Jen ch 15-20 vocab

Question 1

clinical decision making

Answer 1

Problem-solving approach that nurses use to define patient problems and select appropriate treatment.

Question 2

concept map

Answer 2

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

Question 3

critical thinking

Answer 3

Active, purposeful, organized, cognitive process used to carefully examine one’s thinking and the thinking of other individuals.

Question 4

decision making

Answer 4

Process involving critical appraisal of information that results from recognizing a problem and ends with generating, testing, and evaluating a conclusion. Comes at the end of critical thinking.

Question 5

diagnostic reasoning

Answer 5

Process that enables an observer to assign meaning to and classify phenomena in clinical situations by integrating observations and critical thinking.

Question 6

evidence based knowledge

Answer 6

Knowledge that is derived from the integration of best research, clinical expertise, and patient values.

Question 7

Inference

Answer 7

(1) Judgment or interpretation of informational cues. (2) Taking one proposition as a given and guessing that another proposition follows.

Question 8

nursing process

Answer 8

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

Question 9

problem solving

Answer 9

Methodical, systematic approach to explore conditions and develop solutions, including analysis of data, determination of causative factors, and selection of appropriate actions to reverse or eliminate the problem.

Question 10

reflection

Answer 10

Process of thinking back or recalling an event to discover the meaning and purpose of that event. Useful in critical thinking.

Question 11

scientific method

Answer 11

Codified sequence of steps used in the formulation, testing, evaluation, and reporting of scientific ideas.

Question 12

assessment

Answer 12

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

Question 13

back channeling

Answer 13

includes active listening prompts such as “all right,” “go on,” or “uh-huh.” These indicate that you have heard what the patient says and are interested in hearing the full story.

Question 14

close-ended question

Answer 14

Form of question that limits a respondent’s answer to one or two words.

Question 15

Concomitant symptoms

Answer 15

any symptom that accompanies a primary symptom.

Question 16

Cue

Answer 16

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

Question 17

database

Answer 17

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

Question 18

functional health patterns

Answer 18

Method for organizing assessment data based on the level of patient function in specific areas (e.g., mobility).

Question 19

nursing health history

Answer 19

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

Question 20

objective data

Answer 20

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

Question 21

open-ended question

Answer 21

Form of question that prompts a respondent to answer in more than one or two words.

Question 22

Review of Sympotoms (ROS)

Answer 22

a systematic approach for collecting the patient’s self-reported data on all body systems. During the ROS ask the patient about the normal functioning of each body system and any noted changes. Such changes are subjective data because they are described as perceived by the patient. Findings from the ROS are later confirmed during the physical examination.

Question 23

subjective data

Answer 23

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

Question 24

validation

Answer 24

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

Question 25

collabrborative problem

Answer 25

Physiological complication that requires the nurse to use nursing- and health care provider–prescribed interventions to maximize patient outcomes.

Question 26

data cluster

Answer 26

Set of signs or symptoms that are grouped together in logical order.

Question 27

defining characteristics

Answer 27

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

Question 28

diagnostic label

Answer 28

name of the nursing diagnosis as approved by NANDA International. It describes the essence of a patient’s response to health conditions in as few words as possible. All NANDA-I approved diagnoses also have a definition. The definition describes the characteristics of the human response identified.

Question 29

etiology

Answer 29

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

Question 30

health promotion nursing diagnosis

Answer 30

a clinical judgment of a person’s, family’s, or community’s motivation, desire, and readiness to increase well-being and actualize human health potential as expressed in their readiness to enhance specific health behaviors such as nutrition and exercise. Health promotion diagnoses can be used in any health state and do not require current levels of wellness

Question 31

medical diagnosis

Answer 31

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

Question 32

North American Nursing Diagnosis Association (NANDA)

Answer 32

Creates a list which identifies and defines nursing diagnosis

Question 33

nursing diagnosis

Answer 33

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 34

related factor

Answer 34

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

Question 35

risk nursing diagnosis

Answer 35

Describes human responses to health conditions/life processes that may develop in a vulnerable individual, family, or community.

