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Assessing

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the process of collecting, organizing, validating, and recording data (information) about a client's health status

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Cephalocaudal

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proceeding in the direction from head to toe

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Closed questions

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restrictive question requiring only a short answer

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Cues

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any piece of information or data that influences decisions

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Data

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information

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Database

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all information about a client, includes nursing health history ans physical assessment, physician's history, physical examination, and laboratory and diagnostic test results

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Directive interview

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a highly structured interview that uses closed questions to elicit specific information

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Inference

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interpretations or conclusions made based on cues or observed data

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Interview

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a planned communication; a conversation with a purpose

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Leading question

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a question that influences the client to give a particular answer

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Neutral question

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a question that does not direct or pressure a client to answer in a certain way

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Nondirective interview

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an interview using open-ended questions and empathetic responses to build rapport and learn client concerns

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Nursing process

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a systemic rational method of planning and providing nursing care

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Objective data

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information (data) that is detectable by an observer or can be tested against an accepted standard; can be seen, heard, felt, or smelled

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Open-ended question

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questions that specify only the broad topic to be discussed and invite clients to discover and explore their thoughts and feelings about the topic

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Rapport

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a relationship between two or more people of mutual trust and understanding

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Review of systems

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(AKA screening examination) a brief review of essential functioning of various body parts or systems

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Subjective data

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data that are apparent only to the person affected; can be described or verified only by that person

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Symptoms

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(AKA covert data) information (data) apparent only to the person affected that can be described or verified only by that person

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Validation

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the determination that the diagnosis accurately reflects the problem of the client, that the methods used for data gathering were appropriate, and that the conclusion or diagnosis is justified by the data

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Defining characteristics

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client signs and symptoms that must be present to validate a nursing diagnosis

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Dependent functions

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with regard to medical diagnoses, physician-prescribed therapies and treatments nurses are obligated to carry out

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Diagnosis

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a statement or conclusion concerning the nature of some phenomenon

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Diagnostic label

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title used in writing a nursing diagnosis; taken from the North American Nursing Diagnosis Association standardized taxonomy of terms

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Etiology

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the causal relationship between a problem and its related or risk factors

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Independent functions

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areas of healthcare unique to nursing, separate and distinct from medical management

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Norm

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an ideal or fixed standard; an expected standard of behavior of group members

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Nursing diagnosis

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the nurse's clinical judgement about individual, family, or community responses to actual and potential health problems/life processes to provide the basis for selecting nursing interventions to achieve outcomes for which the nurse is accountable

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PES format

answer

the three essential components of nursing diagnostic statements including the terms describing the problem, the etiology of the problem, and the defining characteristics or cluster of signs and symptoms

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Qualifiers

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words that have been added to some NANDA labels to give additional meaning to the diagnostic statement

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Risk factors

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factors that cause a client to be vulnerable to developing a health problem

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Risk nursing diagnosis

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clinical judgement that a problem does not exist, but the presence of risk factors indicates that a problem is likely to develop unless nurses intervene

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Standard

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a generally accepted rule, model, pattern, or meaasure

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Syndrome diagnosis

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a diagnosis that is associated with a cluster of other diagnosis

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Taxonomy

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a classification system or set of categories, such as nursing diagnoses, arranged on the basis of a single principle or consistent set of principles

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Wellness diagnosis

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(NANDA) describes human responses to levels of wellness in an individual, family, or community that have a readiness for enhancement

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Collaborative care plans

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(AKA critical pathways) multidisciplinary guidelines for client care based on specific medical diagnoses designed to achieve predetermined outcome

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Collaborative interventions

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actions the nurse carries out in collaboration with other health team members, such as physical therapists, social workers, dietitians, and physicians

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Concept map

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a visual tool in which ideas or data are enclosed in circles or boxes of some shape and relationships between these are indicated by connecting lines or arrows

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Dependent interventions

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activities carried out on the orders or supervision of a licensed physician or other health care provider authorized to write orders for nurses

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Discharge planning

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the process of anticipating and planning for client needs after discharge

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Formal nursing care plan

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a written or computerized guide that organizes information about the client's care

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Goals/desired outcomes

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a part of a care plan that describes, in terms of observable client responses, what the nurse hopes to achieve by implementing the nursing interventions

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Independent interventions

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activities that the nurse is licensed to initiate as a result of the nurse's own knowledge and skills

