question

During which of the five steps in the Nursing Process does the nurse determine whether outcomes of care are achieved? 1. Implementation 2. Evaluation 3. Planning 4. Analysis

answer

2. Evaluation (occurs when actual outcomes are compared with expected outcomes and reflect goal achievement. If the goal is achieved, the patient's needs are met). rationale 1. Implementation (Outcomes are not determined but rather planned nursing care is delivered.)3. Planning (Expected outcomes are determined but their achievement is measured in another step of the Nursing process. 4. Analysis (Outcomes are no determined; rather, the nurse identifies human response to actual or potential health problems).

question

Then considering the Nursing Process, the word "observe" is to "assess" as the word "explore" is to:1. Plan 2. Analyze 3. Evaluate 4. Implement

answer

2. Analyze (Observe means to view something scientifically, and assess means to collect info. The word analyze fits the analogy. Explore means to examine. Analyze means to in investigate. RATIONALES: 1. Plan (means to design an intention) 3. Evaluate (to come to a conclusion about a patient's response to a nursing intervention. 4. Implement (carry out an action).

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4. Is based on the patient's medical problem

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ANSWER:

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4. Be assisted to the commode every two hours and whenever necessary"

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ANSWER:

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4. Counselor

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ANSWER:

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4. Evaluation

answer

ANSWER:

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4. Goal

answer

ANSWER:

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4. Implementation

answer

ANSWER:

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4. Social service record

answer

ANSWER:

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4. Be given aspirin every eight hours whenever necessary"

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ANSWER:

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4. Set the time frames for goals

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ANSWER:

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4. Analysis

answer

ANSWER:

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4. Related risk factors

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ANSWER:

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4. Validate the medical diagnosis

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ANSWER:

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4. Dizziness

answer

ANSWER:

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4. Medical diagnosis

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ANSWER:

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4. Determine significance of the information

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ANSWER:

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4. Review the defining characteristics

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ANSWER:

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4. Identify important data

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ANSWER:

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4. "Will a home health aide help me with my care at home?"

answer

ANSWER:

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4. Implementation

answer

ANSWER:

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4. Implementation

answer

ANSWER:

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4. Implement

answer

ANSWER:

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4. Interviewing

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ANSWER:

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4. Making decisions about the effectiveness of patient care

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ANSWER:

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4. "I have the urge to urinate"

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ANSWER:

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4. "I ate only 50% my breakfast"

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ANSWER:

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4. Dyspepsia

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ANSWER:

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5.____Hypotension

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ANSWER:

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5. "Did you sleep last night after I gave you the sleeping medication?"

answer

ANSWERS/RATIONALES:

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JQ1: Assessment

answer

The collection of data, verification, organization, and communication of data.

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JQ2: Diagnosis, Actual (related to, as evidenced by)

answer

The formulation of the diagnostic statement.

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JQ2: Diagnosis, Risk (related to)

answer

The formulation of the diagnostic statement.

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JQ2: How to formulate nursing diagnosis

answer

1. Problem

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JQ3: Planning

answer

Identification of measurable, realistic outcomes and goals

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JQ4: Implementation

answer

Implementation of the plan of care

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JQ4a: Implementation Patient Variables

answer

1. Developmental play

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JQ4b: Implementation Nursing Variables

answer

1. Resources

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JQ5: Evaluation

answer

Assessing, judging, and evaluating the extent to which the outcomes and goals were met.

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JQ6: Etiology

answer

The contributing factor used in the nursing diagnostic statement to identify client health heeds that assist in the formulation of the nursing diagnosis.

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JQ7: Defining Characteristics

answer

The subjective and objective data that support the identified nursing diagnosis.

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Describe the outcome categories.

answer

Cognitive: knowledge Psychometer: new skills Affective: Values, beliefs and attitudes

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Parts of the measurable outcome

answer

1. Subject: Patient 2. Verb: Action word (pt will walk) 3. Performance criteria (20' in hall) 4. Conditions (w/o walker or assist by Friday 1/1/16 5. Target Time

question

A client interview consists of three phases. The nurse recognizes that those phases are: 1. Orientation, working, termination 2. Introduction, controlling, selection 3. Introduction, assessment, conclusion 4. Orientation, documentation, database

answer

1. Orientation, working, termination

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Jessica's PPT Nursing Process Q2: Which subjective assessment data are most supportive of a client's diagnosis of anxiety? 1. Diaphoretic and cool skin 2. An apical pulse rate of 120 beats per minute 3. Reports "needing to leave now" 4. Claims "something is terribly wrong"

answer

3. Reports "needing to leave now" Subjective data are clients' perceptions about their health problems. The statement by the client regarding his sense of impending doom is the best example of subjective data regarding his anxiety because it is his own verbalization of the problem. Cool, damp skin is an example of objective data. Objective data are observations or measurements made by the data collector. A pulse rate is an example of objective data. Objective data are observations or measurements made by the data collector. While a client statement regarding the need to leave the hospital is subjective in nature, it is not as strong an indicator of anxiety as is the verbalization of impending doom.

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Of the following statements, which one is an example of an appropriately written nursing diagnosis? 1. Risk for change in body image related to cancer 2. Cardiac output decreased related to motor vehicle accident 3. Ineffective airway clearance related to increased secretions 4. Potential for injury related to improper teaching in the use of crutches

answer

3. Ineffective airway clearance related to increased secretions, 1. Ineffective airway clearance related to increased secretions is written appropriately. It identifies a problem using a NANDA International diagnostic statement and connects it to its etiology.

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Identify the defining characteristics in the following nursing diagnosis: Altered speech related to recent neurological disturbance, as evidenced by inability to speak in complete sentences. 1. "Altered speech"2. "As evidenced by" 3. "Recent neurological disturbances" 4. "Inability to speak in complete sentences"

answer

4. "Inability to speak in complete sentences" Defining characteristics are assessment findings that support the nursing diagnosis. In this example, the inability to speak in complete sentences supports the nursing diagnosis of altered speech. "Altered speech" is the diagnostic label identifying the problem. "As evidenced by" is a connecting statement for the problem and the defining characteristics. "Recent neurological disturbances" is the etiology.

