Chapters 15, 17, 18, 20 Flashcards
1
Q
What is the nurse’s responsibility in making clinical decisions?
A
The nurse recognizes patient health-related needs, forms clinical judgments using critical thinking, and makes timely decisions on when and how to act.
2
Q
How do nurses use critical thinking in patient assessment?
A
Nurses assess each patient, sort information into patterns, identify problems, recognize changes, and make appropriate judgments under pressure.
3
Q
What are the key components of critical thinking in nursing?
A
Critical thinking skills include interpretation, analysis, inference, evaluation, explanation, and self-regulation.
4
Q
What does ‘interpretation’ involve in nursing practice?
A
Interpretation involves orderly data collection about patients, applying reasoning to identify patterns, and gathering additional data to clarify uncertainties.
5
Q
What is the importance of ‘analysis’ in nursing?
A
Analysis requires open-mindedness and careful consideration of information to avoid assumptions and identify true problems or trends.
6
Q
What does ‘inference’ mean in the context of nursing?
A
Inference involves examining the meaning and significance of findings and identifying relationships among them.
7
Q
How is ‘evaluation’ defined in nursing practice?
A
Evaluation is the objective assessment of situations using criteria to determine the results of nursing actions and personal behavior.
8
Q
What does ‘explanation’ entail in nursing?
A
Explanation involves supporting findings and conclusions using knowledge and experience to choose patient care strategies.
9
Q
What is ‘self-regulation’ in nursing?
A
Self-regulation is the reflection on experiences and performance, taking responsibility for actions and outcomes, and identifying improvement areas.
10
Q
What is the relationship between the nursing process and critical thinking?
A
The nursing process (ADPIE) utilizes critical thinking skills to connect reasoning with patient care, involving knowledge, experience, environment, attitudes, and standards.
11
Q
What is a nursing diagnosis?
A
A nursing diagnosis is made when a nurse applies critical thinking to identify health-related problems or potential issues based on patient data.
12
Q
What is the purpose of nursing diagnosis in practice?
A
Nursing diagnosis facilitates treatment of human responses and advocacy in the care of individuals.
13
Q
Give an example of a nursing diagnosis.
A
An example of a nursing diagnosis is impaired skin integrity, identified through inflamed wound edges and patient complaints of pain and tenderness.
14
Q
What are the three types of diagnosis?
A
The three types of diagnosis are medical diagnosis, nursing diagnosis, and collaborative problems.
15
Q
What is a medical diagnosis?
A
A medical diagnosis is the identification of a disease condition based on specific assessment findings, medical history, and laboratory results.
16
Q
What is a nursing diagnosis?
A
A nursing diagnosis is a clinical judgment made by a RN to describe a patient’s response or vulnerability to health conditions that the nurse is licensed to treat.
17
Q
What are collaborative problems?
A
Collaborative problems require both medical and nursing interventions, using physician prescribed therapy along with nursing interventions.
18
Q
How do defining characteristics and etiology individualize a nursing diagnosis?
A
Defining characteristics (observed signs and symptoms) and etiology (underlying causes) create a personalized picture of a patient’s health concern, allowing for tailored nursing interventions.
19
Q
What is the benefit of standardized terminology in nursing diagnosis?
A
Standardized terminology provides diagnostic clarity and effective communication between medical personnel.
20
Q
How can the Nursing Diagnosis Handbook be used?
A
The Nursing Diagnosis Handbook can be used to look up specific patient symptoms, etiology, medical diagnoses, and problems to better assess a patient.
21
Q
What are the three components of a nursing diagnosis?
A
The three components of a nursing diagnosis are problem, etiology, and symptoms.
22
Q
How to write a problem-focused nursing diagnosis?
A
Write a problem-focused diagnosis related to (characteristics).
23
Q
How to write a risk diagnosis?
A
Write a risk diagnosis as ‘Risk for (related factors) as evidenced by (defining characteristics).’
24
Q
What is critical thinking?
A
The ability to think critically involves considering a wide range of information and not being limited to what is learned in school.
25
What does independent thinking entail?
Independent thinking means evaluating information and ideas without being constrained by preconceived notions or biases.
26
What is responsibility in critical thinking?
Responsibility in critical thinking means being accountable for decisions and actions.
27
What is risk-taking in critical thinking?
Risk-taking involves making decisions without causing harm to others.
28
What does discipline refer to in critical thinking?
Discipline refers to paying attention to details, considering options, and making informed decisions.
29
What is humility in the context of critical thinking?
Humility involves admitting to limitations in one's knowledge or skills.
