Term
| Why do nurses use critical thinking? |
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Definition
| to solve client problems and make better decisions. |
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Term
| What are the 5 phases of the nursing process? |
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Definition
*assessment
*diagnosis(analysis)
*planning
*implementation(intervention)
*evaluation
(A.D.P.I.E) |
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Term
| If a patient tells you they have had a great amount of pain in their joints, this is what type of data? |
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Definition
| Subjective data-(symptoms) |
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Term
| Blood pressure reading is what type of data? |
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Definition
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Term
| To complete the assessment phase what has to be done? |
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Definition
| The nurse needs to record the client data by using accurate documentation. |
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Term
| T/F nursing diagnosis is a medical diagnosis of the illness itself? |
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Definition
| F: nursing diagnosis is a response of/to illness. |
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Term
| Critical thinking involves the nurse differentiating between statements of fact, inference, judgment, and opinion. |
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Definition
fact= verified through investigation
Inference= conclusions drawn from fact, a statement about something not currently known.
Judgments=evaluation of facts, type of opinion.
Opinions-beliefs formed over time and include judgments that may fit facts or be in error. |
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Term
| A patient has diarrhea and the physician orders a bulk laxative daily. The nurse, doesn't realize that bulk laxatives can help solidify certain types of diarrhea and concludes"the physician does not know the patient has diarrhea." This is an example of what type of statement? |
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Definition
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Term
A patient says that he is hungry but whenever food is served he does not eat. Which of the following should you do?
1)Asses why the client is not eating the food.
2)Continue to leave the food at the bedside until the patient is hungry enough to eat.
3)Notify primary care provider that tube feeding may be indicated soon.
4)Believe the client is not hungry. |
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Definition
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Term
The client who is short of breath benefits from the head of the bed being elevated. Being this position can result in skin breakdown in the sacral area, the nurse decides to study the amount of sacral pressure occurring in other positions. This is an example of what?
1.The scientific method
2.The trial and error method
3.intuition
4.The nursing process |
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Definition
| 1. The scientific method. |
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Term
In the decision making process, the nurse sets and weights the criteria, examines alternatives, and performs which of the following before implementing the plan?
1.reexamine the purpose for making the decision
2.consults the client and family members to determine their view of the criteria
3.identifies and considers various means for reaching the outcomes
4.determines the logical course of action should intervening problems arise. |
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Definition
| 4.Determine the logical course of action, should intervening problems arise. |
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Term
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Definition
| all the information about a client. (ex. history, physical assessment. lab results..) |
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Term
| T/F The secondary source is the client. |
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Definition
| F: the primary source is the client. Secondary source is family members, heath records and reports, diagnostic analyses... |
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Term
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Definition
| reason the patient is visiting the doctors office/ hospital |
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Term
| To observe, you need to use some of your senses like what? |
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Definition
*sight
*smell
*hearing
*touch |
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Term
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Definition
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Term
Core attributes of critical thinking:
Reflection
Context
Dialogue
Time |
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Definition
Reflection:determining what data are relevant and making connections between that data and the decisions reached.
Context:an essential consideration in nursing, taking knowledge and applying it to real people.
Dialogue: the process of serving as both teacher and student.
Time: emphasizes past learning in current situations that then guide to future actions. |
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Term
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Definition
| systematic rational method of planning and providing individualized nursing care. |
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Term
These activities are part of which nursing phase? (A.D.P.I.E.)
Physical assessment
Health history
Review client records |
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Definition
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Term
These activities are part of which nursing phase? (A.D.P.I.E.)
Interpret and analyze data
Identify gaps and inconsistencies
Determine clients strengths, risks, diagnoses, and problems |
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Definition
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Term
These activities are part of which nursing phase? (A.D.P.I.E.)
Set priorities and goals/outcomes in collaboration with client
select nursing strategies/ interventions |
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Definition
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Term
These activities are part of which nursing phase? (A.D.P.I.E.)
Perform planned nursing interventions
Determine the nurse's need for assistance
Reassess the client to update the database |
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Definition
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Term
These activities are part of which nursing phase? (A.D.P.I.E.)
Judge whether goals/outcomes have been achieved
Relate nursing actions to client outcomes
Make decisions about problem status |
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Definition
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Term
which of the following behaviors is most representative of the nursing diagnosis phase of the nursing process?
1.Identifying major problems or needs?
2.Organizing data in the client's family history
3.reviews results of laboratory tests
4.documents care |
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Definition
| 1.Identifying major problems or needs |
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Term
Which of the following behaviors would indicate that the nurse was utilizing the assessment phase of the nursing process to provide nursing care?
1.Purpose hypothesis
2.Generates desired outcomes
3.Reviews results of lab tests
4.Administering an antibiotic |
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Definition
| 3.Reviews results of lab tests |
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Term
Which of the following elements is best categorized as secondary subjective data?
1.The nurse measures a weight loss of 10 pounds since the last clinic visit
2.Spouse states the client has lost all appetite
3.The nurse palpates edema in lower extremities
4.Client states severe pain when walking upstairs |
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Definition
| 2.Spouse states the client has lost all appetite |
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Term
Which interview question is most likely to elicit the clients feelings about a recent diagnosis?
1."What did the doctor tell you about your diagnosis?"
2."Are you worried about how the diagnosis will affect you in the future?"
3."Tell me your reactions to the diagnosis"
4."How is your family responding to the diagnosis?" |
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Definition
| 3."Tell me about your reactions to the diagnosis." |
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Term
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Definition
| Classification of categories arranged based on a single principle or set of principals. |
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Term
Types of nursing diagnoses:
*risk nursing diagnosis
*wellness diagnosis
*possible nursing diagnosis
*syndrome diagnosis |
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Definition
*nursing risk diagnosis- clinical judgment that a problem does not exist, but the presence of risk factors indicates that a problem is likely to develop unless nurses intervene.