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In order that they are clear and easily understood by other members of the health care team, the nurse recognizes that client goals or outcomes should be documented according to specific criterion. Of the following, the outcome statement that best meets the established criteria is:1. "Client will describe activity restrictions."2. "Client will verbalize understanding of treatments." 3. "Client will be ambulated in hallway 3 times each day." 4. "Client's respiratory rate will remain within 20 to 24 breaths per minute by 9/24."

answer

ANSWER: 4. "Client's respiratory rate will remain within 20 to 24 breaths per minute by 9/24." RATIONALE: "Client's respiratory rate will remain within 20 to 24 breaths per minute by 9/24" is a correctly written outcome statement. It is client-centered, singular, observable, measurable, time-limited, and realistic.

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Which of the following is the best example of an intermediate prioritized client need for a client diagnosed with risk of injury related to poor skin integrity? 1. Applying adequate clothing to ensure the client's warmth 2. Providing sufficient quantities of an aloe-based skin lotion 3. Helping the client select her favorite foods from the menu form 4. Dressing the client's feet in non-skid soled slippers when ambulating

answer

2. Providing sufficient quantities of an aloe-based skin lotion RATIONALE:An intermediate priority is one that involves the non-emergent, non-life-threatening needs of the client. Having sufficient aloe-based lotion is required for maintaining good skin integrity but is not required for meeting a life-threatening need. Although the other options are an intermediate need, they are not the best option because they are not directly related to the client's stated nursing diagnosis.

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An example of a cognitive nursing skill is: 1. Providing a soothing bed bath 2. Communicating with the client and family 3. Giving an injection to the client per the physician's orders 4. Recognizing the potential complications of a blood transfusion

answer

4. Recognizing the potential complications of a blood transfusion RATIONALE: Cognitive skills involve the application of nursing knowledge. Understanding normal and abnormal physiological and psychological responses is a cognitive skill, as in recognizing the potential complications of a blood transfusion.

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Which of the following interventions is the best example of an indirect intervention directed towards client safety? 1. Checking on a restrained client every 15 minutes 2. Performing hand hygiene between client contacts 3. Including the diagnosis at risk for injury related to falls to a client's care plan 4. Turning on a night light to illuminate the path to the bathroom

answer

4. Turning on a night light to illuminate the path to the bathroom RATIONALE: 4. Indirect care interventions are treatments performed away from the client but on behalf of the client or group of clients. For example, indirect care measures include actions for managing the client's environment (e.g., safety and infection control), documentation, and interdisciplinary collaboration. Directly impacting the light level in a client's room to minimize the risk for falls is the best example of a safety-oriented indirect care intervention.

question

The nurse formulates a diagnosis of knowledge deficit related to complications of pregnancy. One outcome criterion is that the client can state five symptoms that indicate a possible problem that should be reported. The client is able to tell the nurse three symptoms. The evaluation statement would be: 1. Goal met; client able to state three symptoms 2. Goal not met; client able to list three symptoms 3. Goal not met; client unable to list five symptoms 4. Goal partially met; client able to state three symptoms

answer

4. Goal partially met; client able to state three symptoms rationale The client is showing changes but does not yet meet criteria set; therefore, the goal is partially met. The client's response, being able to state three symptoms, does not meet or exceed the outcome criteria of being able to state five symptoms. The client's response, being able to list three symptoms, demonstrates some change. If the client were showing no progress, then the goal would not be met. If the client were showing no progress, then the goal would not be met. However, this client's response does indicate some change.

question

The nurse has determined the following outcome for a client with a skin impairment: "Erythema will be reduced in 3 days." Evaluation will specifically focus on: 1. Selection of appropriate wound care 2. Notation of the odor and color of drainage 3. Inspection of the color and condition of the area 4. Measurement of the diameter of the ulceration daily

answer

3. Inspection of the color and condition of the area 3. Erythema is reddening of the skin; therefore, the evaluation should specifically focus on inspection of the color of the skin, as stated in the outcome criterion.

question

assessment

answer

a systematic process by which the nurse collects and analyzes data about a patient

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case management

answer

assignment of a health care provider to oversee the progress and issues of a patient

question

clinical pathways

answer

multidisciplinary plan in which clinical interventions are scheduled over time for high risk, high volume types of medical diagnoses

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diagnosis

answer

identification of a disease or condition by scientific evaluation of physical signs and symptoms

question

evaluation

answer

determination made about the extent to which identified outcomes have been met in the nursing care plan

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implementation

answer

phase of the nursing process that includes ongoing activities and performance of interventions to meet patient outcomes

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managed care

answer

a system that involves control over primary health care services in a medical group practice.

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nursing diagnosis

answer

a clinical judgment about individual, family or community responses to an actual or high risk health problem

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nursing process

answer

systematic method by which nurses plan and provide care for patients

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risk diagnosis

answer

a clinical judgment that an individual, family or community is vulnerable to develop a problem related to current conditions of that patient

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syndrome

answer

a cluster of actual or risk nursing diagnoses that are predicted to be present in certain circumstances

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variance

answer

an unexpected event that occurs during the use of a clinical pathway; may be positive or negative

question

what are the two main methods of data collection?

answer

nursing interview for facts about the patient's life and the physical examination for subjective and objective data gathering

question

what are the 4 types of assessments?

answer

initial assessment; focus assessment; time lapsed reassessment; and emergency assessment

question

what is the group that defines nursing diagnoses?

answer

North American Nursing Diagnosis Association (NANDA)

question

what are the six stages of the nursing process?

answer

assessment, nursing diagnosis, outcome identification, planning, implementation and evaluation

question

what is the purpose of the assessment data?

