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Funda LEC > Nursing Process > Flashcards

Nursing Process Flashcards

1
Q

involves identifying the problem and making choices that direct the course toward the desired
outcome.

A

problem solving

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2
Q

a generic process that can be applied to any problem.

A

problem solving

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3
Q

places emphasis on judgment, priorities and decision making.

A

problem-solving process

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4
Q

encourages clinical judgment and accountability.

A

problem-solving process

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5
Q

the foundation of nursing process, but the term cannot be used interchangeably.

A

problem-solving process

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6
Q

the systematic identification of a problem.

A

(1) problem-solving process

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7
Q

determination of goals related to the problem.

A

(2) problem-solving process

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8
Q

identification of possible solutions to achieve these goals.

A

(3) problem-solving process

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9
Q

implementation of selected solutions.

A

(4) problem-solving process

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10
Q

evaluation of goal achievement.

A

(5) problem-solving process

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11
Q

counterpart of data collection in the problem-solving process to nursing process?

A

assessment
- data collection
- data interpretation

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12
Q

counterpart of problem definition in the problem-solving process to nursing process?

A

nursing diagnosis

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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)

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14
Q

counterpart of implementation in the problem-solving process to nursing process?

A

implementation

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15
Q

counterpart of evaluate and revise process in problem-solving process to nursing process?

A

evaluation and modification

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16
Q

the cornerstone of the nursing profession.

A

nursing process

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17
Q

Skill in utilizing the nursing process
is essential for the clinical application of ___ and ___ in nursing practice.

A

knowledge, theory

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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

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19
Q

Through the ___, nursing was able to be its
own specific body of knowledge.

A

nursing process

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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

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21
Q

introduced three steps of nursing process as follows: Assessment, decision, nursing
action (1959).

A

dorothy johnson

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22
Q

identified three steps of nursing process: client’s behavior, nurse’s reaction, nurse’s
action (1961).

A

ida jean orlando

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23
Q

suggested the four components of nursing process namely, assessing, planning,
implementing, and evaluating (1967).

A

yura and walsh

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24
Q

described nursing process as discover, delve, decide, do, discriminate (1967).

A

knowles

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25
Q

5 D of nursing process.

A

discover, delve, decide, do, discriminate

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26
Q

four components of nursing process.

A

assessing, planning, implementing, and evaluating

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27
Q

three steps of nursing process (1961)

A

client’s behavior, nurse’s reaction, nurse’s
action

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28
Q

3 steps of nursing process (1959)

A

Assessment, decision, nursing
action

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29
Q

who assigned the six steps of nursing process?

A

American Nurses Association

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30
Q

Diagnosis distinguished a separate step of nursing process (1973)

A

American Nurses Association

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31
Q

Diagnosis of actual and potential health problems delineated as integral part of nursing practice (1980)

A

American Nurses Association

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32
Q

steps of nursing process: lydia hall

A

note observation, ministration of care, validation.

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33
Q

steps of nursing process: dorothy johnson

A

Assessment, decision, nursing action (1959).

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34
Q

steps of nursing process: ida jean orlando

A

client’s behavior, nurse’s reaction, nurse’s
action (1961).

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35
Q

steps of nursing process: yura and walsh

A

assessing, planning, implementing, and evaluating (1967).

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36
Q

nursing process: knowles

A

discover, delve, decide, do, discriminate (1967).

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37
Q

what makes the nursing process efficient and effective (4)

A

organized, systematic, goal oriented, and humanistic care

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38
Q

Is collecting, validating, organizing and recording data about the clients health status (May be an individual, family or community).

A

assessment

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39
Q

to establish a data base.

A

assessment

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40
Q

Gathering of information about the client, considering the physical, psychological, emotional, socio-cultural and spiritual factors that may affect his/her health status.

A

collection of data

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41
Q

two types of data

A

subjective data (symptoms) and objective data (signs)

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42
Q

Those that can be describe only by the person experiencing it, e.g. vertigo (dizziness), pain, tinnitus (ringing of the ears).

A

subjective data (symptoms)

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43
Q

Those that can be observed and measured e.g. pallor, diaphoresis, BP-120/80, reddish urine.

A

objective data (signs)

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44
Q

two methods of data collection

A

interview and observation

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45
Q

planned purposeful conversation

A

interview

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46
Q

E.g. use of senses, use units of measure, physical examination techniques, interpretation of laboratory results.

A

observation

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47
Q

two sources of data

A

primary and secondary

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48
Q

source of data: patient/client

A

primary

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49
Q

source of data: Family members, Significant others, Patient’s record/chart, Health team members, Related literature.

