Nursing Process Flashcards
1
Q
involves identifying the problem and making choices that direct the course toward the desired
outcome.
A
problem solving
2
Q
a generic process that can be applied to any problem.
A
problem solving
3
Q
places emphasis on judgment, priorities and decision making.
A
problem-solving process
4
Q
encourages clinical judgment and accountability.
A
problem-solving process
5
Q
the foundation of nursing process, but the term cannot be used interchangeably.
A
problem-solving process
6
Q
the systematic identification of a problem.
A
(1) problem-solving process
7
Q
determination of goals related to the problem.
A
(2) problem-solving process
8
Q
identification of possible solutions to achieve these goals.
A
(3) problem-solving process
9
Q
implementation of selected solutions.
A
(4) problem-solving process
10
Q
evaluation of goal achievement.
A
(5) problem-solving process
11
Q
counterpart of data collection in the problem-solving process to nursing process?
A
assessment
- data collection
- data interpretation
12
Q
counterpart of problem definition in the problem-solving process to nursing process?
A
nursing diagnosis
13
Q
counterpart of plan (goal setting and identify solution) in the problem-solving process to nursing process?
A
plan
- goal identification / nursing outcomes classification (NOC)
- plan intervention / nursing intervention classification (NIC)
14
Q
counterpart of implementation in the problem-solving process to nursing process?
A
implementation
15
Q
counterpart of evaluate and revise process in problem-solving process to nursing process?
A
evaluation and modification
16
Q
the cornerstone of the nursing profession.
A
nursing process
17
Q
Skill in utilizing the nursing process
is essential for the clinical application of ___ and ___ in nursing practice.
A
knowledge, theory
18
Q
T/F: Nursing process is synonymous with the problem-solving approach for considering the healthcare and nursing care needs of the clients.
A
True
19
Q
Through the ___, nursing was able to be its
own specific body of knowledge.
A
nursing process
20
Q
originated the term Nursing Process in 1955. She introduced three-steps of nursing process: note observation, ministration of care, validation.
A
lydia hall
21
Q
introduced three steps of nursing process as follows: Assessment, decision, nursing
action (1959).
A
dorothy johnson
22
Q
identified three steps of nursing process: client’s behavior, nurse’s reaction, nurse’s
action (1961).
A
ida jean orlando
23
Q
suggested the four components of nursing process namely, assessing, planning,
implementing, and evaluating (1967).
A
yura and walsh
24
Q
described nursing process as discover, delve, decide, do, discriminate (1967).
A
knowles
25
5 D of nursing process.
discover, delve, decide, do, discriminate
26
four components of nursing process.
assessing, planning, implementing, and evaluating
27
three steps of nursing process (1961)
client’s behavior, nurse’s reaction, nurse’s
action
28
3 steps of nursing process (1959)
Assessment, decision, nursing
action
29
who assigned the six steps of nursing process?
American Nurses Association
30
Diagnosis distinguished a separate step of nursing process (1973)
American Nurses Association
31
Diagnosis of actual and potential health problems delineated as integral part of nursing practice (1980)
American Nurses Association
32
steps of nursing process: lydia hall
note observation, ministration of care, validation.
33
steps of nursing process: dorothy johnson
Assessment, decision, nursing action (1959).
34
steps of nursing process: ida jean orlando
client’s behavior, nurse’s reaction, nurse’s
action (1961).
35
steps of nursing process: yura and walsh
assessing, planning, implementing, and evaluating (1967).
36
nursing process: knowles
discover, delve, decide, do, discriminate (1967).
37
what makes the nursing process efficient and effective (4)
organized, systematic, goal oriented, and humanistic care
38
Is collecting, validating, organizing and recording data about the clients health status (May be an individual, family or community).
assessment
39
to establish a data base.
assessment
40
Gathering of information about the client, considering the physical, psychological, emotional, socio-cultural and spiritual factors that may affect his/her health status.
collection of data
41
two types of data
subjective data (symptoms) and objective data (signs)
42
Those that can be describe only by the person experiencing it, e.g. vertigo (dizziness), pain, tinnitus (ringing of the ears).
subjective data (symptoms)
43
Those that can be observed and measured e.g. pallor, diaphoresis, BP-120/80, reddish urine.
objective data (signs)
44
two methods of data collection
interview and observation
45
planned purposeful conversation
interview
46
E.g. use of senses, use units of measure, physical examination techniques, interpretation of laboratory results.
observation
47
two sources of data
primary and secondary
48
source of data: patient/client
primary
49
source of data: Family members, Significant others, Patient’s record/chart, Health team members, Related literature.