Question 36

collaborative interventions

Answer 36

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

Question 37

consultation

Answer 37

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

Question 38

critical pathways

Answer 38

Tools used in managed care that incorporate the treatment interventions of caregivers 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 39

dependent nursing interventions

Answer 39

Physician-initiated interventions are dependent nursing interventions, or actions that require an order from a physician or another health care professional. The interventions are based on the physician’s or health care provider’s response to treat or manage a medical diagnosis. Advanced practice nurses who work under collaborative agreements with physicians or who are licensed independently by state practice acts are also able to write dependent interventions.

Question 40

expected outcome

Answer 40

a measurable criterion to evaluate goal achievement. Once an outcome is met, you then know that a goal has been at least partially achieved. Sometimes several expected outcomes must be met for a single goal.

Question 41

goal

Answer 41

broad statement that describes a desired change in a patient’s condition or behavior.

Question 42

independent nursing interventions

Answer 42

actions that a nurse initiates. These do not require an order from another health care professional. As a nurse you act independently on a patient’s behalf. Nurse-initiated interventions are autonomous actions based on scientific rationale.

Question 43

interdisciplinary care plans

Answer 43

more institutions are developing interdisciplinary care plans which include contributions from all disciplines involved in patient care. The interdisciplinary plan is designed to improve the coordination of all patient therapies and communication among all disciplines.

Question 44

long term goal

Answer 44

an objective behavior or response that you expect a patient to achieve over a longer period, usually over several days, weeks, or months (eg: patient will be tobacco free in 60 days)

Question 45

nursing care plan

Answer 45

includes nursing diagnoses, goals and/or expected outcomes, specific nursing interventions, and a section for evaluation findings so any nurse is able to quickly identify a patient’s clinical needs and situation.

Question 46

nursing-sensitive patient outcome

Answer 46

a measurable patient, family or community state, behavior, or perception largely influenced by and sensitive to nursing interventions

Question 47

patient-centered goal

Answer 47

reflects a patient’s highest possible level of wellness and independence in function. It is realistic and based on patient needs and resources

Question 48

planning

Answer 48

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

Question 49

priority setting

Answer 49

the ordering of nursing diagnoses or patient problems using determinations of urgency and/or importance to establish a preferential order for nursing actions

Question 50

scientific rationale

Answer 50

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

Question 51

short-term goal

Answer 51

an objective behavior or response that you expect a patient to achieve in a short time, usually less than a week. In an acute care setting you often set goals for over a course of just a few hours

Question 52

activities of daily living (ADLs)

Answer 52

Activities usually performed in the course of a normal day in the patient’s life such as eating, dressing, bathing, brushing the teeth, or grooming.

Question 53

adverse reaction

Answer 53

Any harmful, unintended effect of a medication, diagnostic test, or therapeutic intervention.

Question 54

clinical practice guideline

Answer 54

or protocol is a systematically developed set of statements that helps nurses, physicians, and other health care providers make decisions about appropriate health care for specific clinical situations

Question 55

counseling

Answer 55

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

Question 56

direct care

Answer 56

treatments performed through interactions with patients

Question 57

implementation

Answer 57

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

Question 58

indirect care

Answer 58

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

Question 59

instrumental activities of daily living (IADLs)

Answer 59

Activities necessary for independence in society beyond eating, grooming, transferring, and toileting; include such skills as shopping, preparing meals, banking, and taking medications

Question 60

lifesaving measure

Answer 60

a physical care technique that you use when a patient’s physiological or psychological state is threatened; to restore physiological or psychological homeostasis

Question 61

nursing intervention

Answer 61

Any treatment based on clinical judgment and knowledge that a nurse performs to enhance patient outcomes. .

Question 62

patient adherence

Answer 62

patients and families invest time in carrying out required treatments

Question 63

preventative nursing actions

Answer 63

Nursing actions directed toward preventing illness and promoting health to avoid the need for primary, secondary, or tertiary health care.

Question 64

standing order

Answer 64

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

Question 65

evaluation

Answer 65

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

Question 66

evaluative measures

Answer 66

assessment skills and techniques (e.g., observations, physiological measurements, patient interview)

Question 67

standard of care

Answer 67

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.