A

secondary

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50
Q

Making sure your information is accurate.

A

verifying/validating data

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51
Q

Clustering facts into groups of information.

A

organizing data

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52
Q

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.

A

nursing diagnosis

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53
Q

nursing diagnoses foster the nurse’s independent or dependent interventions?

A

independent

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54
Q

(e.g., patient comfort or relief)

A

independent practice

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55
Q

interventions driven by physician’s orders (e.g., medication administration).

A

dependent

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56
Q

nursing diagnoses are developed based on data obtained during the?

A

nursing assessment

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57
Q

To identify client’s health care needs and to prepare diagnostic statements.

A

nursing diagnosis

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58
Q

primary organization for defining, researching, revising, distributing
and integrating standardized nursing diagnoses worldwide.

A

NANDA-I (North American Nursing Diagnosis Association)

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59
Q

what is included in the NANDA nursing diagnoses?

A

definitions, defining characteristics, related factors or risk factors

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60
Q

NANDA-I has worked in the nursing diagnoses field for about?

A

45 years

61
Q

The taxonomy of the nursing diagnoses created by NANDA-I is translated into how many languages?

A

18 languages

62
Q

Nursing diagnoses are a critical part of ensuring that the knowledge and contribution of nursing practice to patient outcomes are found within the?

A

electronic health record (HER)

63
Q

three part of the NANDA-I system nursing diagnosis

A

diagnostic label/human response, related factors or cause of the response, and defining characteristics

64
Q

A clinical judgment about human experience/responses to health conditions/life processes that exist in an individual, family, or community. (ex. sleep deprivation)

A

problem-focused diagnosis

65
Q

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

A

risk diagnosis

66
Q

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.

A

health promotion diagnosis

67
Q

sleep deprivation

A

problem-focused diagnosis

68
Q

A clinical judgment describing a specific cluster of nursing diagnoses that occur together, and are best addressed together and through similar interventions.

A

syndrome diagnosis

69
Q

risk of shock

A

risk diagnosis

70
Q

readiness for enhanced nutrition

A

health promotion diagnosis

71
Q

relocation stress syndrome

A

syndrome diagnosis

72
Q

three components of nursing diagnosis

A

P - problem statement/label/definition, E - etiology/related factors/causes, S - signs and symptoms/defining characteristics

73
Q

components of problem-focused or actual diagnoses

A

PES

74
Q

components of risk diagnoses

A

PE

75
Q

components of health promotion or wellness diagnoses

A

P

76
Q

comprises a cluster of problems

A

syndrome diagnoses

77
Q

rules for writing nursing diagnoses: what to state? human response or client need?

A

human response

78
Q

rules for writing nursing diagnoses: how to connect human response to etiology? related to or due to?

A

related to

79
Q

it means to analyze assessment information and derive meaning from this analysis.

A

to diagnose in nursing

80
Q

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.

A

first

81
Q

which is correct: High risk for injury related to absence of side rails or High risk for injury related to disorientation.

A

second

82
Q

which is correct: Mastectomy related to cancer or High risk for self-concept disturbance related to the effects of mastectomy (surgical
removal of breast).

A

second

83
Q

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.

A

planning

84
Q

To identify the client’s goals and appropriate nursing interventions

A

planning

85
Q

To direct client activities

A

planning

86
Q

To promote continuity of care

A

planning

87
Q

To focus charting requirements

A

planning

88
Q

To allow for delegation of specific activities.

A

planning

89
Q

To direct activities to be carried out in the implementation phase.

A

plan nursing interventions

90
Q

“any treatment base upon clinical judgment and knowledge that a nurse performs to enhance client outcomes”

A

nursing interventions

91
Q

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

A

nursing interventions

92
Q

nursing interventions are also called?

A

nursing orders

93
Q

independent, dependent and interdependent activities that nurses carry out to provide client care

A

nursing intervention

94
Q

a written summary of the care that a client to receive.

A

nursing plan of care

95
Q

blueprint of the nursing process

A

nursing plan of care

96
Q

what must be identified for each goal?

A

outcome criteria

97
Q

what are called to substantiate nursing diagnosis?

A

sufficient data

98
Q

each intervention should be supported by a?

A

scientific rationale

99
Q

justification or reason for caring out in the intervention

A

scientific rationale

100
Q

address whether each goal was completely met, partially met, or completely unmet.

A

evaluation

101
Q

Refers to formulating and documenting measurable, realistic, client-focused goals. It provides the basis for evaluating nursing diagnosis.