answer

it helps point to a nursing diagnosis; it is a communication tool for other health care team members

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which patient's needs are assessed?

answer

immediate; physical, psychological, spiritual and social

question

what other factors are important in the patient's response to illness?

answer

family, culture, and religion

question

what is data clustering?

answer

the process of grouping related patient subjective and objective data together

question

what is the purpose of data clustering?

answer

it helps to identify patterns that will aid in identification of nursing diagnoses

question

who is responsible for analysis of the data and identification of a nursing diagnosis?

answer

RNs

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what is the difference between ad actual and risk nursing diagnosis?

answer

actual is a current human response to conditions that exist; risk is a potential human response to conditions that make the patient vulnerable

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how should nursing diagnoses be written

answer

exactly as they appear in NANDA sources

question

how should nursing diagnoses be prioritized?

answer

according to Maslow's Hierarchy of Needs, e.g. physiologic needs first followed by the ascending steps of Maslow's pyramid

question

what do the nursing diagnoses lead to?

answer

a nursing care plan

question

what is the significance of the care plan?

answer

it is a communication tool that helps coordinate and ensure the continuity of patient care

question

what are patient goals?

answer

statements of observable patient responses; what the patient will do not what the nurse will do

question

how should patient goals be written?

answer

in terms of how the patient will respond within a given time frame

question

what are three important characteristics of patient goals?

answer

they must be timed, realistic and measurable (stated in terms of actions that are observable)

question

what is another name for interventions?

answer

nursing orders (nursing actions by the nursing staff to help the patient achieve the stated goals)

question

what is different about nursing orders?

answer

for the most part, they are actions that can be done by nurses without an MD order like "patient will be turned and repositioned q2 hours on the even hours."

question

what should nursing orders contain?

answer

an action verb, specific instructions to the nursing staff as to where and how the action should be done and times or dates when the action should be done

question

can following MD orders ever be part of the interventions?

answer

yes because nursing judgment is still used in giving prn medications or wound care

question

what are the important factors in evaluation statements?

answer

specific details about how well or how poorly the patient has achieved the goal related to evidence of the response to the interventions

question

can evaluation statements be negative?

answer

yes; they can state: goal met, goal partially met or goal not met

question

what activities are part of the evaluation phase?

answer

observation of the changes in patient behavior to judge how well they meet the goal statements

question

what happens if the goal is not met?

answer

new approaches may be necessary to help the patient achieve the goal

question

what happens if the goals are met?

answer

they are eliminated from a revised care plan and other goals related to other problems can be added

question

what phases of the nursing process must be documented?

answer

all of them

question

when is a focus assessment advisable?

answer

if the patient is critically ill, disoriented or unable to respond

question

what other times is a focus assessment used?

answer

continuously during nurse patient contact e.g. hydration assessment, vital signs, and during evaluation of outcomes

question

when documenting using focus charting, which format does the nurse use?

answer

nursing diagnoses are used as an index for the documentation

question

what is critical thinking?

answer

unbiased thinking with a purpose

question

what are some criteria for critical thinking?

answer

it looks beneath the surface; it is logical and fair; it can include "thinking outside the box"

question

what characteristics do critical thinkers have in common?

answer

use reason rather than prejudice; look for relationships between concepts and ideas; realize they do not know everything and are open to new possibilities

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What are the 5 steps of the nursing process in order?

answer

1. Assessment. 2. Nursing Diagnosis. 3. Planning. 4. Implementing. 5. Evaluating.

question

During the Assessment process, you ___________ from primary source (the patient) and secondary source (family, etc.)

answer

collect data

question

During the Assessment process, you have to (1)_______, (2)_________, and (3)_________ the data you have collected.

answer

1. Interpret. 2. Validate. 3. Analyze.

question

During the Assessment process, you have to apply (1)_______________, personal knowledge, clinical experiences, and (2)__________________.

answer

1. Critical thinking. 2. Standards of practice.

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During the Assessment process, you will establish a database for the patient of perceived (1)__________, (2)__________, and (3)___________.

answer

1. needs. 2. health problems. 3. responses.

question

What can guide you through your initial assessment and screening?

answer

Cues and Inferences

question

What are 2 comprehensive assessment approaches?

answer

1. Gordon's Functional Health Patterns. 2. Problem Oriented Approach.

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What are the two types of data that you can collect?

answer

Subjective and Objective

question

What is subjective data?

answer

Usually provided by the patient. Patient's verbal description of personal health problems. Feelings, perceptions, and expressions of the patient.

question

What is objective data?

answer

Is measurable and based on an accepted standard. Ex. centimeters on a measuring tape) Is measurements or observations of the patient's health problems. Is collected by family, health care team, medical records.

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When conducting a patient centered interview, what kind of question allows the patient to tell in their own words their health care concerns?

answer

Open ended questions.

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What kind of questions are "yes" or "no" type questions, and used to acquire specific information?

answer

Closed ended questions.

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Documentation of nursing health history is __________. (6)

answer

1. Timely. 2. Accurate. 3. Thorough. 4. Required for patient record keeping. 5. Considered not done if not documented. 6. A legal and professional responsibility.