30
What are the criteria used in priority setting for nursing care?
Priorities help anticipate and sequence nursing interventions by ranking nursing diagnoses in order of importance. They are set in collaboration with health care providers, patients, and family when appropriate. Priorities can be categorized as high, intermediate, and low.
## Footnote
High priority diagnoses may include: Risk for violence, impaired gas exchange, impaired cardiac function.
31
What are the different steps in the nursing process?
The nursing process involves assessment, diagnosis, planning, implementation, and evaluation.
32
What is the difference between a goal and an expected outcome in nursing?
Goals are broad general statements that provide direction for planning nursing interventions, while expected outcomes are specific and measurable statements of action for the patient within a specific time frame.
33
What does SMART stand for in writing an outcome statement?
SMART stands for Specific, Measurable, Achievable, Realistic, and Timed. Each component ensures that the outcome statement is clear and actionable.
34
What does the 'S' in SMART represent?
'S' stands for Specific: it refers to specific patient behavior or response, not generalized or broad.
## Footnote
Example: Patient ambulates in the hall 3 times a day by 4/11/2025.
35
What does the 'M' in SMART represent?
'M' stands for Measurable: you must be able to measure or observe whether a change takes place within the patient's status.
## Footnote
Example: Body temp will remain below 99.9 degrees Fahrenheit.
36
What does the 'R' in SMART represent?
'R' stands for Realistic: set outcomes that are realistic and relevant for the patient.
## Footnote
Example: Does the patient have help from a caregiver to assist with intervention at home?
37
What does the 'T' in SMART represent?
'T' stands for Timed: set a specific time frame for the goal to be met.
38
What are nurse-initiated interventions?
Nurse-initiated interventions are independent actions taken by a nurse in response to a nursing diagnosis without supervision or orders from others.
## Footnote
Example: Positioning patients to reduce pressure injuries, instructing patients about side effects.
39
What are the types of interventions in nursing?
Interventions can be nurse-initiated, physician-initiated, or collaborative.
40
What are physician initiated interventions?
Physician initiated interventions are dependent nursing interventions that require an order from a health care provider.
## Footnote
Examples include administering medications, implementing invasive procedures, and preparing a client for diagnostic tests.
41
What are interdependent initiated interventions?
Interdependent initiated interventions are therapies that require the combined knowledge, skills, and expertise of multiple health care providers.
## Footnote
Examples include social work, occupational therapy, rehabilitation, and pharmacy.
42
What are the six important factors to consider when selecting nursing interventions?
1. Desired patient outcomes
2. Characteristics of the nursing diagnosis
3. Research based knowledge for the intervention
4. Feasibility for doing the intervention
5. Acceptability to the patient
6. Capability and competency of the nurse
43
What is the significance of desired patient outcomes in selecting nursing interventions?
Desired patient outcomes serve as the criteria against which to judge interventions.
## Footnote
They are often based on NANDA diagnoses.
44
Why is research based knowledge important in nursing interventions?
Research based knowledge provides evidence that indicates the effectiveness of the intervention.
## Footnote
It helps ensure that interventions are grounded in scientific evidence.
45
What does feasibility for doing the intervention entail?
Feasibility involves being aware of the patient's total care plan, the limitations for implementing the intervention, the cost, and the amount of time required.
46
Why is acceptability to the patient important in nursing interventions?
Acceptability promotes informed choices and considers patient values and beliefs, allowing for the offering of choices in interventions.
47
What does capability and competency of the nurse refer to?
It refers to whether the nurse understands the rationale behind the intervention and possesses the necessary skills needed for its implementation.
48
What are nurse initiated interventions ?
Nurse initiated interventions are the independent nursing interventions that a nurse initiates in response to a nursing diagnosis without supervision or orders from others. EX: positioning patients to reduce pressure injuries, health promotion and education
49
What are direct care interventions?
Direct care interventions involve providing direct intervention to a patient, such as registration, insertion of a urinary catheter, or discharge counseling.
50
What are indirect care interventions?
Indirect care interventions are performed away from a patient but on behalf of the patient, such as managing the patient's environment, infection control, and documentation.
51
What are the key functions of the helping role in nursing?
The key functions include:
- The Teaching-Coaching Function
- The Diagnostic and Patient-Monitoring Function
- Effective Management of Rapidly Changing Situations
- Administering and Monitoring Therapeutic Interventions
- Monitoring and Ensuring the Quality of Health Care Practices
- Organizational and Work-Role Competencies
52
What is the scope of nursing interventions?
