Nursing Process

Question 1

standardized nursing language:
defines nursing’s _____ and _____ in healthcare

Answer 1

contribution and impact
*defines what nurses do

Question 2

standardized nursing language:
gives nurses more ______ and ______

Answer 2

EB outcomes and interventions

Question 3

standardized nursing language:
is easily integrated into ____

Answer 3

EMR

Question 4

standardized nursing language:
standardizes ______ for nursing curriculum

Answer 4

knowledge

Question 5

standardized nursing language:
promotes _______

Answer 5

nursing research

Question 6

standardized nursing language example?

Answer 6

nurses : altered skin integrity
others : wound

Question 7

nursing process:
human response to ____ or ____ problem

Answer 7

actual or potential

Question 8

aspects of the nursing process?

Answer 8

holistic
scientific
EBP
individualized
analyzed information

Question 9

what is included in the clinical judgement measurement model?

Answer 9

recognize and analyze cues
prioritize hypotheses
generate solutions
take actions
evaluate outcomes
*parallels ADPIE

Question 10

what is ADPIE?

Answer 10

assessment
diagnosis
planning
implementing
evaluating

Question 11

analyze _____ vs _____ to create a nursing diagnosis

Answer 11

actual vs risk

Question 12

how many parts in an actual nursing diagnosis?

Answer 12

3

Question 13

how many parts in a risk nursing diagnosis?

Answer 13

2

Question 14

what two goals are involved in planning?

Answer 14

patient outcomes
nursing interventions

Question 15

what does a nursing care plan allow for?

Answer 15

individualized care
set priorities
facilitate communication
promote continuity
evaluate patient response
create a record

Question 16

characteristics of nursing assessments?

Answer 16

purposeful
prioritized
complete
systematic
accurate
relevant
recorded in standard manner

Question 17

what are the different types of assessment?

Answer 17

initial- admission and shift
focused
time-lapsed

Question 18

admission assessment requirements?

Answer 18

completed within 8 hours and in depth (3/4 pages)
*sets baseline for the hospital stay

Question 19

shift assessment requirements?

Answer 19

quicker and shorter (1/2 pages)
*sets baseline for shift duration

Question 20

what is a focused assessment?

Answer 20

focuses on only ONE system
*assess problems that could be connected to primary issue
ex. not listening to bowel sounds if problem is with the heart

Question 21

what is time-lapsed assessment?

Answer 21

looking at one thing over a specified period of time (like a follow up but with a specific purpose)
ex. skin wound assessed, comes back in two weeks (predetermined time) to assess same wound

Question 22

what is critical thinking?

Answer 22

mental process of recognizing, analyzing, applying, and evaluating information to reach a conclusion

Question 23

what is clinical thinking?

Answer 23

using critical thinking in a clinical setting to make nursing care decisions based on EBP

Question 24

which is the best source of assessment data?

Answer 24

patient
followed by
family and significant others
patient record
other healthcare professionals

Question 25

what is a nursing diagnosis?

Answer 25

a clinical judgement about an individual's responses to actual or potential health problems

Question 26

nursing diagnosis provides the basis for selection of ________ and the ________ to achieve the set outcomes

Answer 26

patient outcomes and nursing interventions

Question 27

steps in diagnostic process: create a list of ________

Answer 27

suspected process

Question 28

steps in diagnostic process: name _____ and _____ problems/diagnoses and clarify what is _____ or _____ contributing to them

Answer 28

actual and potential causing or contributing

Question 29

steps in diagnostic process: determine ______ that must be managed for a risk DX

Answer 29

risk factors

Question 30

steps in diagnostic process: confirm _____ for an actual DX

Answer 30

defining characteristics

Question 31

steps in diagnostic process: prioritize _____

Answer 31

nursing diagnoses

Question 32

what are the three parts of an actual nursing diagnosis?

Answer 32

problem, etiology (cause of problem), defining characteristics (evidence)

Question 33

how do you phrase an actual nursing diagnosis?

Answer 33

problem R/T etiology AEB defining characteristics (subjective and objective data that supports problem)

Question 34

what is a secondary etiology?

Answer 34

usually a medical diagnosis *used for clarity ex. nurses cannot diagnose arthritis so you would say pain (problem) R/T tissue inflammation (etiology) secondary to arthritis (secondary etiology)

Question 35

what does etiology drive?

Answer 35

nursing interventions *what we will do

Question 36

what are the nursing diagnoses that have etiologies?

Answer 36

problem (actual) and syndromes

Question 37

what component are risk diagnoses missing?

Answer 37

defining characteristics - they don't have the problem but are at risk for it

Question 38

which nursing diagnoses have risk factors?

Answer 38

risk diagnoses

Question 39

what is the nursing dx for pneumonia?

Answer 39

ineffective airway clearance

Question 40

what is the nursing dx for amputation?

Answer 40

disturbed body image

Question 41

what is the nursing dx for type 2 diabetes mellitus?

Answer 41

risk for unstable blood glucose

Question 42

what is the nursing dx for post-op prostatectomy?

Answer 42

impaired urinary elimination

Question 43

what nursing dx for cerebrovascular accident?

Answer 43

self care deficit: dressing

Question 44

maslow's hierarchy of needs: level 1

Answer 44

physiological needs *most important

Question 45

maslow's hierarchy of needs: level 2

Answer 45

safety and security

Question 46

maslow's hierarchy of needs: level 3

Answer 46

love and belonging

Question 47

maslow's hierarchy of needs: level 4

Answer 47

self esteem

Question 48

maslow's hierarchy of needs: level 5

Answer 48

self actualization

Question 49

what is maslow's used for?

Answer 49

to set priorities

Question 50

benefits of nursing diagnoses: ______ patient care

Answer 50

individualizing

Question 51

benefits of nursing diagnoses: defining ______ to healthcare admins, legislators, and providers

Answer 51

domain of nursing

Question 52

benefits of nursing diagnoses: seeking funding for nursing and ______

Answer 52

reimbursement for nursing services

Question 53

problem states drives _____

Answer 53

patient outcomes

Question 54

what are the 4 types of outcomes?

Answer 54

cognitive psychomotor affective physiologic

Question 55

what is a cognitive outcome?

Answer 55

increase in patient knowledge

Question 56

what is a psychomotor outcome?

Answer 56

patients achievement of new skills

Question 57

what is an affective outcome?

Answer 57

changes in patient values, beliefs, and attitudes

Question 58

what is a physiologic outcome?

Answer 58

physical changes in the patient

Question 59

which outcome is the hardest to change/achieve?

Answer 59

affective

Question 60

smart goals?

Answer 60

specific measurable attainable realistic time bound

Question 61

what are the actions based on patient response to POC in the evaluation phase?

Answer 61

direct future care terminate modify continue

Question 62

what are the never events?

Answer 62

pressure injuries 3 and 4 falls and trauma surgical site infection vascular-catheter assoc infection CAUTI admin of incompatible blood

Question 63

what are the always events?

Answer 63

identifying patients by more than one source mandatory read backs med error reduction strategies result tracking available critical information

Question 64

terminate POC?

Answer 64

when each expected outcome is achieved

Question 65

modify POC?

Answer 65

if there are difficulties achieving outcomes

Question 66

continue POC?

Answer 66

if more time is needed to achieve outcomes