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Fundamentals Ch16-20
Test 2
Question | Answer |
---|---|
The Nursing Process is the fundamental... | blueprint for how to care for patients. |
the Nursing Process is also a standard of practice, which, when followed correctly, protects nurses... | against legal problems related to nursing care. |
With the Nursing Process, you perform assessment to gather information needed to... | make an accurate judgement about a patient's current condition. |
The data collected during assessment is obtained from either:... (5) | the patient, the family, a member of the health care team, medical records, or medical literature. |
Data is collected through the patient via... (3) | patient-centered interviews, nursing health history, physical examination, results of lab/diagnostic tests. |
A successful patient-centered interview requires... | preparation. |
A patient-centered interview involves... (4) | setting the stage & agenda, collecting the assessment/nursing health history, terminating the interview. |
When *setting the stage*, before you can collect personal health data, a patient has to sign... | an authorization. due to HIPPAA regulations. |
When *setting an agenda* during a patient-centered interview, ask the patient for... | a list of chief concerns or problems. |
When collecting an assessment or nursing health history during a patient-centered interview, start with... | open-ended questions. |
When *terminating the interview* during a patient-centered interview, include both... | a summary, and accuracy check of information collected. |
Patients are forced do describe situations with more than one or two words when you use... | open-ended questions. |
Back channeling involves using... | active listening prompts, such as "go on" and "uh-huh." |
Back channeling encourages a patient to... | give more information. |
When *probing* a patient during an interview, ask as many questions as you can until the patient... | has nothing else to say. |
Clarify previous information by asking... | close-ended questions. |
You gather a *nursing health history* during either... | your initial or an early contact with the patient. |
The information in a patient's health history provides data on both... | the patient's health care experiences and current health habits. |
You can collect data on a patient's self-reported data on all body systems with the... | *Review of Systems* (*ROS*) |
A physical examination is used to collect data by investigating the body to... | determine its state of health. |
Data is collected from diagnostic and laboratory tests which provide further explanations of alterations or problems identified during either... | the nursing health history, or physical examination. |
One critical thinking aspect of assessment is continuous *interpretation* of... | data. |
As you *interpret data* and form a database, you begin to see *data clusters* which are... | groups of signs and symptoms that you group together in a logical way. |
Data clusters clearly identify a patient's... | health problems. |
To avoid making incorrect inferences, before you complete *data interpretation* always... | *validate the data*. |
*Validation* of assessment data is... | the comparison of data with another source to determine data accuracy. |
*Data validation* opens the door for... | gathering more assessment data. |
Data validation opens the door for gathering more assessment data because it involves... | clarifying vague or unclear data. |
identification of a disease based on eval of physical s/s, the pts medical hx & results of diagn tests & procedures medical is AKA | diagnosis. |
A *Nursing Diagnosis*, the second step of the *Nursing Process*, is a formal statement of... | an actual or potential health problem that a nurse can legally and independently treat. |
Examples of nursing diagnoses are... | acute pain, and nausea. |
Diagnoses that require treatment by multiple disciplines are known as... | *collaborative problems*. |
A nursing diagnosis is essential because accurate diagnosis of patient problems ensures that you... | select more effective and efficient nursing interventions. |
The diagnostic process flows from the assessment process and includes... | decision making steps. |
Nursing diagnoses are outlined by... | NANDA international. |
The steps included within the *diagnostic* process include:... (3) | data clustering, identifying patient health problems, and formulating the diagnosis. |
A *data cluster* is a set of... | signs or symptoms, gathered during assessment, that you group together in a logical way. |
*Data clusters* are patterns of data that contain... | *defining characteristics* |
*Defining characteristics* are clinical criteria that are both... | observable and verifiable. |
*Defining characteristics* support... | identification of a nursing diagnosis. |
Often a patient has defining characteristics that apply to... | more than one diagnosis. |
When interpreting data to form a diagnosis, remember that the absence of certain defining characteristics suggests that you... | reject a diagnosis under consideration. |
Always examine the defining characteristics in your database carefully to either... | support or eliminate a nursing diagnosis. |
To individualize a nursing diagnosis further, you identify the associated... | *related factor*. |