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What techniques does the physical examination involve? (4)

answer

1. Inspection. 2. Palpation. 3. Percussion. 4. Auscultation.

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A ______________ is a set of signs or symptoms gathered during assessment that you group together in a logical way.

answer

data cluster

question

What are "defining characteristics"?

answer

symptoms, subjective and objective data.

question

What are some examples of Defining Characteristics?

answer

Pain level of 7 on scale of 1-10. Crying. Sweating. Heart Rate 66 and regular. "I hate to eat anything green". "Sometimes I bleed when I have a bowel movement". Black, tarry stools

question

What are the 3 types of nursing diagnosis?

answer

1. Actual Nursing Diagnosis. 2. Risk Nursing Diagnosis. 3. "Health Promotion Nursing Diagnosis.

question

What is an "Actual Nursing Diagnosis"?

answer

Describes human responses to health conditions or life processes.

question

What is a "Risk Nursing Diagnosis"?

answer

Describes human responses to health conditions/life processes that may develop

question

What is a "Health Promotion Nursing Diagnosis"?

answer

A clinical judgment of motivation, desire, and readiness to enhance well-being and actualize human health potential

question

How do you write a nursing diagnosis?

answer

Start with the "nursing diagnosis" followed by "Related to" ______ followed by "As evidenced by" ________. Example: Acute Pain "related to" muscle tenderness "as evidenced by" pain level of 8 on scale of 1-10 of right calf area.

question

assess (nursing process step)

answer

Determine the need for nursing care.

question

concept mapping

answer

An instructional strategy that requires learners to identify, graphically display, and link key concepts. Concept maps, also called cognitive maps, mind maps, and meta cognitive tools for learning, are a proven means to promote critical thinking and self-directed learning.

question

critical thinking

answer

A systematic way to form and shape one's thinking. It functions purposefully and exactingly. It is thought that is disciplined, comprehensive, based on intellectual standards, and, as a result, well-reasoned.

question

critical thinking indicators

answer

Evidence based descriptions of behaviors that demonstrate the knowledge, characteristics, and skills that promote critical thinking in clinical practice.

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decision making

answer

Purposeful, goal directed effort applied in a systematic way to make a choice among alternatives. [Lipe and Beasley (2004)]

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evaluate

answer

Reassess the patient for effectiveness of care.

question

expected outcomes

answer

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

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implement

answer

Putting into motion the plan of care.

question

intuitive problem solving

answer

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

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nursing diagnosis

answer

Actual and potential health problems.

question

nursing process

answer

A systematic method that directs the nurse and patient, as together they accomplish the following: Assessment, Diagnosis, Outcome Identification/Planning, Implementation, and Evaluation.

question

care plan

answer

A detailed schedule outlining the practitioner's and the patient's activities and responsibilities designed to achieve goals of therapy, and to resolve and prevent drug therapy problems.

question

scientific problem solving

answer

A systematic, seven-step, problem-solving process that involves (1) problem identification, (2) data collection, (3) hypothesis formulation, (4) plan of action, (5) hypothesis testing, (6) interpretation of results, and (7) evaluation, resulting in conclusion or revision of the study.

question

standards for critical thinking

answer

Attributes include: clear, precise, specific, accurate, relevant, plausible, consistent, logical, deep, broad, complete, significant, adequate (for the purpose), and fair.

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trial-and-error problem solving

answer

Involves testing any number of solutions until one is found that works for that particular problem.

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assessing

answer

The systematic and continuous collection, validation, analysis, and communication of patient data, or information.

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cue

answer

A hint or clue that something may be wrong.

question

data

answer

Information.

question

database

answer

Includes all the pertinent patient information collected by the nurse and other healthcare professionals.

question

emergency assessment

answer

Identifies life threatening problems.

question

focused assessment

answer

The nurse gathers data about a specific problem that has already been identified.

question

inference

answer

The judgment you reach about a cue.

question

initial assessment

answer

Performed shortly after the patient is admitted to a healthcare agency or service.

question

interview

answer

A planned communication.

question

minimum data set

answer

Specifies the information that must be collected from every patient and uses a structured assessment form to organize or cluster this data.

question

nursing history

answer

Identifies the patient's health status, strengths, health problems, health risks, and need for nursing care.

question

objective data

answer

Observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing them. Objective data observed by one person can be verified by another person observing the same patient.

question

observation

answer

The conscious and deliberate use of the five senses to gather data. Skilled nurses use each nurse-patient interaction to observe and to interpret meaningful stimuli (data).

question

physical assessment

answer

The examination of the patient for objective data that may better define the patient's condition and help the nurse in planning care. The physical assessment normally follows the nursing history and interview, and may verify data gathered during the history or yield new data.

question

review of systems (ROS)

answer

The nursing physical assessment involves the examination of all body systems in a systematic manner, commonly using a head-to-toe format. Four methods are used to collect data during a physical assessment: inspection, palpation, percussion, and auscultation.

question

subjective data

answer

Information perceived only by the affected person; these data cannot be perceived or verified by another person.

question

time-lapsed assessment

answer

Scheduled to compare a patient's current status to baseline data obtained earlier.

question

validation

answer

The act of confirming or verifying.

question

actual nursing diagnoses

answer

Represents a problem that has been validated by the presence of major defining characteristics. This type of nursing diagnosis has four components: label, definition, defining characteristics, and related factor.

question

collaborative problems

answer

Certain physiologic complications that nurses monitor to detect onset or changes in status. Nurses manage collaborative problems using physician-prescribed and nurse interventions to minimize the complications of the event. (Moyet 2010 p. 24)

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cue

answer

Term often used to denote significant data or data that influences the formulation of a diagnosis.

question

data cluster

answer

A grouping of patient data or cues that points to the existence of a patient health problem.

question

diagnosing

answer

Purpose includes: (1) identify how an individual, group, or community responds to actual or potential health and life processes; (2) identify factors that contribute to or cause health problems (etiologies); and (3) identify resources or strengths the individual, group, or community can draw on to prevent or resolve problems.