secondary
50
Making sure your information is accurate.
verifying/validating data
51
Clustering facts into groups of information.
organizing data
52
A part of the Nursing Process, and is a clinical judgment about individual, family, or community experiences / responses to actual or potential health problems / life processes.
nursing diagnosis
53
nursing diagnoses foster the nurse's independent or dependent interventions?
independent
54
(e.g., patient comfort or relief)
independent practice
55
interventions driven by physician's orders (e.g., medication administration).
dependent
56
nursing diagnoses are developed based on data obtained during the?
nursing assessment
57
To identify client’s health care needs and to prepare diagnostic statements.
nursing diagnosis
58
primary organization for defining, researching, revising, distributing
and integrating standardized nursing diagnoses worldwide.
NANDA-I (North American Nursing Diagnosis Association)
59
what is included in the NANDA nursing diagnoses?
definitions, defining characteristics, related factors or risk factors
60
NANDA-I has worked in the nursing diagnoses field for about?
45 years
61
The taxonomy of the nursing diagnoses created by NANDA-I is translated into how many languages?
18 languages
62
Nursing diagnoses are a critical part of ensuring that the knowledge and contribution of nursing practice to patient outcomes are found within the?
electronic health record (HER)
63
three part of the NANDA-I system nursing diagnosis
diagnostic label/human response, related factors or cause of the response, and defining characteristics
64
A clinical judgment about human experience/responses to health conditions/life processes that exist in an individual, family, or community. (ex. sleep deprivation)
problem-focused diagnosis
65
Describes human responses to health conditions/life processes that may develop in a vulnerable individual/family/community.
risk diagnosis
66
A clinical judgment about a person’s, family’s or community’s motivation and desire to increase wellbeing and actualize human health potential as expressed in the readiness to enhance specific health behaviors, and can be used in any health state.
health promotion diagnosis
67
sleep deprivation
problem-focused diagnosis
68
A clinical judgment describing a specific cluster of nursing diagnoses that occur together, and are best addressed together and through similar interventions.
syndrome diagnosis
69
risk of shock
risk diagnosis
70
readiness for enhanced nutrition
health promotion diagnosis
71
relocation stress syndrome
syndrome diagnosis
72
three components of nursing diagnosis
P - problem statement/label/definition, E - etiology/related factors/causes, S - signs and symptoms/defining characteristics
73
components of problem-focused or actual diagnoses
PES
74
components of risk diagnoses
PE
75
components of health promotion or wellness diagnoses
P
76
comprises a cluster of problems
syndrome diagnoses
77
rules for writing nursing diagnoses: what to state? human response or client need?
human response
78
rules for writing nursing diagnoses: how to connect human response to etiology? related to or due to?
related to
79
it means to analyze assessment information and derive meaning from this analysis.
to diagnose in nursing
80
which is correct: High risk for ineffective airway clearance related to thick, copious mucus secretions or High risk for ineffective airway clearance related to
pneumonia.
first
81
which is correct: High risk for injury related to absence of side rails or High risk for injury related to disorientation.
second
82
which is correct: Mastectomy related to cancer or High risk for self-concept disturbance related to the effects of mastectomy (surgical
removal of breast).
second
83
Involves determining beforehand the strategies or course of actions to be taken before implementation of nursing care. To be effective, involve client and his family in planning.
planning
84
To identify the client’s goals and appropriate nursing interventions
planning
85
To direct client activities
planning
86
To promote continuity of care
planning
87
To focus charting requirements
planning
88
To allow for delegation of specific activities.
planning
89
To direct activities to be carried out in the implementation phase.
plan nursing interventions
90
“any treatment base upon clinical judgment and knowledge that a nurse performs to enhance client outcomes”
nursing interventions
91
used to monitor health status; prevent, resolve, or control a problem; assist of activities of daily living (ADL’s); or promote optimum health and independence
nursing interventions
92
nursing interventions are also called?
nursing orders
93
independent, dependent and interdependent activities that nurses carry out to provide client care
nursing intervention
94
a written summary of the care that a client to receive.
nursing plan of care
95
blueprint of the nursing process
nursing plan of care
96
what must be identified for each goal?
outcome criteria
97
what are called to substantiate nursing diagnosis?
sufficient data
98
each intervention should be supported by a?
scientific rationale
99
justification or reason for caring out in the intervention
scientific rationale
100
address whether each goal was completely met, partially met, or completely unmet.
evaluation
101
Refers to formulating and documenting measurable, realistic, client-focused goals. It provides the basis for evaluating nursing diagnosis.
