Chapter 2 Nursing Process Key Terms

Question 1

Assessment

Answer 1

It is the systematic collection of facts or data.

Question 2

Collaborative problems

Answer 2

Are there potential complications from a disorder, test, or treatment that the nurse cannot treat independently, such as bleeding? They represent an interdependent domain of nursing practice.

Question 3

Concept Mapping

Answer 3

Also known as care mapping, it is a method of organizing information in graphic or pictorial form. It is created by identifying a main subject with interconnected links to related components.

Question 4

Critical Thinking

Answer 4

Which is a process of objective reasoning or analyzing facts to reach a valid conclusion.

Question 5

Database or Initial Assessment

Answer 5

Initial information about the client’s physical, emotional, social, and spiritual health.

Question 6

Diagnosis

Answer 6

It is the identification of health-related problems.

Question 7

Evaluation

Answer 7

It is how nurses determine whether a client has reached a goal.

Question 8

Focus Assessmsnt

Answer 8

It is information that provides more details about specific problems and expands the original database.

Question 9

Functional Assessment

Answer 9

is a comprehensive evaluation of a client’s physical strengths and weaknesses in areas such as;
(1) the performance of activities of daily living;
(2) cognitive abilities;
(3) social functioning.

Question 10

Goals

Answer 10

Identify specific evidence for each nursing diagnosis that a client’s problem is trending toward resolution or has been resolved.

Question 11

Health Promotion Diagnosis

Answer 11

A concern with which a healthy person desires nursing assistance to maintain or achieve a higher level of wellness.

Question 12

Implementation

Answer 12

This means carrying out the plan of care.

Question 13

Long term Goals

Answer 13

These outcomes take weeks or months to accomplish for clients with chronic health problems who require extended care in a nursing home or who receive community health or home health services.

Question 14

NANDA International

Answer 14

It is the authoritative organization for developing and approving nursing diagnoses.

Question 15

Nursing Care Plans

Answer 15

Written assignments on standardized worksheets contain a column for nursing diagnoses, outcome criteria, nursing interventions, and the rationale for each intervention for each assigned client.

Question 16

Nursing Diagnosis

Answer 16

A health issue that can be prevented, reduced, resolved, or enhanced through independent nursing measures.

Question 17

Nursing Orders

Answer 17

Directions for a client’s care within a nursing care plan: identify the what, when, where, and how of performing nursing interventions.

Question 18

Nursing Process

Answer 18

It is an organized sequence of problem-solving steps used to identify and manage clients’ health problems.

Question 19

Objective Data

Answer 19

Observable and measurable facts.

Question 20

Outcome Criteria

Answer 20

Sometimes called goals, identify specific evidence for each nursing diagnosis that a client’s problem is trending toward resolution or has been resolved.

Question 21

Planning

Answer 21

The process of prioritizing nursing diagnoses and collaborative problems, identifying measurable expected outcomes, selecting appropriate interventions, and documenting the plan of care.

Question 22

Problem Focus Diagnosis

Answer 22

A problem that currently exists.

Question 23

Risk Diagnosis

Answer 23

A problem the client is uniquely at risk of developing.

Question 24

Short Term Goals

Answer 24

Outcomes are achievable in a few days to 1 week more often in acute care settings because most hospital stays are only a few days or no longer than one week.

Question 25

Signs

Answer 25

An example is a client’s blood pressure measurement.

Question 26

Standards of Care

Answer 26

Policies that indicate which activities will be provided to ensure quality client care and clinical pathways relieve the nurse from writing time-consuming plans.

Question 27

Subjective Data

Answer 27

Information that only the client feels and can describe.

Question 28

Symptoms

Answer 28

an example is pain.

Question 29

Syndrome Diagnosis

Answer 29

A cluster of problems related to an event or situation that can be managed together.

Question 30

The Joint Commission

Answer 30

A not-for-profit organization accrediting health care organizations in the United States requires that every client’s medical record provides evidence of the planned interventions for meeting the individualized client’s needs, but not necessarily a nursing plan of care.