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diagnostic error

answer

Erroneously labeling selected patient health patterns as unhealthy.

question

health problem

answer

A condition that necessitates intervention to prevent or resolve disease or illness or to promote coping and wellness.

question

medical diagnoses

answer

Identifies diseases, whereas nursing diagnoses focus on unhealthy responses to health and illness.

question

nursing diagnoses

answer

Actual or potential health problems that can be prevented or resolved by independent nursing intervention.

question

possible nursing diagnoses

answer

Statements describing a suspected problem for which additional data are needed. Additional data are used to confirm or rule out the suspected problem.

question

risk nursing diagnoses

answer

Clinical judgments that an individual, family, or community is more vulnerable to develop the problem than others in the same or similar situation.

question

standard

answer

A generally accepted rule, measure, pattern, or model to which data can be compared in the same class or category; a norm.

question

syndrome nursing diagnoses

answer

Comprise a cluster of actual or risk nursing diagnoses that are predicted to be present because of a certain event or situation; for example, Rape-Trauma Syndrome or Post-Trauma Syndrome.

question

wellness diagnoses

answer

Clinical judgments about an individual, group, or community in transition from a specific level of wellness to a higher level of wellness.

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clinical pathways

answer

Tools used in case management to communicate the standardized, interdisciplinary plan of care for patients.

question

critical pathways

answer

Same as a clinical pathway.

question

CareMaps

answer

Another name for clinical or critical pathways.

question

computerized plans of nursing care

answer

A nursing care plan that is part of an electronic medical record

question

consultation

answer

A process in which two or more individuals with varying degrees of experience and expertise discuss a problem and it's solution.

question

criteria

answer

Measurable qualities, attributes, or characteristics that specify skills, knowledge, or health states. They describe acceptable levels of performance by stating the expected behaviors of the nurse or the patient.

question

discharge planning

answer

Best carried out by the nurse who has worked most closely with the patient and family, possibly in conjunction with a nurse or social worker with a broad knowledge of existing community resources.

question

expected outcome

answer

Used to refer to the more specific measurable criteria used to evaluate the extent to which a goal has been met.

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goal

answer

An aim or an end.

question

initial planning

answer

Developed by the nurse who performs the admission nursing history and the physical assessment. A comprehensive plan that addresses each problem listed in the prioritized nursing diagnoses and identifies approriate patient goals and the related nursing care.

question

Kardex care plan

answer

The plan of nursing care for each patient is concisely recorded on a folded card and placed in a central file where it is easily accessible.

question

nursing intervention

answer

Any treatment, based on clinical judgement and knowledge, that a nurse performs to enhance patient outcomes.

question

nursing interventions classifications (NIC)

answer

The first comprehensive, validated list of nursing interventions applicable to all settings that can be used by nurses in multiple specialties, greatly facilitates the work of identifying appropriate interventions.

question

nursing outcomes classifications (NOC)

answer

The first comprehensive standardized language used to describe the patient outcomes that are responsive to nursing intervention.

question

ongoing planning

answer

Carried out by any nurse who interacts with the patient. It's chief purpose is to keep the plan up to date to facilitate the resolution of health problems, manage risk factors, and promote function.

question

outcome identification

answer

The nurse works in partnership with the patient and family to: Establish priorities; Identify and write expected patient outcomes; select evidence based nursing interventions; communicate the plan of nursing care.

question

patient outcome

answer

An expected conclusion to a patient health problem, or in the event of a wellness diagnosis, an expected conclusion to a patient's health expectation.

question

plan of nursing care

answer

Patient care plan - the written guide that directs the efforts of the nursing team as nurses work with patients to meet their health goals.

question

planning

answer

A process that includes defining goals, establishing care strategies, and developing plans to coordinate nursing activities.

question

standardized care plans

answer

Prepared plans of care that identify the nursing diagnoses, outcomes, and related nursing interventions common to a specific population or health problem.

question

collaborative interventions

answer

Interdependent nursing actions that are performed jointly by nurses and other members of the healthcare team.

question

delegation

answer

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

question

evidence-based practice

answer

A problem-solving approach to making clinical decisions, using the best evidence available (considered "best" because it is collected from sources such as published research, national standards and guidelines, and reviews of targeted literature).

question

implementing

answer

A step in the nursing process in which nursing actions planned in the previous step (Outcome Identification and Planning) are carried out.

question

nurse-initiated intervention

answer

Independent nursing actions or nurse-prescribed interventions carried out as in response to patient needs identified during assessment and noted in the plan of care, as well as any other actions that nurses initiate without direction or supervision of another healthcare professional.

question

nursing interventions

answer

Defined by the Nursing Interventions Classification (NIC) project as "any treatment based upon clinical judgement and knowledge that a nurse performs to enhance patient/client outcomes".

question

physician-initiated intervention

answer

Dependent nursing actions that involve carrying out physician-prescribed orders.

question

protocols

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Written plans that detail the nursing activities to be executed in specific situations.

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standing orders

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Empower the nurse to initiate actions that ordinarily require the order or supervision of a physician.

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unlicensed assistive personnel (UAP)

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Individuals who are trained to function in an assistive role to the licensed registered nurse (RN) in the provision of patient activities as delegated by and under the supervision of the registered professional nurse.

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concurrent evaluation

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Conducted by using direct observation of nursing care, patient interviews, and chart review to determine whether the specified evaluative criteria are met.

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criteria

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Measurable qualities, attributes, or characteristics that specify skills, knowledge, or health states. They describe acceptable levels of performance by stating the expected behaviors of the nurse or the patient.

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evaluating

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The nurse and patient together measure how well the patient has achieved the outcomes specified in the plan of care.

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nursing audit

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A method of evaluating nursing care that involves reviewing patient records to assess the outcomes of nursing care or the process by which these outcomes were achieved.

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outcome evaluation

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Evaluation that focuses on measurable changes in the health status of the patient or the end results of nursing care.

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peer review

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The evaluation of one staff member by another staff member on the same level in the hierarchy of the organization; an important mechanism nurses can use to improve their professional performance.

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performance improvement

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Commitment to healthier patients, quality care, reduced costs, and making a difference; accomplished by discovering a problem, planning a strategy, implementing a change, and assessing the change to see if the goal is met.

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process evaluation

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Evaluation that focuses on the nature and sequence of activities carried out by nurses implementing the nursing process.

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quality-assurance program

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Specialty designed program that promotes excellence in nursing.