outcome identification
102
To provide individualized care
outcome identification
103
To promote client participation
outcome identification
104
To plan care that is realistic and measurable
outcome identification
105
To allow involvement of support people.
outcome identification
106
Established priorities
outcome identification
107
is something that takes precedence in position, deemed the most important among several items.
priority
108
a decision-making process that ranks the order of nursing diagnoses in terms of importance to the client.
priority setting
109
what should be given the highest priority?
life-threatening situations (airway), or use the principle of ABC
110
potentially life-threatening and require
immediate action. Examples include Impaired Gas Exchange, Ineffective Breathing Pattern, and Self-directed Risks for Violence.
high-priority nursing diagnoses
111
could result in unhealthy consequences,
such as physical and emotional impairment, but are not life-threatening. Examples include
Fatigue, Activity Intolerance, Ineffective Coping, and Dysfunctional Grieving.
medium-priority nursing diagnoses
112
problems that usually can be resolved easily with minimal interventions and are unlikely to significant dysfunction. Examples include sensation of hunger in a client who is NPO in preparation for a diagnostic procedure, minimal pain on the third postoperative day, related to ambulation.
low-priority nursing diagnoses
113
an educated guess, made as broad statement, about what the client’s state will be after the nursing intervention is carried out.
client goal
114
written to indicate a desired state. They contain an action verb and a qualifier
that indicate the level of performance that needs to be achieved.
behavioral goals
115
description of the parameter for achieving the goal.
qualifier
116
description of the parameter for achieving the goal.
short-term goals
117
requires more time (several weeks or months).
long-term goals
118
specific, measurable, realistic statements of goal attainment.
outcome criteria
119
written in a manner that answers the questions: who, what actions, under what circumstances, how well, and when.
outcome criteria
120
the characteristics of well stated outcome criteria are?
SMART
121
meaning of SMART
S - specific, M - measurable, A - attainable, R - realistic, and T - time-framed
122
how do you describe a defining characteristic in a nursing diagnoses?
manifested by
123
A broadly stated objective that indicates an overall picture of the state of the client if the problem is resolved
client goal
124
Specific, measurable, realistic statement that can be evaluated to judge goal attainment. Stated as behavioral objectives, they include the verb, a short phrase describing the specific measure to be accomplished, and a time reference.
client outcome criteria
125
Is putting the nursing care plan into action.
implementation
126
To carry out plan of nursing intervention to help the client attain goals and achieve optimal level of health.
implementation
127
four activities during implementation
reassessing, set priorities, perform nursing intervention, and record actions
128
activity during implementation: To ensure prompt attention to emerging problems
reassessing
129
activity during implementation: To determine the order in which nursing interventions are carried out.
set priorities
130
activity during implementation: This may be independent, dependent, or collaborative measure.
perform nursing intervention
131
activity during implementation: To complete nursing interventions, relevant documentation should be done.
record actions
132
rule of documentation
something that is not written is considered as not done
133
four requirements of implementation
knowledge, technical skills, communication skills, and therapeutic use of self
134
requirement of implementation: Include intellectual skills like problem-solving, decision-making, and teaching.
knowledge
135
requirement of implementation: To carry out treatments and procedures
technical skills
136
requirement of implementation: Use the verbal and non-verbal communication to carry out planned nursing interventions.
communication skills
137
requirement of implementation: It is willing and being able to care.
therapeutic use of self
138
three types of nursing interventions
independent or nurse-initiated, dependent or physician-initiated, and interdependent or collaborative
139
Are autonomous actions based on scientific rationale that is executed to benefit the client in a predicted way related to the nursing diagnosis and client-centered goals.
independent or nurse-initiated interventions
140
Can solve the client’s problems without consultation or collaboration with the physician or other health care professionals.
independent or nurse-initiated interventions
141
Are based on the physician’s response to a medical diagnosis.
dependent or physician-initiated interventions
142
The nurse intervenes by carrying out physician’s written orders, but requires nursing judgment or decision making.
dependent or physician-initiated interventions
143
Are therapies that require the knowledge, skills and expertise of multiple health care
professionals.
interdependent or collaborative interventions
144
Is assessing the client’s response to nursing intervention and then comparing the response to predetermined standards or outcome criteria.
evaluation
145
To appraise the extent to which goals and outcomes criteria of nursing cares have been achieved.
evaluation
146
what to compare during evaluation
client's response to goal and outcomes criteria
147
nursing process requires that the nurse communicates directly and consistently with the client.
interpersonal
148
nursing process steps may overlap because they are interrelated.
cyclical
149
nursing process is applicable to individuals, families and communities.
universal
