Nursing Process Key Terms

Question 1

thought that is disciplined, comprehensive, based on intellectual standards, and well-reasoned

a systemic way to form and shape thoughts that functions purposefully and exactingly

Answer 1

Critical Thinking

Question 2

ways of thinking about patient care issues

determining, preventing, and managing patient problems

Answer 2

Clinical Reasoning

Question 3

refers to result of critical thinking or clinical reasoning

conclusion/decision a nurse makes

Answer 3

Clinical Judgment

Question 4

between caregiver and patient that is focused on promoting or restoring health and well-being of the patient

Answer 4

Therapeutic Relationships

Question 5

care of patient by clinician who utilizes clinical reasoning and reflective practice to guide

Answer 5

Thoughtful Practice

Question 6

model of patient care based on holistic roots in which nurse uses every clinical encounter to assess how patient is doing and communicating respect, care, and compassion

Answer 6

Person-Centered Care

Question 7

direct understanding of a situation based on a background of experience, knowledge, and skill that makes expert decision making possible

Answer 7

Intuitive Problem Solving

Question 8

5-step systematic process for giving patient care

assessing, diagnosing, planning, implementing, evaluting

Answer 8

Nursing Process

Question 9

to systematically and continuously collect, validate, and communicate patient data

Answer 9

Assessing

Question 10

significant info that is helpful in making decisions

Answer 10

Cue

Question 11

judgment reached about a cue

Answer 11

Inference

Question 12

comes from the patient or the patient’s family

abstract data like symptoms (pain)

Answer 12

Subjective Data

Question 13

can be measured

vital signs, inspection, palpation, etc

Answer 13

Objective Data

Question 14

assess a specific problem

Answer 14

Focused Assessment

Question 15

rapid focused assessment conducted when addressing a life-threatening or unstable situation

Answer 15

Emergency Assessment

Question 16

scheduled exam to compare patient’s current status to baseline data obtained earlier

Answer 16

Time-Lapsed Assessment

Question 17

comprehensive nursing assessment resulting in baseline data

Answer 17

Initial Assessment

Question 18

conscious and deliberate use of 5 senses to gather data

Answer 18

Observation

Question 19

act of confirming/verifying

Answer 19

Validation

Question 20

analysis of patient data to identify patient strengths and health problems that independent nursing intervention can prevent or resolve

Answer 20

Diagnosing

Question 21

actual or potential health problem that independent nursing interventions can prevent or resolve

defining characteristics are present as risk factors

Answer 21

Nursing Diagnosis

Question 22

statement about a specific disease process using terminology from a well-developed classification system accepted by medical profession

Answer 22

Medical Diagnosis

Question 23

acceptable, expected level of performance established by authority, custom or consent

Answer 23

Standard

Question 24

grouping of patient data or cues that points to existence of patient health problem

Answer 24

Data Cluster

Question 25

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

Answer 25

Expected Outcome

Question 26

an aim or an end

Answer 26

Goal

Question 27

establish patient goals to prevent, reduce, or resolve the problems identified in nursing diagnoses and determination of related nursing interventions

Answer 27

Planning

Question 28

observation of patient to demonstrate resolution of problems identified by nursing diagnoses and general problem list, along w/ time frame for accomplished these outcomes

Answer 28

Outcome Identification

Question 29

written guide to direct the efforts of the nursing team as they work with the patient to meet health goals

specifies prioritized nursing diagnoses, patient goals, and nursing orders

Answer 29

Nursing Care Plan

Question 30

any treatment, based on clinical judgment and knowledge, that a nurse performs to enhance patient outcomes

there are nurse-initiated, physician-initiated, and collaborative interventions

Answer 30

Nursing Intervention

Question 31

specified behavior

Answer 31

Criteria

Question 32

carry out the plan of care

Answer 32

Implementing

Question 33

transfer of responsibility for the performance of an activity to another individual while retaining accountability for the outcome

Answer 33

Delegation

Question 34

individual who is trained to function in an assistive role to the licensed registered nurse in the provision of patient activities as delegated by and under the supervision of the registered professional nurse

Answer 34

Unlicensed Assistive Personnel (UAPs)

Question 35

ongoing process of questioning and evaluating practice and advancing informed practice

Answer 35

Clinical Inquiry

Question 36

document that details the nursing care to be implemented in specific nursing situations, frequently when a physician is not present

may expand scope of nursing responsibilities

Answer 36

Standing Orders

Question 37

written plan that details the nursing care to be implemented in specific situations

Answer 37

Protocols

Question 38

measurement of extent to which patient has achieved goals specified in plan of care

Answer 38

Evaluating

Question 39

rules or guidelines that allow nurses to carry out professional roles, serving as protection for the nurses, the patient, and the institution where health care is given

Answer 39

Standards

Question 40

judgment summarizing nurse’s findings after data have been collected and interpreted to determine patient outcome achievement

Answer 40

Evaluative Statement

Question 41

objective and subjective data

Answer 41

Assessment

Question 42

priority problem

could be actual or potential problem

Answer 42

Diagnosis

Question 43

Goals/Outcomes

prioritizing long term and short term goals

Maslow’s Heirarchy of Needs

ABCs - Airway, Breathing, Circulation

Answer 43

Plan

Question 44

Take Action!

complex - teaching plans
simple - raise head of bed

Answer 44

Intervention

Question 45

Was the intervention successful?
- Did they improve?
- Did they remain the same?
- Did they decline?

Answer 45

Evaluation