Chapter 5 Fundamentals

Question 0

Data

Answer 0

Specific pieces of information on a specific topic

Question 1

Cues

Answer 1

Are pieces of data or information that influence decisions

Question 2

Database

Answer 2

All the information gathered about a patient and documented.

Question 3

Defining characteristics

Answer 3

Are those characteristics (signs and symptoms) that must be present for particular nursing diagnosis to be appropriate for that patient.

Question 4

Etiologic factors

Answer 4

Are the causes of the problem. Ex. Mrs. Torres case etiologic factor for her decreased mobility is neurological impairment.

Question 5

Expected outcome

Answer 5

Is a specific statement regarding the goal the patient is expected to achieve as a result of nursing intervention.

Question 6

Goal

Answer 6

Is a broad idea of what is to be achieved through nursing intervention

Question 7

Inferences

Answer 7

Conclusions made based on observed data

Question 8

Interview

Answer 8

Conversation in which facts are obtained

Question 9

Nursing diagnosis

Answer 9

Statement indicates the patient’s actual health status or the risk of a problem developing the causative or related factors and specific defining characteristics (signs and symptoms)

Question 10

Objective data

Answer 10

Information obtained through the senses and hands on physical examination is objective data

Question 11

Signs

Answer 11

Our abnormalities that can be verified by repeat examination and our objective data.

Question 12

Subjective data

Answer 12

Data obtained from the patient verbally. Cannot be verified by nurse

Question 13

Symptoms

Answer 13

Are factors the patient has said are occurring they cannot be verified by examination. symptoms are subjective data

Question 14

When should nursing care plan begin to be documented?

Answer 14

Should be documented in the medical records soon after the admissions assessment.