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Indicator

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an observable client state, behavior or self-reported perception or evaluation; similar to desired outcomes in traditional language

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Individualized care plan

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a plan tailored to meet the unique needs of a specific client-needs that are not addressed by the standardized plan

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Informal nursing care plan

answer

a strategy for action that exists in the nurse's mind

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Multidisciplinary care plan

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a standardized plan that outlines the care required for clients with common, predictable-usually medical-conditions

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Nursing intervention

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

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Nursing interventions classifications (NIC)

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a taxonomy of nursing actions each of which includes a label, a definition, and a list of activities

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Nursing outcomes classification (NOC)

answer

a taxonomy for describing client outcomes that respond to nursing interventions

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Policies

answer

rules developed to govern the handling of frequently occurring situations

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Priority setting

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the process of establishing a preferential order for nursing strategies

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Procedure

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steps used in carrying out policies or activities

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Protocol

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a predetermined and preprinted plan specifying the procedure to be followed in a particular situation

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Rationale

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a scientific reason for selecting a specific action

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Standardized care plan

answer

formal plan that specifies the nursing care for groups of clients with common needs (Ex: all clients with myocardial infarction)

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Standing order

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an order that may be carried out indefinitely until another order is written to cancel it, or that may be carried out for a specified number of days

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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 family history 3) Establishing short-term and long-term goals 4) Administering an antibiotic

answer

1) Identifying major problems or needs

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Which of the following behaviors would indicate that the nurse was utilizing the assessment phase of the nursing process to provide nursing care? 1) Proposes hypotheses 2) Generates desired outcomes 3) Reviews results of laboratory tests 4) Documents care

answer

3) Reviews results of laboratory tests

question

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 sever pain when walking up stairs

answer

2) Spouse states the client has lost all appetite

question

The nurse wishes to determine the clients feelings about a recent diagnosis. Which interview question is most likely to elicit this information? 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 about your reactions to the diagnosis" 4) "How is your family responding to the diagnosis?"

answer

3) "Tell me about your reactions to the diagnosis"

question

The use of a conceptual or theoretical framework for collecting and organizing assessment data ensures which of the following ? 1) Correlation of the data with other members of the health care team 2) Demonstration of cost-effective care 3) Utilization of creativity and intuition in creating a plan of care 4) Collection of all necessary information for a thorough appraisal

answer

4) Collection of all necessary information for a thorough appraisal

question

Which of the following is the purpose of assessing? 1) Establish a database of client responses to his or her health status 2) Identify client strengths and problems 3) Develop an individualized plan of care 4) Implement care, prevent illness, and promote wellness

answer

1) Establish a database of client responses to his or her health status

question

In the validating activity of the assessing phase of the nursing process, the nurse performs which of the following? 1) Collects subjective data 2) Applies a framework to the collected data 3) Confirms data is complete and accurate 4) Records data in the client record

answer

3) Confirms data is complete and accurate

question

A major characteristic of the nursing process is which of the following? 1) A focus on client needs 2) Its static nature 3) An emphasis on physiology and illness 4) Its exclusive use by and with nurses

answer

1) A focus on client needs

question

Which of the following would be true regarding use of the observing method of data collection? 1) When observing, the nurse uses only one the visual sense 2) Observing is done only when no other nursing interventions are being performed at the same time 3) Data should be gathered as it occurs, rather than in any particular order 4) Observed data should be interpreted in relation to other sources of collected data

answer

4) Observed data should be interpreted in relation to other sources of collected data

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Which of the following represent effective planning of the interview setting? Select all that apply 1) Keep the lighting dimmed so as not to stress the client's eyes 2) Ensure that no one can overhear the interview conversation 3) Stand near the client's head while he or she is in the bed or chair 4) Keep approximately 3 feet from the client during the interview 5) Use a standard form to be sure all relevant data are covered in the interview

answer

2) Ensure that no one can overhear the interview conversation 4)Keep approximately 3 feet from the client during the interview 5) Use a standard form to be sure all relevant data are covered in the interview

question

*KEY CONCEPTS* The nursing process is a systematic, rational method of planning and providing individualized care for individuals, families, communities and groups

answer

*KEY CONCEPTS* The goals of the nursing process are to identify a client's health status and actual or potential health care needs, to establish plans to meet the identified needs, and to deliver and evaluate specific nursing interventions to meet those needs

question

*KEY CONCEPTS* The nursing process is organized into five interrelated, interdependent phases: assessing, diagnosing, planning, implementing, and evaluating

answer

*KEY CONCEPTS* The nursing process can be used in all health care settings. It is cyclic and dynamic, client centered, interpersonal and collaborative, universally applicable, focuses on problem solving and decision making, and requires critical thinking

question

*KEY CONCEPTS* Assessing involves collecting, organizing, validating, and documenting data

answer

*KEY CONCEPTS* Diagnosing is analyzing data, identifying a client's potential or actual health problems, and formulating diagnostic statements

