Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Fundamentals 2 > Chapters 14 & 16 > Flashcards

Chapters 14 & 16 Flashcards

1
Q

describes the responses to health conditions or life processes that exist in an individual, family or community

A

Actual Nursing Diagnosis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

the collection of data pertinent to the patient’s health status or situation

A

Assessment

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

a condition or ethology identified from the patient’s assessment data. It is associated with the patient’s actual or potential response to the health problem and can be changed through the use of nursing interventions. 


A

Related Factor

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

objective or subjective signs and symptoms, clusters of signs and symptoms, or risk factors that lead to a diagnostic conclusion

A

Clinical Criteria

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

patients’ verbal descriptions of their health concerns

A

Subjective Data

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

describes levels of wellness in an individual, family, or community that can be enhanced. A clinical judgement. Transition from a specific level to a higher level

A

Wellness Nursing Diagnosis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

systematic methods for collecting data on all body systems

A

Review of Systems

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

describes human response to health conditions or life processes that will possibly develop into a vulnerable individual, family or community

A

Risk Nursing Diagnosis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

an objective behaviour or response that a patient is expected to achieve in a short time, usually less than a week

A

Short Term Goal

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

level of quality or attainment

A

Standards

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

can be answered stating yes or no

A

Closed-Ended Questions

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

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

A

Collaborative Problem

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

a visual representation that show the connection between a patient’s health problems

A

Concept Map

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

involves seeking the expertise of a specialist, such as a nurse educator, registered nurse, or a clinical nurse specialist, to identify ways of approaching and managing the planning and implementation of therapies

A

Consultation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

inter professional treatment plans that outline the treatments or interventions that patients may require for treatment of a condition

A

Critical Pathways

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

information that a nurse obtains through use of the senses (e.g. crying)

A

Cue

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

another name for a condition

A

Etiology

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

the identification of the nature of an illness or other problem by examination of the symptoms

A

Diagnosis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

describes the essence of a patient’s response to health conditions in as few words as possible

A

Diagnostic Label

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

assessing the patient’s response to the selected intervention to determine whether the intervention was effective

A

Evaluation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

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

A

Data Analysis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

an organized collection of structured information, or data, typically stored electronically in a computer system

A

Database

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

the clinical criteria or assessment findings that help confirm an actual nursing diagnosis

A

Defining Characteristics

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

specific patient behaviours or physiological responses that nurses set to achieve through nursing diagnosis or collaborative problem resolution

A

Expected Outcomes

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

also known as expected outcomes

A

Goals

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

care and support plans are developed with the person

A

Person-Centred Plan of Care

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

a clinical judgement of a person’s, family’s or community’s motivation and desire to increase well-being and actualize human health potential, as expressed in their readiness to enhance specific health behaviours, such as those related to nutrition and exercise

A

Health Promotion Nursing Diagnosis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

carrying out a plan

A

Implementation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

a specific and measurable behavioural response that reflects a patient’s highest possible level of wellness and independence in function

A

Person-Centred Goal

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

involves the creation of a formal plan that prescribes strategies and alternatives attain the expected outcomes

A

Planning

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

the ranking of nursing diagnoses or patient problems, using principles such as urgency or importance, to establish a preferential order for nursing action

A

Priority Setting

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

ones judgement or interpretation of a cue (e.g. crying means they are sad or afraid)
Interview - organized conversation with the patient

A

Inference

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

card-filing system that allows quick reference to the needs of the patient for certain aspects of nursing care

A

Kardex

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

objective behaviour or response that a patient is expected to achieve over a longer period, usually over several days, weeks or months

A

Long-Term Goal

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

the identification of a disease, condition on the basis of specific evaluation of physical signs, symptoms, the patient’s medical history, and the results of diagnostic test and procedures

A

Medical Daignosis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

an approved nursing diagnosis

A

NANDA International

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

a clinical judgement about individual, family, or community responses to actual and potential health problems or life processes that is within the domain of nursing

A

Nursing Diagnosis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
36
Q

a detailed database the allows them to plan and carry out nursing care to meet patients’ needs

A

Nursing Health History

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
37
Q

a cognitive framework through which the nurse aims to identify, diagnose, and treat actual and potential health issues and challenges of patients from a holistic perspective

A

Nursing Process

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
38
Q

observations or measurements of a patient’s health status

A

Objective Data

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
39
Q

help to determine the patient’s priorities and primary concerns, which can sometimes be different from what the nurse initially thinks the concern

A

Open-Ended Question

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
40
Q

the comparison of data with another source to determine data accuracy

A

Validation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
41
Q

Which indication is served by setting a time frame for outcomes of care?

A

When the patient is expected to respond in the desired manner

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
42
Q

Diagnostic label and Related factors make up a

A

Nursing diagnosis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
43
Q

Which topic would a nursing health history interview ideally focus on?

