answer 4

symptoms knowable only by the patient

Question 5

care plan

Answer 5

a documented strategy that includes the health-care provider’s orders, nursing diagnosis, and nursing order

Question 6

critical thinking

Answer 6

skillful reasoning and logic thought to determine the merits of a belief or action

Question 7

to avoid making decisions based on assumptions, nurses must do what to the information they obtain?

Answer 7

validate

Question 8

nursing process

Answer 8

overlapping, 5 step method for decision making

Question 9

rapport

Answer 9

creating a relationship of mutual trust

Question 10

Assessment

Answer 10

gathering information through signs & symptoms, patient history, & subjective objective findings
- interview (asking questions)
- performing a focused body system assessment to determine deviations from normal
- reviewing laboratory and diagnostic tests

Question 11

techniques nurses use to gather data about patient’s body

Answer 11

• inspection: visual examination of the patient’s body for rashes; breaks in the skin
• palpation: touching or feeling the torso & limbs for pulses, abnormal lumps; temp
• auscultation: listening for abnormal sounds in the lungs, heart, or bowels
• percussion: using tapping movements to detect abnormalities of the internal organs

Question 12

Diagnosis

Answer 12

formulation of nursing diagnoses through an analysis of the assessment information you have gathered.

Question 13

nursing diagnosis

Answer 13

concise statement of a problem that the patient is experiencing as a result of the patient’s medical diagnoses
- are selected based on definitions and defining characteristics
- FOCUS ON PATIENT’S NEEDS

Question 14

defining characteristics

Answer 14

signs & symptoms experienced by the patient that directly influence the nursing diagnosis

Question 15

Planning

Answer 15

process of determining priorities and what nursing actions should be performed to help resolve or manage each patient problem
- nurse determines expected outcomes for patient to meet for the nursing diagnosis to be resolved

Question 16

Implementation (interventions)

Answer 16

process of taking actions to resolve the patient’s problem

Question 17

Evaluation

Answer 17

performed when the nurse reflects on the interventions performed and decides whether the patient is now closer to achieving goals and outcomes set in the planning step

Question 18

What are the LPN/LVN responsibilities mostly in the nursing process?

Answer 18

participates mostly in the remaining steps of planning, intervention, and evaluation
- does not mean that LVN cannot perform assessment skills, but shared and sometimes confirmed with RN

Question 19

What are the responsibilities of the RN in the nursing process?

Answer 19

from assessment through evaluation and includes outcome identification

Question 20

What can LVNs not delegate?

Answer 20

nursing decisions & care planning

Question 21

Can nurses examine laboratory and diagnostic tests?

Answer 21

yes, although health-care providers will review the results, the nurses are able to examine them as well

Question 22

Physicians, physician assistants and nurse practitioners all focus on medical diagnoses based on what?

Answer 22

signs, symptoms, laboratory findings, and test results

Question 23

Maslow’s Hierarchy: physiological needs

Answer 23

food, air, water, temperature regulation, elimination, rest, sex, and physical activity

Question 24

Maslow’s Hierarchy: safety and security

Answer 24

protection, emotional and physical safety and security, order, law, stability, shelter

Question 25

Maslow’s Hierarchy: love and belonging

Answer 25

giving and receiving affection, meaningful relationships, belonging to group(s)

Question 26

Maslow’s Hierarchy: self-esteem

Answer 26

pride, sense of accomplishment, recognition by others

Question 27

Maslow’s Hierarchy: cognitive

Answer 27

knowledge, understanding, exploration

Question 28

Maslow’s Hierarchy: aesthetic

Answer 28

symmetry, order, beauty

Question 29

Maslow’s Hierarchy: self-actualization

Answer 29

personal growth, reaching potential

Question 30

Maslow’s Hierarchy: transcendence

Answer 30

of self; helping others self-actualize

Question 31

According to Abraham Maslow (American psychologist) what needs to be met before the higher steps can be addressed?

Answer 31

their physiological needs
- nurses must address physiological needs of survival first with their patients and then the needs related to relationship issues in the love and belonging tier

Question 32

physical assessment: inspection

Answer 32

visual examination of patient’s body for rashes; breaks in skin; & normal appearance of eyes, ears
- ex: purplish marks on her arm where the bandage for her IV line had been, skin is torn

Question 33

physical assessment: palpation

Answer 33

touching or feeling the torso & limbs for pulses, abnormal lumps
- ex: you document that the patient’s pedal pulses are absent

Question 34

physical assessment: auscultation

Answer 34

listening for abnormal sounds in the lungs, heart, or bowels
- to assess bowel sounds

Question 35

physical assessment: percussion

Answer 35

using tapping movements to detect abnormalities of internal organs
- ex: NP places places hand on woman’s back and then taps her own middle finger on her other hand

Question 36

PES statements

Answer 36

• problem: diagnostic concept/label based on patient’s needs
• etiology: causative factor(s) & is connected to diagnostic label by words “related to”
• signs & symptoms: data collected & evidence used to to support diagnostic label - linked to “as evidenced by”

Question 37

North American Nursing Diagnosis Association (NANDA-I lists)

Answer 37

responsible for creating & maintaining approved list of nursing diagnoses to be used

Question 38

What are nursing goals?

Answer 38

overall direction in which one must progress to improve a problem

Question 39

long term goals

Answer 39

not expected to be met before the patient is discharged from the hospital - ongoing process of improvement/gradual change

Question 40

short term goals

Answer 40

expected to be met by the time of discharge/transfer to another level of care

Question 41

expected outcome

Answer 41

statements of measurable action for patient within a specific time frame and in response to nursing interventions