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quality improvement

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The commitment and approach used to continuously improve every process in every part of an organization, with the intent of meeting and exceeding customer expectations and outcomes.

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retrospective evaluation

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Evaluation that may use post discharge questionnaires, patient interviews, or chart review to collect data.

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standards

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The levels of performance accepted and expected by the nursing staff or other health team members. They are established by authority, custom, or consent.

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structure evaluation

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Focuses on the environment in which care is provided.

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change-of-shift report

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Given by a primary nurse to the nurse replacing him or her or by the charge nurse to the nurse who assumes responsibility for continuing care of the patient.

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charting by exception (CBE)

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Shorthand documentation method that makes use of well defined standards of practice; only significant findings or "exceptions" to these standards are documented in narrative notes.

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collaborative pathway

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Same as critical pathway; used in the case management model; specifies the plan of care linked to expected outcomes along a timeline.

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confer

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Consult with someone to exchange ideas or to seek information, advice, or instructions.

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consultation

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The process of inviting another professional to evaluate the patient and make recommendations to you about his or her treatment.

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critical pathway

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Same as collaborative pathway; used in the case management model; specifies the plan of care linked to expected outcomes along a timeline.

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discharge summary

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Documentation that concisely summarizes the reason for treatment, significant findings, the procedures performed and rendered, the patient's condition on discharge or transfer, and any specific pertinent instructions given to the patient and family.

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documentation

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The written or typed legal record of all pertinent interactions with the patient - assessing, diagnosing, planning, implementing, and evaluating.

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electronic medical record (EMR)

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Data can be distributed among many caregivers in a standardized format, allowing them to compare and uniformly evaluate patient progress easily.

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flow sheet

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Documentation tools used to record routine aspects of nursing care.

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focus charting

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Purpose is to bring the focus of care back to the patient and the patient's concerns.

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graphic sheet

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A form used to record specific patient variables such as pulse, respiratory rate, blood pressure readings, body temperature, weight, fluid intake and output, bowel movements, and other patient characteristics.

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incident report

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Also called a variance or occurrence report, is a tool used by healthcare agencies to document the occurrence of anything out of the ordinary that results in or has the potential to result in harm to a patient, employee, or visitor.

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minimum data set

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Specific categories of information that will use uniform definitions to create a common language among healthcare data users.

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narrative notes

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Progress notes written in a source oriented record that address routine care, normal findings, and patient problems identified in the plan of care.

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nursing informatics

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A specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice.

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OASIS

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Outcome and Assessment Information Set - key component in Medicare's partnership with the home care industry to foster and monitor improved home healthcare outcomes.

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patient record

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A compilation of a patient's health information.

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personal health record (PHR)

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Records that contain an individual's medical history, including diagnoses, symptoms, and medications.

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PIE charting

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Unique in that it does not develop a separate plan of care. The plan of care is incorporated into the progress notes in which problems are identified by number.

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problem-oriented medical record (POMR)

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Originated in the 1960s by Dr. Lawrence Weed; organized around a patient's problems rather than around sources of information.

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progress notes

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Notes written to inform caregivers of the progress a patient is making toward achieving expected outcomes.

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referral

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The process of sending or guiding the patient to another source for assistance.

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SBAR communication

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(Situation, Background, Assessment, Recommendation) - framework for communication between members of the healthcare team about a patient's condition.

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SOAP format

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(Subjective, Objective, Assessment, Plan) - used to organize data entries in the progress notes of the POMR.

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source-oriented record

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Documentation system in which each healthcare group records data on its own separate form.

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variance charting

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The usual format is the unexpected event, the cause of the event, actions taken in response to the event, and discharge planning, when appropriate.

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(Answer: ) B (Rationale- The nurse identifies human responses to actual or potential health problems during the nursing diagnoses step of the nursing process. During the assessment step, the nurse collects data. During the planning step, the nurse develops strategies to resolve or decrease the patient's problem. During evaluation, the nurse determines the effectiveness of the plan of care.)

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The nurse in charge identifies a patient's responses to actual or potential health problems during which step of the nursing process? A. Assessing B. Diagnosing C. Planning D. Evaluating

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(Answer: ) D (Rationale: During the evaluation step of the nursing process the nurse determines whether the goals established have been achieved, and evaluates the success of the plan. Answer A involves data collection. Answer B involves setting priorities, and Answer C is the actual intervention.)

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A nurse is revising a client's care plan. During which step of the nursing process does such a revision take place? A. Assessment B. Planning C. Implementation D. Evaluation

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(Answer: ) D (Rationale: You should begin with the simplest interventions. Answer A is incorrect because medications should be avoided whenever possible. Answer B would be a thorough sleep assessment, and should be done only after common sense interventions fail. Answer C would be appropriate only after common sense interventions fail.)

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Which intervention should the nurse in charge try first for a client that exhibits signs of sleep disturbance? A. Administer sleeping medication before bedtime B. Ask the client each morning to describe the quantity of sleep the night before C. Teach the client relaxation techniques, such as guided imagery and progressive muscle relaxation D. Provide the client normal sleep aids, such as pillows, back rubs, and snacks

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(Answer: ) C (Rationale- Making appropriate referrals is a valid part of planning the client's care. The nurse normally does not provide sex counseling. While providing time for privacy and providing support for the spouse is important, it is not as important as referring the client to a sex counselor/appropriate professional)

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A nurse is assigned to care for a postoperative male client who has diabetes mellitus. During the assessment interview, the client reports that he's impotent and says he's concerned about the effect on his marriage. In planning this client's care, the most appropriate intervention would be to: A. Encourage the client to ask questions about personal sexuality B. Provide time for privacy C. Suggest referral to a sex counselor or other appropriate professional D. Provide support for the spouse

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(Answer: ) A (Rationale - According to Maslow, elimination is a first-level or physiological need. Security and safety are second-level needs, and belonging is a third-level need.)

