NURSING PROCESS Flashcards

1
Q

deliberative, systematic phase of the
nursing process that involves decision
making and problem solving.

A

planning

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2
Q

Refers to the client’s assessment data and
diagnostic statements for direction in
formulating client goals and designing the
nursing interventions required to present,
reduce or eliminate the client’s health
problems ; nurse’s responsibility

A
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3
Q

begins with the first client contact
and continuous until Nurse-Client
relationship ends, usually, when the client is
discharged from the health agency

A

planning

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4
Q

The nurse performs the admission
assessment usually develops the initial
comprehensive plan of care.

A

initial planning

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5
Q

The nurse has the benefit of seeing the client’s
body language and can gather intuitive kinds
of information that are not available solely
from the

A

written database

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6
Q

• Occurs at the beginning of a shift as the
nurse plans the care to be given that day
• All nurses who work with the client do
ongoing planning.

A

ongoing planning

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7
Q

→ To determine whether the client’s health
status has changed
→ To set priorities for the client’s care during
the shift
→ To decide which problems to focus on
during the shift
→ To coordinate the nurse’s activities so that
more than one problem can be addressed
at each client contact

A

purposes of ongoing planning

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8
Q

process of anticipating and planning
for needs after discharge, is crucial part of
a comprehensive health care plan and
should be addressed in each client’s care
plan ; begins at first client contact

A

discharge planning

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9
Q

process of establishing
a preferential sequencing for addressing
nursing diagnosis and intervention

A

setting priorities

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10
Q

In Maslow’s Hierarchy of Needs,
the physiologic needs of a person such
as air, food, and water, are basic needs
to life and receive _ priority

A

highest

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11
Q

what are the factors to consider when assigning priorities

A

client’s health values and beliefs
client’s priorities
resources available to the nurse and client
urgency of the health problem
medical treatment plan

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12
Q

Is a desired outcome or change in client
behavior

A

goal

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13
Q

More specific, measurable criteria used to
evaluate whether goal has been met

A

expected outcome

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14
Q

a comprehensive taxonomy of patient
outcomes influenced by nursing care.

A

nursing outcomes classification (NOC)

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15
Q

is required in all phases of the Nursing
Process.

A

standardized or common nursing language

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16
Q

Goals that can happen quickly

A

short term goals

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17
Q

Goals that take a long time to achieve

A

long term goals

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18
Q

Goals and outcomes are derived from the
client’s nursing diagnoses – primarily formt
he ; contains the unhealthy response, what should change

A

diagnostic label

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19
Q

is the client, any
part of the client, or some attribute of
the client, such as the client’s pulse or
urinary output

A

subject

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20
Q

specifies an action the client is
to perform

A

verb

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21
Q

may be added to
the verb to explain the circumstances under
which the behavior is to be performed ; what, where, when, or how

A

condition or modifier

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22
Q

indicates the standard by
which a performance is evaluated or the
level at which the client will perform the
specified behavior ; speed, accuracy, distance, quality

A

criterion of desired performance

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23
Q

The establish a time-achievement criterion,
the nurse needs to ask

A

how long

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24
Q

To establish accuracy criterion, the nurse
asks

A

how well

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25
Q

Write goals and outcomes in terms of __ not nurse activitie

A

client responses

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26
Q

Make sure that each goal is derived from
only __ nursing diagnosis.

A

one

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27
Q

Nursing process is action oriented, client
centered and outcome directed ; action phase in which
the nurse performs the nursing intervention ; doing and documenting

A

implementation

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28
Q

Treatments performed through interaction
with patients ; medication, IV insertion, counseling

A

direct care

29
Q

performed away from the
patient but on behalf of the patient or
group of patients ; managing environment, documentation, interdisciplinary collaboration

A

indirect care

30
Q

Nurse initiated intervention ; without supervision or directions from the others ; licensed to initiate on the basis of their knowledge and skills

A

independent nursing intervention

31
Q

Health care provider-initiated intervention ; orders or supervision of a licensed pysicians

A

dependent intervention

32
Q

• Interdependent intervention
• Are therapies that require the combined
knowledge, skill & expertise of multiple
health care providers
• Actions the nurse carries out in
collaboration with other health team
members

A

collaborative intervention

33
Q

safe and appropriate for age, health condition ; achievable w resources available ; congruent w client’s beliefs and other therepies ; based on nursing knowledge and experience; established standards

A

criteria for choosing nursing intervention

34
Q

• Problem Solving
• Decision Making
• Critical thinking

A

cognitive skills

35
Q

• Verbal non verbal communication
• Therapeutic communication

A

interpersonal skills

36
Q

• Manipulating equipment
• Giving injections
• Bandaging
• Moving, lifting and repositioning the client

A

technical skills

37
Q

what is the implementation process

A

reassing a patient
determining the nurse’s need for assistance
implementing nursing intervnetion
supervising the delegated care
documenting nursing activities