A

The patient

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
44
Q

Which type of nursing diagnosis has the nurse given to a patient who ice diagnosed with urinary stress incontinence?

A

Actual diagnosis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
45
Q

Which basic concept would a nursing care plan emphasize?

A

Nursing diagnosis
Goals and expected outcomes
Specific nursing interventions

46
Q

What is a measurable criterion used to evaluate goal achievement?

A

Expected outcome

46
Q

The following categories are examples of:
Environmental
Physiological
Genetic
Chemical elements

A

Risk factors

46
Q

Which type of question is used when starting the assessment of a patient?

A

Open-ended

47
Q

The following is:
Review assessment data
Cluster clinical criteria that form a pattern
Choose a diagnostic label
Consider the context of a patient’s health problems and select a related factor

A

The correct order for a new patient admitted to the nursing unit

48
Q

A benefit of an accurate nursing diagnosis

A

It helps ensure effective and efficient nursing interventions

49
Q

Which statement describes a health promotion diagnosis, according to the North American Nursing Diagnosis Association International (NANDA)?

A

It indicates a person’s readiness to enhance specific health behaviours for well-being

50
Q

During which process is the nurse avoiding an error when comparing the defining characteristics for acute pain with those for chronic pain and in the end selecting acute pain as the correct diagnosis?

A

Data interpretation

50
Q

Which item would the nurse focus on when formulating a nursing diagnosis?

A

Potential response to a health problem

51
Q

Which time does implementation begin as the fourth step of the nursing process?

A

After the care plan has been developed

51
Q

The following patient-related data is considered _________ __________?
Age
Sex
Place of birth

A

identifying information

51
Q

Setting the stage
Gathers information about chief concern, or problems - sets an agenda
Assessment / health history
Termination

A

Stages of a patient-centred interview in order

52
Q

Which item describes a possible result of an incorrect nursing diagnosis?

A

Undesirable outcomes with patient care

53
Q

The following are examples of:
Missing data
Inaccurate data
Disorganization
Lack of knowledge or skill

A

Factors cause errors in data collection

53
Q

Interpretation a nurse would make about a patient who is scheduled for a cholecystectomy and is restless, has poor eye contact when speaking, and is asking a namer of questions?

A

The patient is anxious

54
Q

These are examples of information that is found in the ___________________:
Age
Marital status
Address
Occupation
Working status
Source of healthcare
Types of insurance

A

Biographical information

55
Q

What kind of report would be used to communicate between the critical care unit and the cardiac unit when a patient is moved?

A

Transfer report

55
Q

Which explanation represents the meaning of SBAR?

A

Situation, background, assessment and recommendation

56
Q

E.g. reposition the patient on right side. Encourage patient to use patient-controlled analgesia (PCA) device
This is a good example of:

A

P statement using the SOAP format

56
Q

What type of interdisciplinary communication may take place when the primary health care provider would like an orthopedist to assess a patient’s complex fracture?

A

Consultation

57
Q

Which Canadian law is violated when the nurse faxes a patient’s medical record to an unknown number?

A

Personal Information Protection and Electronic Documents Act (PIPEDA)

58
Q

Which method will the nurse use to dispose of printed patient information?

A

Place in a secure canister for shredding

59
Q

Which type of report would include the patient’s condition, anticipated condition, medications, and nursing interventions fulfilled so the next nurse on shift can follow the correct treatment and care for the patient?

A

Change-of-shift report

60
Q

Which mode is used for the routine exchange of info among the members of the healthcare team?

A

Written reports
Oral communication

60
Q

Which information does the nurse access in order to contact a patient’s guardian and update them about the patient’s health status?

A

Admission sheet

61
Q

Which item warns a healthcare provider when prescribing medications using an EHR that the patient is allergic to prescribed medication and requires a change?

A

Clinical decision support system (CDSS)

62
Q

Which classification is present when the nurse preforms a postoperative examination of a patient after left knee replacement surgery and finds the patient is experiencing a low-grade temperature, but the critical pathway on the patient unit indicates that the patient should be afebrile, normotensive, and eugenic after knee replacement surgery?

A

Variance

62
Q

The following are examples that describe the purpose of ____________:
Helps in identifying trends in systems an unit operations that justify change
Helps quality improvement programs
Helps to identify need to change a procedure or policy

A

An incident report

63
Q

Which type of record system allows the nurse to access patient’s medial record and review the education that other nurses provided to the patient during and initial hospitalization and three subsequent clinical visits?

A

Electronic health record

64
Q

Which statement indicates a nurse understands the major advantage of using computerized provider order entry (CPOE)?

A

CPOE reduces transcription errors

65
Q

Which response would the nurse make when a patient asks for a copy of their medical record?