*wellness diagnosis-"describes human responses to levels of wellness in an individual, family or community that have a readiness for enhancement"
*possible nursing diagnosis- evidence about a health problem is incomplete or unclear.
*syndrome diagnosis-diagnosis associated with a cluster of other diagnoses. |
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Term
| Qualifiers are words that give additional meaning to the diagnostic statement: |
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Definition
deficient
impaired
decreased
ineffective
compromised |
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Term
| Defining characteristics: |
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Definition
| the cluster of signs and symptoms that indicate the presence of a particular diagnostic label. |
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Term
| Nursing diagnostic process has three steps: |
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Definition
1) analyzing data
2) identifying health problems, risks, and strengths
3) formulating diagnostic statements |
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Term
| What are the three components of a nursing diagnosis? |
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Definition
1) problem
2) etiology
3) signs and symptoms |
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Term
The nurse is conducting the diagnosing phase for a client with a seizure disorder. Which of the following elements exists between data analysis and formulating the diagnostic statement?
1. assess the client's needs
2. delineate the client's problems and strengths
3. determine which interventions are most likely to succeed
4. estimate the cost of several different approaches |
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Definition
| 2. delineate the client's problems and strengths |
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Term
In the diagnostic statement "excess fluid volume related to decreased venous return as manifested by lower extremity edema," the etiology of this problem is which of the following?
1)excess fluid volume
2)decreased venous return
3)edema
4)unknown |
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Definition
| 2.decreased venous return |
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Term
Which of the following nursing diagnoses contains the proper components?
1)risk for caregiver role strain related to unpredictable illness course
2)risk for falls related to tendency to collapse when having difficulty breathing
3)decreased communication related to stroke
4)sleep deprivation secondary to fatigue and a noisy environment |
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Definition
| 1.Risk for caregiver role strain related to unpredictable illness course. |
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Term
One of the primary advantages of using a three-part diagnostic statement such as the problem-etiology-signs/symptoms (PES) format includes which of the following?
1)decreases the cost of health care
2)improves communication between nurse and client
3)helps the nurse focus on heath and wellness elements
4)standardizes organization of client data |
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Definition
| 4.standardizes organization of client data |
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Term
A collaborative (multidisciplinary)problem is indicated instead of a nursing or medical diagnosis:
1.if both medical and nursing interventions are required to treat the problem.
2.when independent nursing actions can be utilized to treat the problem.
3.in cases where nursing interventions are the primary actions required to treat the problem.
4.when no medical diagnosis (disease) can be determined. |
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Definition
| 1. If both medical and nursing interventions are required to treat the problem. |
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Term
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Definition
| "Any treatment based upon clinical judgment and knowledge, that a nurse performs to enhance patient/client outcomes" |
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Term
| Planning process engages in these activities: |
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Definition
*setting priorities
*establishing client goals/desired outcomes
*selecting nursing interventions
*writing individualized nursing interventions on care plans |
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Term
After being admitted directly to the surgery unit a 75-yr-old client who had elective surgery to replace an arthritic hip was discharged from the postanesthesia recovery unit. The client has been on the orthopedic floor several hours. Which of the following types of planning will be least useful during the first shift on the orthopedic unit?
1. initial
2. ongoing
3. discharge
4. strategic |
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Definition
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Term
The client with a fractured pelvis requests that family members be allowed to stay overnight in the hospital room. Before determining whether or not this request can be honored, the nurse should consult which of the following?
1. hospital policies
2. standardized care plans
3. orthopedic protocols
4. standards of care |
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Definition
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Term
The nurse assesses a postoperative client with an abdominal wound and finds the client drowsy when not aroused. The client's pain is ranked a 2 (0-!0) scale, vital signs are within range, extremities are warm but with very dry skin. The client declines oral fluids due to nausea, and reports no bowel movement in the past 2 days. Hip dressing is dry with drains intact. Which of the following is considered high priority for a change in the current care plan?
1.pain
2.nausea
3.constipation
4.potential for wound infection |
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Definition
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Term
The nurse selects the nursing diagnosis of Risk for Impaired Skin Integrity related to immobility, dry skin, and surgical incision. Which of the following represents a properly stated outcome/ goal? the client will:
1. turn in bed q2h
2. report the importance of applying lotion to skin daily
3. have intact skin during hospitalization
4. use a pressure-reducing mattress |
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Definition
| 3. have intact skin during hospitalization |
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Term
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Definition
| doing and documenting the activities that are the specific nursing actions needed to carry out the interventions. |
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Term
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Definition
| Unexpected occurrence involving death or serious physical or psychological injury or the risk thereof. |
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Term
When initiating the implementation phase of the nursing process, the nurse performs which of the following steps first?
1. carrying out nursing interventions
2. determining the need for assistance
3. reassessing the client
4. documenting interventions |
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Definition
| 3. reassessing the client |
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Term
| T/F It is acceptable practice to document a nursing activity before it is carried out in certain circumstances? |
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Definition
| F: It is NEVER acceptable to document before performing the nursing activity. |
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Term
| The primary purpose for the evaluation phase is what? |
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Definition
| to determine that desired outcomes have been met. |
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Term
The process of implementing should be:
*Reassessing the client
*determining the nurse's need for assistance
*implementing the nursing interventions
*supervising the delegated care
*documenting nursing activities |
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Definition
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