38
Q

→ Continuous process with each patient
interaction modification of a care plan
to meet a client whose status has
changed significantly
→ The nurse must reassess the client to
make sure if intervention is still needed
→ New data may indicate a need to
change the priorities of care of the

A

reassessing the client

39
Q

→ The nurse unable to implement the nsg
activity safely or deficiently alone (e.g.
ambulating an unsteady obese client)
→ assistance would reduce stress on the
client (e.g. turning a person who
experience acute pain when moved)
→ The nurse lack of knowledge or skills in
implementing a particular nursing
activities (e.g. nurse

A

determining the nurses need for assistance

40
Q

→ Base nursing interventions on scientific
knowledge, nursing research &
professional standards of care
→ Clearly understand the intervention to
be implemented & question any that
are not understood
→ Adapt activities to the individual client

A

implementing nursing interventions

41
Q

→ The nurse responsible for the overall
care must ensure that the activities have
been implemented according to the
care plan
→ The nurse validate & responds to any
adverse findings or client response, this
may involve modifying nursing care

A

supervising delegated care

42
Q

→ the nurse completes the implementing
phase by recording the interventions &
client responses in the nursing progress
notes
→ Nursing care must not be recorded in
advance
→ The nurse may record routine or
recurring activities ( eg mouth care) in
the client record at the end of the shift

A

documenting nursing activities

43
Q

planned, ongoing, purposeful activity
in which the clients & health care
professionals determine:
→ the clients progress towards
achievement of goals/outcomes
→ The effectiveness of the nursing care
plan

A

evaluation

44
Q

The desired outcomes must be stated
concretely in _- terms

A

behavioral

45
Q

→ During assessment the nurse collects data
for the purposes of __

A

making diagnosis

46
Q

→ During evaluation the nurse collects data
for purposes of __

A

comparing it to preselected
goals/outcomes & judging the effectiveness
of the nursing care

47
Q

what are the components of the evaluation phase

A

collecting data
comparing data w desired outcomes
relating nursing acts
drawing conclusions ab problem stat
continuing, modifying, or terminating the nursing care plan

48
Q

The nurse collects data so that conclusions
can be drawn about whether

A

goals have been met

49
Q

• Data must be recorded _ and _ to facilitate the next part of
evaluating process

A

concisely &
accurately

50
Q

the client
response is the same as the desired
outcome

A

goal was met

51
Q

either a
short term outcome was achieved but the
long term goal was not, or desired goal
was incompletely attained

A

goal was partially met

52
Q

TRUE OR FALSE

It should never be assumed that a nursing
activity was the cause of or the only factor
in meeting, partially meeting, or not
meeting a goal

A

TRUE

53
Q

The actual problem stated in the nursing
diagnosis has been resolved or the
potential problem is being prevented &
risk factors no longer exist

A

drawing conclusions

54
Q

• The potential problem stated in the nursing
diagnosis is being prevented but the risk
factors are still present

A

drawing conclusions

55
Q

• The actual problem still exist even though
some goals are being met

A

drawing conclusions

56
Q

incomplete or incorrect database ; the nurse needs to

A

reassess the client and record new data (new data may indicate the need for
new nursing diagnosis, new goals, nursing
intervention)

57
Q

If the database is incomplete new
diagnostic statements may be required
• If the database is complete the nurse needs
to analyze whether the problems were
identified correctly & whether the nursing
diagnoses were relevant to the database

A

planning

58
Q

• If the nursing diagnosis was inaccurate,
obviously the goal/outcome statement will
need revision
• If the nursing diagnosis was appropriate
the nurse then checks if the goals were
realistic & attainable

A

desired outcomes

59
Q

Even all the sections of care plan appear
to be satisfactory, the manner in which the
plan was implemented may have
__

A

interfered with goal achievement

60
Q

an ongoing systematic process designed
to evaluate & promote excellence in the
health care provided to clients ; evaluation of level of care provided in health care agency ; limited to the evaluation of the performance

A

quality assurance program

61
Q

what are the components of quality assurance

A

structure evaluation
process evaluation
outcome evaluation

62
Q

Focuses on the setting in which care is
given

A

structure evaluation

63
Q

Focuses on how the care was given

A

process evaluation

64
Q

→ Focuses on demonstrable changes in the
client’s health status as a result of nursing
care

A

outcome evaluation

65
Q

Follows client’s care rather than
organizational structure ; process rather than individuals ; systematic approach with an intention of improving
quality of care rather than ensuring quality
of care.

A

quality improvement

66
Q

rather than individuals, uses a systematic
approach with an intention of improving
quality of care rather than ensuring quality
of care ; national voluntary standards for nursing sensitive care

A

national quality forum

67
Q

Refers to the examination or review of
records

A

audit

68
Q

→ Is the evaluation of a client’s record after
discharge from an agency
→ Relating to the past events

A

retrospective audit

69
Q

→ Is the evaluation of a client¡¦s health care
while the client is still receiving care from
the agency

A

concurrent audit