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*KEY CONCEPTS* Planning involves setting priorities, formulating goals/desired outcomes, and selecting nursing interventions

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*KEY CONCEPTS* Implementing is carrying out the nursing interventions. It includes reassessing the client, determining the nurse's need for assistance, supervising delegated care, and documenting nursing activities

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*KEY CONCEPTS* Evaluating is the process of comparing data to outcomes to determine the status of the problem. It includes review and modification of the care plan

answer

*KEY CONCEPTS* Assessment involves active participation by the client and nurse in obtaining subjective and objective data about the client's health status

question

*KEY CONCEPT* Subjective data are the client's personal perceptions, often gathered during the nursing health history

answer

*KEY CONCEPT* Objective data (Ex: data observed and/or collected during the physical examination) are detectable by an observer

question

*KEY CONCEPT* The client is the primary source of data. Secondary sources are family members and other support persons, other health professionals, records and reports, laboratory and diagnostic analyses, and relevant literature

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*KEY CONCEPTS* The primary methods of data collection are observing, interviewing, and examining

question

*KEY CONCEPTS* Observation is a conscious, deliberate skill involving use of the senses

answer

*KEY CONCEPTS* The nurse uses a combination of directive and nondirective interviewing (including closed and open-ended questions) to obtain the nursing health history

question

*KEY CONCEPTS* Nursing models provide formats for collecting and organizing client data

answer

*KEY CONCEPTS* The nursing assessment must be complete and accurate because nursing diagnoses and interventions are based on this information

question

*KEY CONCEPTS* Some data must be validated. Subjective data can be used to validate objective data, and vice versa

answer

*KEY CONCEPTS* The purpose of the NANDA International is to define, refine, and promote a taxonomy of nursing diagnostic terminology

question

The nurse is conducting the diagnosing phase (nursing diagnosis) of the nursing process for a client with a seizure disorder. Which step 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

answer

2) Delineate the client's problems and strengths

question

In the diagnostic statement "Excess Fluid Volume related to decreased venous return as manifested by lower extremity edema (swelling)," the etiology of the problem is which of the following? 1) Excess fluid volume 2) Decreased venous return 3) Edema 4) Unknown

answer

2) Decreased venous return

question

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) Impaired Communication related to stroke 4) Sleep Deprivation secondary to fatigue and a noisy environment

answer

1) Risk for Caregiver Role Strain related to unpredictable illness course

question

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 health and wellness elements 4) Standardizes organization of client data

answer

4) Standardizes organization of client data

question

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

answer

1) If both medical and nursing interventions are required to treat the problem

question

In the case in which a client is vulnerable to developing a health problem, the nurse chooses which type of nursing diagnosis status? 1) A risk nursing diagnosing 2) A wellness nursing diagnosis 3) A health promotion nursing diagnosis 4) An actual nursing diagnosis

answer

1) A risk nursing diagnosing

question

Which of the following is true regarding the state of the science in regards to nursing diagnosis? 1) The original taxonomy has proven to be adequate in scope 2) the organizing framework of the taxonomy is based on the work of Florence Nightingale 3) More research is needed to validate and refine the diagnostic labels 4) New diagnostic labels are approved by means of a vote of registered nurses

answer

3) More research is needed to validate and refine the diagnostic lables

question

Which of the following would indicate a significant cue when comparing data to standards? Select all that apply 1) The client has moved partway toward a set goals (Ex: weight loss) 2) The client's vision is within normal range only when wearing glasses 3) A child is able to control bladder and bowels at age 18 months 4) A woman widowed recently states she is "unable to cry" 5) A 16-year-old high school student reports spending 6 hours doing homework five nights per week

answer

1) The client has moved partway toward a set goal (ex: weight loss)

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