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Using Maslow's hierarchy of needs, a nurse assigns the highest priority to which client need? A. Elimination B. Security C. Safety D. Belonging

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(Answer: ) A (Rationale- Risk for aspiration takes priority because general anesthesia may impair gag and swallow reflexes. The other options, although important, are secondary to this.)

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A female client who received general anesthesia returns from surgery. Postoperatively, which nursing diagnosis takes highest priority for this client? A. Risk for aspiration R/T anesthesia B. Deficient fluid volume R/T blood and fluid loss from surgery C. Impaired physical mobility R/T surgery D. Acute pain R/T surgery

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(Answer: ) A (Rationale- The first priority is to evaluate airway patency. Pain management and splinting are important for client comfort, but come after an airway assessment. Coughing and deep breathing may be contraindicated if the client has internal bleeding and other injuries.)

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A male client is admitted to the hospital with blunt chest trauma after a motor vehicle accident. The first nursing priority for this client would be to:A. Assess the client's airway B. Provide pain relief C. Encourage deep breathing and coughing D. Splint the chest wall with a pillow

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(Answer: ) D (Rationale- A nursing diagnosis is a statement about a patient's actual or potential health problem that is within the scope of independent nursing intervention. Medical terminology is never part of the nursing diagnosis.)

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The guidelines for writing an appropriate nursing diagnosis include all of the following except: A. State the diagnosis in terms of a problem, not a need B. Use nursing terminology to describe the patient's response C. Use statements that assist in planning independent nursing interventions D. Use medical terminology to describe the probable cause of the patient's response

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(Answer: ) D (Rationale- A, B, & C are incorrect. These are not independent nursing interventions because they require a physician's order.)

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Independent nursing interventions commonly used for immobilized patients include all of the following except:A. Active or passive ROM exercises, body repositioning, and ADLs as tolerated B. Deep-breathing and coughing exercises with change of position every 2 hours C. Diaphragmatic and abdominal breathing exercises D. Weight bearing on a tilt table, total parenteral nutrition, and vitamin therapy

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(Answer: ) A (Rationale- Independent nursing interventions for a patient with pressure ulcers commonly include changing positions. B, C, & D all require a physician's order. Additionally, a drying agent, answer B would be contraindicated because the wound needs moisture to heal.)

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Independent nursing interventions commonly used for patients with pressure ulcers include: A. changing the patient's position regularly to minimize pressure B. Applying a drying agent such as an antacid to decrease moisture at the ulcer site C. Debriding the ulcer to remove necrotic tissue, which can impede healing D. Placing the patient in a whirlpool bath containing povidone-iodine solution as tolerated

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(Answer: ) C (Rationale- The appropriate diagnosis for a patient with excessively dry skin is impaired skin integrity - actual not potential. R/T dehydration is appropriate because the patient complained of thirst.)

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While the nurse is providing a patient personal hygiene, she observes that his skin is excessively dry. During the procedure, he tells her that he is very thirsty. An appropriate nursing diagnosis would be: A. Potential for impaired skin integrity R/T altered gland function B. Potential for impaired skin integrity R/T dehydration C. Impaired skin integrity R/T dehydration D. Impaired skin integrity R/T altered circulation

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(Answer: ) D (Rationale- Preventative measures, such as these, will prevent the skin from cracking, which would make the client more prone to infection. The other 3 answers are options, however NOT the best choice for this particular situation.)

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The most important nursing intervention to correct skin dryness is:A. avoid bathing until the condition is remedied and notify physician B. ask physician to refer the patient to a dermatologist C. Consult the dietitian about increasing fat intake, and take necessary measures to prevent infection D. encourage the patient to increase fluid intake, use nonirritating soap, and apply lotion to involved areas

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Answer A (Rationale- A. This is an example of an appropriately written nursing diagnosis. It consists of a diagnostic label and the associated etiology. Nursing interventions can be directed at treating or managing the behavior of insufficient medication use. note: for purposes of this example there are no signs and symptoms listed. In an actual diagnosis the S/S would need to be listed as well.B. This nursing diagnosis is not written correctly. What could be a defining characteristic S/S is used as an etiology. This nursing diagnosis could be rewritten more appropriately as Impaired mobility related to pain as evidenced by difficulty ambulating. C. This nursing diagnosis is written incorrectly because it identifies the equipment rather than the client's response to the equipment. It would be appropriate to state deficient knowledge regarding the need for cardiac monitoring. D. This nursing diagnosis is written incorrectly because it identifies a nursing intervention, not the client's problem. It could be reworded, Diarrhea related to food intolerance for example.)

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Which of the following is an appropriately written nursing diagnosis? A) Pain related to insufficient use of medication B) Pain related to difficulty ambulating C) Anxiety related to cardiac monitor D) Bedpan required frequently as a result of altered elimination pattern

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Answer c (Rationale- C: Accountability refers to individuals being answerable for their actions. It involves follow-up and a reflective analysis of one's decisions to evaluate their effectiveness. A. Selecting the medication schedule for the client is an example of taking responsibility. B. Implementing discharge-teaching plans that meet individual needs is an example of autonomy.D. Promoting participation of all staff members in unit meetings is an example of promoting authority.)

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Accountability is a critical aspect of nursing care. An example of accountability is demonstrated by: A) Selecting the medication schedule for the client B) Implementing discharge teaching plans that meet individual needs C) Evaluating the client's outcomes after implementation of care D) Promoting participation of all staff members in unit meetings

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answer B (Rationale- B. The client's request would be of low priority because it is not directly related to a specific illness or prognosis. A. The client's request is not an immediate priority. It is not a life-threatening situation.) C. The client's request is not an intermediate priority. An intermediate priority is one that involves the nonemergency, non-life threatening needs of the client. D. The client's request is not a high priority. It is not a life-threatening situation.

