Ch. 8

Question 1

Nursing Process

Answer 1

a professional nurse approach to identify diagnosing, and treating human responses to health and illness( American Nurses association 03’)

Question 2

The Nursing process includes which 5 steps?

Answer 2

1. Assessment
2. Nursing diagnosis
3. planning
4. Implementation
5. Evaluation

Question 3

Assessment

Answer 3

is the deliberate and systematic collection of data about a patient.

Question 4

Nursing diagnosis

Answer 4

is a clinical judgment about individual. family or community responses to actual and potential health problems or life processes.

Question 5

Planning

Answer 5

set goals of care and desired outcomes and identify appropriate nursing actions

Question 6

implement

Answer 6

perform the nursing actions identified in planning

Question 7

Evaluate

Answer 7

determine if goals met and outcomes achieved.

Question 8

Cue

Answer 8

information that you obtain through use of senses.

Question 9

Inference

Answer 9

is your judgment or interpretation of those cues.

Question 10

Subjective data

Answer 10

patients verbal descriptions of health care problems.

Question 11

Objective data

Answer 11

are observations or measurements of a patient’s health status.

Question 12

Medical diagnosis

Answer 12

is the identification of a disease condition based on an evaluation of physical signs, symptoms, history, and diagnostic tests and procedures.

Question 13

A collaborative problem

Answer 13

is an actual or potential physiological complication that nurses monitor to detect the onset of changes in a patient’s status

Question 14

An interview consists of which 3 phases?

Answer 14

Orientation, working and termination.

Question 15

NANDA International 2009

Answer 15

The North American Nursing Diagnosis Association “To develop, refine, and promote a taxonomy (model) of nursing diagnostic terms of general use for professional nurses”.

Question 16

Data clusters

Answer 16

organizing and analysis of data collection and keeping in mind the patient’s response to illness.

Question 17

Data analysis

Answer 17

involves recognizing patterns or trends in the clustered data, comparing them with standards, and then coming to a reasoned conclusion about the patient’s response to a health problem.

Question 18

NANDA-I has identified 5 types of nursing diagnosis, what are they?

Answer 18

Actual 
Health promotion 
Risk 
Syndrome 
Wellness

Question 19

Name the 2 part form of the nursing diagnosis?

Answer 19

Diagnostic label

Related factor

Question 20

Diagnostic label

Answer 20

is the name of the nursing diagnosis within the NANDA-I taxonomy. It describes the essence of a patient’s response to health condition in as few words as possible.

Question 21

Related factor

Answer 21

a condition or etiologic factor that appears to show some type of patterned relationship with the nursing diagnosis.

Question 22

Etiology

Answer 22

is always within the domain of nursing practice and a condition that responds to nursing interventions.

Question 23

Definition

Answer 23

NANDA-I approves a definition for each diagnosis following clinical use and testing.

Question 24

Risk factors

Answer 24

environmental, physiological, genetic, or chemical elements that increase the vulnerability of an individual, family, or community, to an unhealthful event.

Question 25

Documentation

Answer 25

after identifying a patients nursing diagnosis, list them on the plan of care, whether this is in the form of computerized care plans or a problem list on the nursing kardex.

Question 26

Planning

Answer 26

involves setting priorities, identifying patient-centered goals and expected outcomes, and prescribing nursing interventions.

Question 27

Scientific rationale

Answer 27

support for why a specific nursing action is chosen.

Question 28

There are 3 categories of nursing interventions:

Answer 28

Nurse-initated.
physician initiated.
collaborative interventions.

Question 29

Nurse initiated

Answer 29

independent-nursing interventions that nurses initiate on their own to act on a patients behalf.

Question 30

Physician-initiated interventions

Answer 30

dependent nursing interventions or actions that require an order from a physician or another health care professional.

Question 31

Collaborative interventions/ interdependent interventions

Answer 31

are therapies that require the combined knowledge and skill, and expertise of multiple health care professionals.

Question 32

Interdisciplinary conferences

Answer 32

Bring professionals from all disciplines involved in the patient’s care to the table so that together they can establish and execute the most appropriate plan of care.

Question 33

When choosing interventions consider 6 factors:

Answer 33

1. characteristics
2. expected outcomes and goals.
3. evidence base
4. feasibility of the intervention
5. acceptability to the patient
6. your own competency.

Question 34

NIC

Answer 34

The Iowa intervention project developed a set of nursing interventions that provides a level of standardization to enhance communication of nursing care across all health care settings and to compare outcomes.

Question 35

Concept map

Answer 35

provides a visual reception of the complex level of thinking that nursing care requires.

Question 36

Critical pathway

Answer 36

Multidisciplinary, outcome-based care plan.

Question 37

Consultation

Answer 37

is a process in which you seek expertise of a specialist, such as your nursing instructor or a clinical nurse specialist, to identify ways to handle problems in patient care management or in the planning and implementation of therapies.

Question 38

Implementation

Answer 38

is the performance of nursing interventions necessary for achieving the goals and expected outcomes of nursing care.

Question 39

A nursing intervention

Answer 39

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

Question 40

Direct nursing interventions

Answer 40

are treatments performed through interactions with patients.

Question 41

Indirect care interventions

Answer 41

are treatments performed away from the patient but on behalf of the patient or group of patients. EX: delegation, environmental safety, infection control, documentation and collaboration.

Question 42

A clinical guideline

Answer 42

or protocol is a document that guides decisions and interactions for specific health care problems or conditions, such as treatment for a patient who has had a stroke or the administration of chemotherapy.

Question 43

Standing order

Answer 43

is a preprinted document containing orders for conduct of routine therapies, monitoring guidelines, and/or diagnostic procedures for specific patients with identified clinical problems.

Question 44

Cognitive skills

Answer 44

involve the application of critical thinking in the nursing process. EX:Recognizing the patients need for nutritional instruction.

Question 45

Interpersonal skills

Answer 45

effective for nursing action, develop a trusting relationship, express a level of caring and communicate clearly with patient and family. EX:Completing a health history. Providing emotional support for family.

Question 46

Psychomotor skills

Answer 46

requires the integration of cognitive and motor activities. EX:preparing and administering an injection. Changing a surgical dressing.