A

Indicate that the patient has the right to read their record

66
Q

Information the nurse should include while giving a change-of-shift report to another nurse who will be caring for a patient the next shift:

A

Patient’s name
Age
Diagnosis
Allergies

67
Q

In a _______________ setting, the usual forms you would see on the patient’s chart are:
Assessment forms
Referral source information
Discipline-specific care plans
Physician’s plan of treatment
Professional order form
Medication administration record
Clinical progress notes
Discharge summary

A

Homecare

68
Q

The following are examples of:
Documenting deviations from established norms
Shorthand method of documenting
Focuses on significant findings, assumes all standards are met unless they are documented
Patient concerns (narrative format)
Subjective assessment 
SOAP
DAR

A

Outcomes of charting by exception (CBE)

69
Q

Enter only _________ and factual information about the patient

A

Objective

70
Q

Used to determine the hours of care and the number of staff required for any given group of patients every shift or every 24 hrs

A

Acuity ratings

71
Q

Incorporates interdisciplinary approach to documenting patient care

A

Case management

71
Q

Information about the assigned patients shared with nurses working on the next shift - can be written summary, or oral at a patient’s bedside.

A

Change-of-shift report

72
Q

Patient meets all standards unless otherwise documented

A

Charting by exception (CBE)

73
Q

Computerized program used within healthcare settings to aid and support clinical decision making

A

Clinical decision support system (CDSS)

73
Q

one professional caregiver gives formal advice about the care of a patient to another caregiver

A

Consultations

74
Q

a computer-based system that is meant to gather, store, and alter clinical data on patients

A

Clinical information system (CIS)

74
Q

allows health care providers to directly enter order for patient care into the hospital information system

A

Computerized provider order entry (CPOE)

75
Q

inter professional care plans that integrate best evidence for the treatment of a condition along a detailed pathway, with expected outcomes noted within an established time frame

A

Critical pathways

76
Q

DAR notes

A

Data, action, response

76
Q

the process of documenting nursing information about nursing care in health records

A

Documentation

77
Q

a digital version of patient data that is found in traditional paper records

A

Electronic health record (EHR)

78
Q

longitudinal (lifetime) record of all health care encounters for an individual patient. Legal record.

A

Electronic medical record (EMR)

79
Q

a combination of hardware and software that protects private. Network resources from outside hackers, network damage, and theft or misuse of information

A

Firewall

80
Q

a one- or two-page form that gathers all the important data regarding a patient’s condition

A

Flow sheets

81
Q

a transdisciplinary study of the data flow and processing into more abstract forms such as information, knowledge, and wisdom along with the associated systems needed to synthesize or develop decision support systems for the purpose of helping the healthcare management process achieve better outcomes in healthcare delivery

A

Health informatics

82
Q

completed whenever an incident occurs

A

Incident (occurrence) report

83
Q

involves the use of data-action-response (DAR) notes. Incorporates all aspects of the nursing process, highlights a patient’s concerns, and can be integrated into any clinical setting

A

Focus charting

84
Q

refers to the management and processing of information, generally with the assistance of computers

A

Information technology (IT)

85
Q

a portable “flip-over” file or binder, kept at the nursing station

A

Kardex

86
Q

oral, written, or audio-recorded exchanges of information between caregivers

A

Reports

87
Q

unexpected occurrences, unmet goals, and interventions not specified within the clinical pathway time frame

A

Variance

87
Q

standardized bedside safe patient handoffs describes patients’ health status and tells staff on the next shift what care patient needs

A

Transfer of accountability (TOA)

88
Q

required when patients are transferred from one unit to another to receive different levels of care

A

Transfer report

88
Q

the patient’s chart is organized so that each discipline (e.g. nursing, medicine, social work, respiratory therapy) has a separate section in which to to record data

A

Source record

89
Q

pre-developed guides by the nursing staff and health care agencies to ensure that patients with a particular condition receive consistent care

A

Standardized care plans

89
Q

SOAP note

A

Subjective data, objective data, assessment, plan

90
Q

SOAPIE note

A

Subjective data, objective data, assessment, plan, intervention, evaluation

91
Q

incorporates the principles of nursing informatics to support he work that nurses do by facilitating the documentation of nursing process activities and offering resources for managing nursing care delivery

A

Nursing clinical information system (NCIS)

91
Q

share important patient information in an effective and efficient way and to help standardize communication

A

Identification-situation-background-assessment-reccomendation-repeat back (I-SBAR-R) technique

91
Q

AKA medical record, health record, or chart - a confidential, permanent legal document of information relevant to a patient’s health care

A

Patient record

91
Q

PIE format

A

Problem, intervention, evaluation

92
Q

an arrangement for services by another healthcare provider

A

Referrals

92
Q

federal legislation that protects personal information, including health information.

A

Personal Information Protection and Electronic Documents Act (PIPEDA)

92
Q

a system for organizing documentation that places the primary focus on the patients’ individual problems

A

Problem-orientated medical record (POMR)

Fundamentals 2 (12 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2025 Bold Learning Solutions. Terms and Conditions