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The nurse is working with a client who is being prepared for a diagnostic test this afternoon. The client tells the nurse she wants to have her hair shampooed. How would the nurse prioritize this client need? A) Immediate priority B) Low priority C) Intermediate priority D) High priority

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(Answer: ) D (Rationale- D: This is the most appropriate intervention statement. It includes the action, frequency, quantity, and method. A. This intervention statement lacks the component of quantity. B. This intervention statement fails to indicate the frequency or method i.e., what is the nurse specifically looking for?. C. This intervention statement omits the method.)

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Nursing interventions should be documented according to specific criteria so they are clearly understood by other members of the nursing team. The most appropriate of the following intervention statements is: A) Offer fluids to the client q 2 hours B) Observe the client's respirations C) Change the client's dressing daily D) Irrigate the nasogastric tube q 2 hours with 30 mL normal saline

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(Answer: ) D (Rationale- D: Psychomotor skills involve the integration of cognitive and motor activities, such as in providing ostomy care. A. Cognitive skills involve the application of nursing knowledge. Knowing the rationale for therapeutic interventions, understanding normal and abnormal physiological and psychological responses, and being able to identify client learning and discharge needs all require cognitive skills. B. Interpersonal skills are used when the nurse interacts with clients, their families, and other health care team members. Effective communication is an example of an interpersonal skill. C. Affective means pertaining to an emotion or mental state.)

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A nurse who specializes in care of clients with ostomies shows a client's significant other how to assist with the manipulation of ostomy equipment. The nurse demonstrating the technique to the client is using what type of nursing skill? A) Cognitive B) Interactive C) Affective D) Psychomotor

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(Answer: ) C (Rationale- C: Using closed-ended questions helps the nurse to acquire specific information about health problems such as symptoms, precipitating factors, or relief measures in an efficient manner. A. Active listening occurs when the nurse uses techniques such as "all right," "go on," or "uh-huh," to indicate that the nurse has heard what the client said and to encourage the client to elaborate further. B. Using open-ended questions prompts the client to describe a situation in more than one or two words. Because it allows the client the opportunity to tell his or her story and reveal what is important, it is not the most efficient method of obtaining specific information regarding a client's signs and symptoms of a health problem. D. In seeking clarification, the nurse attempts to make the broad meaning of the message more understandable. The nurse can restate or repeat the client's message.)

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During an interview, the nurse needs to obtain specific information about the signs and symptoms of a health problem. To obtain these data most efficiently, the nurse should use: A) Active listening B) Open-ended questions C) Closed-ended questions D) Seeking clarification

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(Answer: ) D (Rationale- D: Subjective data are clients' perceptions about their health problems. Feeling anxious and tense is information that only the client can provide. a. Objective data are observation or measurements made by the data collector. In this example, the nurse is making the observation that the client appears sleepy. b. "No distress noted" is an example of objective data because it is an observation made by the nurse. c. "Abdomen soft and non-tender" is an example of objective data because it is an observation made by the nurse, not a client's perception.)

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Which of the following is classified as subjective data? A) Client appears sleepy B) No distress noted C) Abdomen soft and non-tender D) States feels anxious and tense

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Which of the following is an appropriate etiology for a nursing diagnosis? A) Incisional pain B) Poor hygienic practices C) Needs bedpan frequently D) Inadequate prescription of medication by the physician

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Answer A (Rationale- A. Incisional pain is an appropriate etiology for a nursing diagnosis. It is a condition that identifies the cause of a client's response to a health problem that a nurse can treat or manage. B. "Poor hygiene practices" would not be an appropriate etiology for a nursing diagnosis because it insinuates a nurse's prejudicial judgment. C. "Needs bedpan frequently" is not an appropriate etiology because it identifies a nursing intervention, not an etiology. D. "Inadequate prescription of medication by the physician" is not an appropriate etiology because it identifies the nurse's problem, not the client's problem. The nursing diagnosis should center attention on client needs.)

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Nursing interventions should be documented according to specific criteria so they are clearly understood by other members of the nursing team. The intervention statement "Nurse will apply warm, wet soaks to the client's leg while the client is awake" lacks which of the following components? A) Method B) Quantity C) Frequency D) Qualifications of the person who will perform the task

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(Answer: ) C (Rationale- The intervention statement does not include how frequently the warm soaks should be applied. A. The method is applying warm wet soaks to the patient's leg while the patient is awake. B. The quantity is warm wet soaks.D. The qualification of the person who will perform the action is the designation of "the nurse.")

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Of the following statements, which one is an example of an appropriately written nursing diagnosis? A) Acute pain related to left mastectomy B) Impaired gas exchange related to altered blood gases C) Deficient knowledge related to need for cardiac catheterization D) Need for high protein diet related to alteration in nutrition

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(Answer: ) A (Rationale- A: If a nurse does not know how to perform a procedure, he or she should seek assistance. Information about the procedure is obtained from the literature and the agency's procedure book. All equipment necessary for the procedure is collected. Finally, another nurse who has completed the procedure correctly and safely provides assistance and guidance. B. Reassessing the client is a partial assessment that may focus on one dimension of the client or on one system. It provides a way to determine whether the proposed nursing action is still appropriate for the client's level of wellness. C. Interpersonal skills are used to develop a trusting relationship, express a level of caring, and communicate clearly with the client, family, and health care team. d. This nursing diagnosis does not identify the problem and etiology. It identifies the client's goal rather than the problem. It could be reworded as Imbalanced nutrition: less than body requirements related to inadequate protein intake.)

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The nurse notes a narcotic is to be administered per epidural cath. The nurse, however, does not know how to perform this procedure. Which aspects of the implementation process should be followed? A) Seek assistance B) Reassess the client C) Use interpersonal skills D) Critical decision making

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D. Critical decision making is used when the nurse implements the care plan by using the knowledge bases necessary for care planning and for then completing the planned interventions most effectively. In this case, the nurse lacks the necessary knowledge and experience and should seek assistance.)

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