KEY TERMS

Question 1

Nursing process

Answer 1

Is a systematic method by which nurses plan and provide care for patients

Question 2

Assessment

Answer 2

A systemic, dynamic way to collect and analyze data about a client
- first step in delivering nursing care

Question 3

Outcome (goal)

Answer 3

Goals are something that a person strives to achieve

Question 4

Cue

Answer 4

Is a piece or pieces of data that often indicate that an actual or potential problem has occurred or will occur

Question 5

Subjective data

Symptoms and subjective cues

Answer 5

Information that is provided by the patient

- examples: pain, fatigue, and Anxiety

Question 6

Objective data

Signs and objective cues

Answer 6

Observable and measurable signs

- examples: observe capillary refill, measure patients blood pressure

Question 7

Primary source

Secondary source

Answer 7

The patient

Family members, significant other, medical record

Question 8

Biographic data

Answer 8

Provide information about the facts or events in a person’s life

Question 9

Database

Answer 9

Large store or bank of information

Question 10

Diagnose

Answer 10

Is to identify the type and cause of a health condition

Question 11

Nursing diagnosis / patient problem statement

Nanda

Answer 11

Type of health problem that can be identified by the nurse

Question 12

Defining characteristics

Answer 12

Are the clinical cues, signs, and symptoms that furnish evidence that the problem exists.

Question 13

Potential patient problems

Answer 13

Two part statements:

1) the patient problem statement with the adjective potential in front of it
2) the risk factors

Question 14

Collaborative problems

Answer 14

Are health related problems that the nurse anticipates based on the condition or diagnosis of a patient

Question 15

Medical diagnosis

Answer 15

Is the identification of a disease or condition with evaluation of physical signs, symptoms, patient interview, laboratory tests, diagnostic procedures, review of medical records and patient history

Question 16

Goal

Answer 16

The purpose to which an effort is directed

Question 17

Planning

Answer 17

Developing and modifying a care plan for a patient ,recording relevant information

Question 18

Nursing interventions

Answer 18

Activities that promote the achievement of desired patient goal

Question 19

Implementation

Answer 19

The nurse and other members of the team put the established plan into action to promote goal achievement

Question 20

Evaluation

Answer 20

Is a determination made about the extent to which the established goals have been achieved

Question 21

Standardized language

Answer 21

Terms that have the same definition and meaning regardless of who uses them

Question 22

Nursing sensitive patient outcomes

Answer 22

The results or outcomes of nursing interventions

Question 23

Managed care

Answer 23

Refers to health care systems that have control over primary health care services and attempt to trim down health care costs

Question 24

Case management

Answer 24

Encompasses planning, coordination of care, and patient advocacy in providing quality

Question 25

Clinical pathway

Answer 25

Is a multidisciplinary plan that incorporates evidence based practice guidelines for high risk, high volume, high cost types of cases

Question 26

Variance

Answer 26

If a patient does not achieve the projected outcome