Chapter 9: Nursing Process; Key Terms

Question 1

Assessment

Answer 1

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

Question 2

Back-Channeling

Answer 2

Active listening technique that prompts a respondent to continue telling a story or describing a situation.

Question 3

Clinical Practice Guideline

Answer 3

A protocol is a systematically developed set of statements that helps nurses and other health care providers make decision about appropriate health care for specific clinical situations

Question 4

Closed-Ended Question

Answer 4

A form of question that limits a respondent’s answer to one or two words

Question 5

Collaborative Interventions

Answer 5

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

Question 6

Collaborative Problem

Answer 6

Physiological complication that require the nurse to use nursing-prescribed and physician-prescribed interventions to maximize patient outcomes

Question 7

Concept Map

Answer 7

A care-planning tool that assists in critical thinking and forming associations between a patient’s nursing diagnoses and interventions

Question 8

Consultation

Answer 8

Process in which the help of a specialist is sought to identify ways to handle problems in patient management or in the planning and implementing of programs

Question 9

Counseling

Answer 9

A problem-solving method used to help patients recognize and manage stress and to enhance interpersonal relationships; helps patients examine alternatives and decide which choices are most helpful and appropriate

Question 10

Critical Pathways

Answer 10

Tools used in managed care that incorporate the treatment interventions of care givers 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 11

Cue

Answer 11

Information that a nurse acquires through hearing, visual observations, touch, and smell

Question 12

Data Analysis

Answer 12

Logical examination of a professional judgment about patient assessment data, used in the diagnostic process to derive a nursing diagnosis

Question 13

Data Cluster

Answer 13

A set of signs or symptoms that are grouped together in logical order

Question 14

Database

Answer 14

Store or bank of information, especially in a form that can be processed by computer

Question 15

Defining Characteristics

Answer 15

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

Question 16

Dependent Nursing Interventions

Answer 16

Actions that require an order from a physician or another health care professional

Question 17

Direct Care Interventions

Answer 17

Treatments performed through interaction with the patient. A patient my require medication administration, insertion, of an intravenous infusion, or counseling during a time of grief

Question 18

Etiology

Answer 18

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

Question 19

Evaluation

Answer 19

Determination of the extent to which established patient goals have been achieved

Question 20

Expected Outcome

Answer 20

Expected conditions of a patient at the end of therapy or of a disease process, including the degree of wellness and the need for continuing care, medications, support, counseling, or education

Question 21

Functional Health Patterns

Answer 21

Methods for organizing assessment data based on the level of patient function in specific areas, for example, mobility

Question 22

Goal

Answer 22

Desired results of nursing actions, set realistically by the nurse and patient as part of the planning stage of the nursing process

Question 23

Health History

Answer 23

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

Question 24

Implementation

Answer 24

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

Question 25

Independent Nursing Intervention

Answer 25

Actions that nurses initiate; do not require direction or an order from another health care professional

Question 26

Indirect Care Interventions

Answer 26

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

Question 27

Inference

Answer 27

A judgement or interpretation of informational cues

Taking one proposition as a given and guessing that another proposition follows

Question 28

Instrumental Activities of Daily Living (IADLS)

Answer 28

Activities that are necessary to be independent in society beyond eating, grooming, transferring, and toileting, and include such skills as shopping, preparing meals, banking, and taking medications

Question 29

Interdisciplinary Care Plans

Answer 29

Contributions from all disciplines involved in patient care, it improves the coordination of all patient therapies

Question 30

Medical Diagnosis

Answer 30

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

Question 31

NANDA International (NANDA-I)

Answer 31

North American Nursing Diagnosis Association organized in 1973, which formally identifies, develops, and classifies nursing diagnoses

Question 32

Nursing Diagnosis

Answer 32

Formal statement of an actual or potential health problem that nurses can legally and independently treat. The second step of the nursing process, during which the patient;s actual and potential unhealthy responses to an illness or condition are identified

Question 33

Nursing Diagnostic Process

Answer 33

Flows from the assessment process and includes data clustering, interpreting, and analyzing, identifying patient needs, and formulating the nursing diagnosis or collaborative problem

Question 34

Nursing Intervention

Answer 34

Any treatment, based upon clinical judgment and knowledge, that a nurse performs to enhance patient outcomes

Question 35

Nursing Process

Answer 35

Systematic problem-solving method by which nurses individualize care for each patient. The 5 steps of the nursing process are; assessment, diagnosis, planning, implementation, and evaluation

Question 36

Nursing-Sensitive Outcome

Answer 36

Outcomes that are within the scope of nursing practice; consequences or effects of nursing interventions that result in changes in the patient;s symptoms, functional status, safety, psychological distress or costs

Question 37

Objective Data

Answer 37

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

Question 38

Open-Ended Questions

Answer 38

A form of question that prompts a respondent to answer in more than one or two words

Question 39

Planning

Answer 39

Process of deigning interventions to achieve the goals and outcomes of health care delivery

Question 40

Related Factor

Answer 40

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

Question 41

Scientific Rationale

Answer 41

Reason, based on supporting literature, why a specific nursing action was chosen

Question 42

Standard of Care

Answer 42

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

Question 43

Standing Order

Answer 43

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

Question 44

Subjective Data

Answer 44

Information gathered from patient statements; the patient;s feelings and perceptions. Not verifiable by another except by inference

Question 45

Validation

Answer 45

Act of confirming, verifying, or corroborating the accuracy of assessment data or the appropriateness of the care plan