A *related factor*, for example an etiology, explains... | factors that lead to the defining characteristics. |
The three types of nursing diagnoses, as defined by NANDA-I (international), include:... | *actual nursing diagnoses*, *risk diagnoses*, and *health promotion diagnoses*. |
An *actual nursing diagnosis* is a judgment that is clinically validated by the presence of major... | defining characteristics. |
A *risk diagnosis* describes human responses to health conditions/life processes that may develop in... (3) | a vulnerable individual, family, or community. |
A *health promotion nursing diagnosis* enhances things such as... | nutrition and exercise. |
Planning involves... (3) | setting priorities, identifying patient-centered goals and expected outcomes, and prescribing individualized nursing interventions. |
Priority setting is the ordering of either... | nursing diagnoses or patient problems. |
Priority setting involves using determinations of urgency and/or importance to establish a... | prioritized order for nursing actions. |
Once you identify nursing diagnoses for a patient, you should set both... | *Goals* and *Expected outcomes*. |
A *Goal* is a broad statement that describes a desired... | change in a patient's condition or behavior. |
An *expected outcome* is a measurable criterion to evaluate.... | *goal* achievement. |
*Outcomes* and *goals* reflect patient behaviors and responses expected as a result of... | nursing interventions. |
Write a *goal* or *expected outcome* to reflect a... | patient's specific behavior |
Do not write a *goal* or *expected outcome* to reflect... | your goals or interventions. |
Each goal and outcome should address only one behavior or response to pinpoint... | where the plan of care needs modification. |
Singular goals and outcomes should always be... (5) | observable, measurable, time-limited, contain mutual factors (i.e., for the patient and the nurse), and be realistic. |
Part of the planning process involves meeting the patient's goals and outcomes by selecting... | appropriate nursing interventions. |
The actual implementation of nursing interventions occurs... | during the implementation phase of the nursing process. |
When selecting the correct nursing intervention, the six important factors to consider are:... | characteristics of NRSG diagnosis, expect outcomes, research base, feasibility, acceptability to the patient, capability of the nurse. |
As you select the NRSG interventions, review your Pt’s needs, priorities, & previous experiences to select the interventions that... | have the best potential for achieving the expected outcomes. |
In regards to *characteristics of the nursing diagnosis*, intervention should first alter... | the etiological factor associated with the diagnosis. |
regards to characteristics of the NRSG diagnosis, if etiological factor can’t be resolved, attempt to direct the intervent to treating... . | the signs and symptoms |
In regards to *feasibility*, intervention includes consideration of both... | time and cost. |
In regards to *capability of the nurse*, interventions requires the nurse to have both efficient.... | psychosocial and psychomotor skills. |
There are multiple expected outcomes within a given.... | goal of care. |
Implementation, the fourth step in the nursing process, formally occurs after... | the nurse develops a plan of care. |
A *nursing intervention* is any treatment based on clinical judgement on knowledge that a nurse performs to... | enhance patient outcomes. |
The two forms of nursing interventions are... | *Direct care* interventions & *Indirect care* interventions. |
Standards for the implementation step of the Nursing Process are defined professionally by... | the American Nurses Association (ANA) |
A *standing order* directs... | the conduct of patient care in a specific clinical setting. |
If in the patient's best interest, *standing orders* give the nurse legal protection to... | intervene appropriately. |
Activities usually performed throughout a normal day, including ambulation, eating, dressing, bathing, and grooming, AKA | *Activities of Daily Living* (*ADLs*) |
Evaluation, final step of the nursing process, is crucial to determine if, after application of the nursing process, the patient's... | condition or well-being improves. |
You conduct *evaluative* measures NOT to determine if nursing interventions were completed, but to determine... | if your patient met *expected outcomes*. |
The *expected outcomes* established during *planning* are the standards against which the nurse judges both whether.. | *goals* have been met and if care is successful. |
Once you deliver an intervention, you gather from the patient, family, and other health care team members both.. | subjective (symptoms) and objective (signs) data. |
Positive evaluations occur when the patient... | meets expected outcomes. |
A patient meeting expected outcomes in a positive evaluation indicates that... | the nursing intervention(s) were effective. |
nurse critically evaluates/revises therapies until the Pt & the nurse successfully & appropriately resolve the problems defined by... | the nursing diagnosis. |
The objective criteria needed to judge the patient's response to care are... | the goals and expected outcomes. |
A *goal* is the expected... | BEHAVIOR or RESPONSE |
An *expected outcome* is the end result that is... | MEASURABLE, DESIRABLE, and OBSERVABLE |