The scope of nursing interventions includes both direct care and indirect care interventions.
53
What are nurse-initiated interventions?
Nurse-initiated interventions are actions taken by nurses based on their own assessment and judgment.
54
What are health care provider-initiated interventions?
Health care provider-initiated interventions are actions directed by a health care provider's orders.
55
Give an example of a nurse-initiated intervention.
An example of a nurse-initiated intervention is conducting a family care plan conference.
56
What is an example of a provider-initiated intervention?
An example of a provider-initiated intervention is a discharge plan.
57
What is the critical thinking element related to knowledge in nursing care implementation?
Knowledge includes understanding anatomy and pathophysiology, as well as clinical guidelines.
58
What interventional activity is associated with performing invasive procedures?
Perform invasive procedures such as IV catheter insertion and tracheal suctioning.
59
What is an example of applying communication principles during a procedure?
Provide coaching during a procedure.
60
What teaching principle should be applied when explaining an intervention?
Provide explanations describing the purpose and self-care implications of an intervention.
61
What does delegation principles involve in nursing care?
Organize multiple interventions for a patient, such as vital signs and early ambulation.
62
How does experience influence nursing interventions?
Experience in administering the same intervention for various patients helps in adapting care.
63
What is the significance of skill competence in nursing?
Adapt intervention to a patient's limitations and perform new procedures practiced in simulation.
64
How should interventions be adapted to the environment?
Administer interventions when no other patient priorities exist and adapt to existing conditions.
65
What attitudes are important in nursing care?
Creativity, calling, and confidence are essential attitudes.
66
What is the role of standards in nursing interventions?
Apply intellectual standards in measurement and adapt interventions to changing patient status.
67
How can knowledge of anatomy be applied in nursing?
Apply knowledge of vein distribution in identifying veins for insertion.
68
What is an example of applying knowledge of pathology in nursing?
Determine frequency of suction based on the pathology of lung disease, such as pneumonia.
69
What should be explained to a patient during nasogastric tube insertion?
Explain each step in a calming manner.
70
What should be included when administering a newly prescribed medication?
Explain its purpose and implications for safe self-administration.
71
What considerations should be made regarding patient stability?
Select the right task and consider whether the patient is stable before delegating tasks.
72
What precautions should be taken when placing a bedpan for older adults?
Use extra caution to support the patient's buttocks to avoid shear or friction.
73
What should be done to ensure competency in nursing procedures?
Reflect on your knowledge and obtain resources from experienced nurses.
74
What is a recommended practice for medication preparation?
Prepare medication in a no-interruption zone and minimize distractions.
75
How should surgical asepsis be applied during dressing changes?
Use surgical asepsis for hospitalized patients and teach clean techniques to caregivers.
76
What should be done for a patient with reduced mobility of hands?
Consult with an occupational therapist and use assistive devices for self-feeding.
77
How should instructions be given to patients during interventions?
Use clear, calm, and confident instructions, explaining the reasons for key steps.
78
What should be anticipated while a patient is ambulating?
Anticipate signs of hypotension or unsteady gait and adjust care accordingly.
79
How should patient education be tailored regarding infection risk?
Provide specific explanations for why the patient is at risk, avoiding generalizations.
80
What is the importance of building trust with patients?
Interventions that build trust require creativity and self-discipline.
81
What is the association between critical thinking and selecting nursing interventions?
Nurses apply critical thinking to carry out nursing interventions using good clinical judgement during implementation. Implementation begins after you develop a patient's plan of care. A nursing intervention is any treatment based on clinical judgement and knowledge that a nurse performs to enhance patient outcomes.
82
What are nursing interventions?
Nursing interventions include direct and indirect care measures that are nurse initiated or provider initiated. A nurse chooses interventions that are most current and scientifically supported when delivering patient centred care.
83
What is a standing order?
A standing order is a preprinted document containing medical orders for routine therapies, monitoring guidelines, and diagnostic procedures for specific patients with identified clinical problems. It directs patient care in a specific clinical setting.
84
How are standing orders approved?
Licensed prescribed providers approve standing orders as they reflect health care provider treatment preferences.
85
What are protocols in nursing?
Protocols provide a detailed set of steps to follow in a specific situation, often including decision points based on patient assessment.
86
What is the difference between standing orders and protocols?
Standing orders allow healthcare providers to perform a specific action without needing immediate physician approval in certain situations, while protocols offer more flexibility allowing for multiple actions based on assessments.
87
What do direct nursing interventions involve?
Direct nursing interventions involve collaboration with patients, their environment, safety, infection control, documentation, and interprofessional communication.