A

outcome identification

102
Q

To provide individualized care

A

outcome identification

103
Q

To promote client participation

A

outcome identification

104
Q

To plan care that is realistic and measurable

A

outcome identification

105
Q

To allow involvement of support people.

A

outcome identification

106
Q

Established priorities

A

outcome identification

107
Q

is something that takes precedence in position, deemed the most important among several items.

A

priority

108
Q

a decision-making process that ranks the order of nursing diagnoses in terms of importance to the client.

A

priority setting

109
Q

what should be given the highest priority?

A

life-threatening situations (airway), or use the principle of ABC

110
Q

potentially life-threatening and require
immediate action. Examples include Impaired Gas Exchange, Ineffective Breathing Pattern, and Self-directed Risks for Violence.

A

high-priority nursing diagnoses

111
Q

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.

A

medium-priority nursing diagnoses

112
Q

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.

A

low-priority nursing diagnoses

113
Q

an educated guess, made as broad statement, about what the client’s state will be after the nursing intervention is carried out.

A

client goal

114
Q

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.

A

behavioral goals

115
Q

description of the parameter for achieving the goal.

A

qualifier

116
Q

description of the parameter for achieving the goal.

A

short-term goals

117
Q

requires more time (several weeks or months).

A

long-term goals

118
Q

specific, measurable, realistic statements of goal attainment.

A

outcome criteria

119
Q

written in a manner that answers the questions: who, what actions, under what circumstances, how well, and when.

A

outcome criteria

120
Q

the characteristics of well stated outcome criteria are?

A

SMART

121
Q

meaning of SMART

A

S - specific, M - measurable, A - attainable, R - realistic, and T - time-framed

122
Q

how do you describe a defining characteristic in a nursing diagnoses?

A

manifested by

123
Q

A broadly stated objective that indicates an overall picture of the state of the client if the problem is resolved

A

client goal

124
Q

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.

A

client outcome criteria

125
Q

Is putting the nursing care plan into action.

A

implementation

126
Q

To carry out plan of nursing intervention to help the client attain goals and achieve optimal level of health.

A

implementation

127
Q

four activities during implementation

A

reassessing, set priorities, perform nursing intervention, and record actions

128
Q

activity during implementation: To ensure prompt attention to emerging problems

A

reassessing

129
Q

activity during implementation: To determine the order in which nursing interventions are carried out.

A

set priorities

130
Q

activity during implementation: This may be independent, dependent, or collaborative measure.

A

perform nursing intervention

131
Q

activity during implementation: To complete nursing interventions, relevant documentation should be done.

A

record actions

132
Q

rule of documentation

A

something that is not written is considered as not done

133
Q

four requirements of implementation

A

knowledge, technical skills, communication skills, and therapeutic use of self

134
Q

requirement of implementation: Include intellectual skills like problem-solving, decision-making, and teaching.

A

knowledge

135
Q

requirement of implementation: To carry out treatments and procedures

A

technical skills

136
Q

requirement of implementation: Use the verbal and non-verbal communication to carry out planned nursing interventions.

A

communication skills

137
Q

requirement of implementation: It is willing and being able to care.

A

therapeutic use of self

138
Q

three types of nursing interventions

A

independent or nurse-initiated, dependent or physician-initiated, and interdependent or collaborative

139
Q

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.

A

independent or nurse-initiated interventions

140
Q

Can solve the client’s problems without consultation or collaboration with the physician or other health care professionals.

A

independent or nurse-initiated interventions

141
Q

Are based on the physician’s response to a medical diagnosis.

A

dependent or physician-initiated interventions

142
Q

The nurse intervenes by carrying out physician’s written orders, but requires nursing judgment or decision making.

A

dependent or physician-initiated interventions

143
Q

Are therapies that require the knowledge, skills and expertise of multiple health care
professionals.

A

interdependent or collaborative interventions

144
Q

Is assessing the client’s response to nursing intervention and then comparing the response to predetermined standards or outcome criteria.

A

evaluation

145
Q

To appraise the extent to which goals and outcomes criteria of nursing cares have been achieved.

A

evaluation

146
Q

what to compare during evaluation

A

client’s response to goal and outcomes criteria

147
Q

nursing process requires that the nurse communicates directly and consistently with the client.

A

interpersonal

148
Q

nursing process steps may overlap because they are interrelated.

A

cyclical

149
Q

nursing process is applicable to individuals, families and communities.

A

universal

Funda LEC (2 decks)

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