88
What do indirect nursing interventions involve?
Indirect nursing interventions involve actions that are performed away from the patient but still benefit their care.
89
How do you select appropriate interventions for an assigned patient?
Selecting appropriate interventions involves assessing the patient's needs and choosing interventions that align with their care plan.
90
What is the purpose of evaluation in nursing?
Evaluation determines whether a patient's condition or well-being improved after nursing interventions were delivered.
91
What are the standards of professional nursing practice for evaluation?
Standards include ANA standards and scope of nursing practice, clinical practice guidelines, intellectual standards, agency policies, and patient expected outcomes.
92
What skills do nurses use during evaluation?
Nurses utilize physical examination skills, observation, and communication to determine patient responses to interventions.
93
What is the relationship among goals of care, expected outcomes, and evaluative measures?
Goals are set for the patient, and evaluative measures assess whether these goals are met through interventions.
94
What does the evaluation process involve?
It involves observational skills, critical thinking, and comparing outcomes for a patient.
95
How does evaluation lead to changes in a plan of care?
If outcomes are not met, reassessment identifies factors interfering with achievement, leading to discontinuation, revision, or modification of the plan.
96
What should be done if a patient's response is unfavorable?
Make changes in the plan of care, consult with healthcare team members, and use the SMART acronym to modify nursing diagnoses.
97
What is the process after modifying a care plan?
Restart the process beginning with assessment.
98
What does the American Nurses Association define in relation to nursing practice?
The American Nurses Association defines standards of professional nursing practice, including standards for the evaluation step of the nursing process.
99
What are the competencies for evaluation in nursing?
The competencies for evaluation include being systematic, using criterion-based evaluation, collaborating with patients and health care providers, using ongoing assessment data to revise a plan, and communicating results to patients and families.
100
What do the standards for evaluation focus on regarding interventions?
The standards focus on nurses delivering interventions responsibly and appropriately to minimize unwarranted or unwanted treatment.
101
What is the first step in the nursing diagnosis process?
A nurse must first review assessment data, noting objective and subjective clinical criteria.
102
What comes after reviewing assessment data in the nursing diagnosis process?
The nurse clusters clinical criteria that form a pattern.
103
What is the next step after clustering clinical criteria?
The nurse chooses the diagnostic label.
104
What is the final step in the nursing diagnosis process?
The nurse considers the context of the patient's health problem and selects a related factor.
105
What type of implementation skill is used when a nurse administers an enema solution?
Psychomotor skill
## Footnote
Psychomotor skills require the integration of cognitive and motor activities to ensure safe intervention.
106
What do interpersonal skills involve?
Developing a trusting relationship, expressing caring, and communicating clearly with patients/families.
107
What do cognitive skills require?
Problem solving and clinical decision making, using facts and thinking strategies.
108
What do collaborative skills involve?
Working or consulting with another health care professional.
109
What critical thinking skill helps the nurse make appropriate decisions about treatment for a postoperative patient experiencing pain?
Diagnostic, Analytical, Systematic, Inquisitive
## Footnote
Some correct answers were not selected.
110
What is critical thinking in nursing?
The ability to think in a systematic and logical manner with openness to question and reflect on the reasoning process.
111
What does it mean to be analytical in critical thinking?
Using logical reasoning to solve a problem.
112
Why is being systematic important in nursing?
It allows the nurse to be organized and focused on the work.
113
What role does inquisitiveness play in nursing?
It is necessary to learn more and acquire knowledge.
114
Is establishing a nursing diagnosis a characteristic of critical thinking?
No, it is a part of the nursing process.
115
What does being assumptive mean in the context of nursing?
Thinking that something is the case, even without proof.
116
How can assumptions affect a nurse's decision-making?
Assumptions may bias a nurse and prevent professional, nonjudgmental decisions about patient care.
117
What is the first step in making a nursing diagnosis?
Assess the patient's health status
## Footnote
This is done by collecting symptomology.
118
What process does a nurse follow after assessing the patient's health status?
Interprets, classifies, and organizes the data (data clustering)
## Footnote
This involves analyzing the collected symptomology.
119
What does the nurse assess for after data clustering?
Related factors and defining characteristics
## Footnote
This helps in understanding the patient's condition better.
120
What does the nurse identify after assessing related factors?
Related patient needs
## Footnote
These needs are crucial for formulating an accurate nursing diagnosis.
121
What is the final outcome of the nursing diagnosis process?
Formulates a nursing diagnosis
## Footnote
This is based on the assessment and identification of patient needs.
