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95 Cards in this Set
- Front
- Back
Which component of the nursing process? |
Assessing |
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Which component of the nursing process? |
Assessing |
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Which component of the nursing process? |
Assessing |
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Which component of the nursing process? |
Assessing |
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What is the primary purpose of assessing? |
To create a database for the client |
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When you make a clinical judgment, you are really performing which component of the nursing process? |
Diagnosing |
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Which component of the nursing process? |
Diagnosing |
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Which component of the nursing process? |
Diagnosing |
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Which component of the nursing process? |
Diagnosing |
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Which component of the nursing process? |
Diagnosing |
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Which component of the nursing process? |
Diagnosing |
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Which component of the nursing process? |
Planning |
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Which component of the nursing process? |
Planning |
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Which component of the nursing process? |
Planning |
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Which component of the nursing process? |
Planning |
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Which component of the nursing process? |
Planning |
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Which component of the nursing process? |
Implementing |
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Which component of the nursing process? |
Implementing |
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Which component of the nursing process? |
Evaluating |
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Which component of the nursing process? |
Evaluating |
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Which component of the nursing process? |
Evaluating |
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Which component of the nursing process? |
Evaluating |
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Which component of the nursing process? |
Evaluating |
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(def) |
Nursing diagnosis |
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A nursing diagnosis is a clinical judgment that is a response to ________ and ________ health problems / life processes. |
Actual and Potential |
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A proper nursing diagnosis provides the basis for what? |
the selection of interventions that will achieve outcomes that the NURSE is accountable for |
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Describe what a "Wellness Nursing Diagnosis" is? |
a clinical judgment about an individual, group, or community in transition from a specific level of wellness to a higher level of wellness |
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What 2 cues must be present for an individual or group to have a wellness diagnosis? |
1. a desire for a higher level of wellness |
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A Wellness Nursing Diagnosis will begin with what specific label? |
"Readiness for Enhanced" |
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The following nursing diagnosis is an example of what type of diagnosis? |
Wellness Nursing Diagnosis |
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What is the primary differences between a nursing diagnosis and a medical diagnosis? |
A nursing diagnosis describes a patient's response to a disease or a condition. It is dynamic (can change as the client's response changes). |
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What is the purpose of using standard terminology (NANDA definitions) when preparing a nursing diagnosis? |
To facilitate communication among nurses |
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A client's database is derived from both the health history and the physical examination. Why would you want to use both sources when determining your nursing diagnoses? |
To promote holistic care of the client |
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A nursing diagnosis provides direction for what? |
the planning of independent nursing interventions |
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How do nursing diagnoses promote professional accountability and autonomy? |
they define and describe the independent area of the nursing practice |
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Diagnosing is a process of ________ and _________. |
analysis and synthesis |
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(def) |
analysis |
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(def) |
synthesis |
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What is the purpose of using Gordan's functional health patterns and a head-to-toe physical assessment? |
to gather and organize information |
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Inferences are made how? |
by comparing the data obtained to standards |
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When comparing the data you obtain to standards, you are essentially asking what basic question when looking at each piece of information? |
Is this normal or abnormal? |
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What are 5 examples of standards that you may compare data with? |
1. normal health patterns |
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The process of determining the relatedness of data and grouping the data is known as what? |
Clustering Data |
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Clustering data increases the accuracy of what? |
inferences |
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What are the 4 guidelines you should follow when clustering data? |
1. search for abnormal cues |
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What is the next step in developing a diagnosis after you have developed a tentative diagnostic label? |
Verify the interpretation with the client. |
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Upon discussion of the tentative diagnostic label with the patient, the nurse and patient can make what (4) possible conclusions? |
1. No problem exists |
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After discussing your interpretation of data with the client and determining a conclusion based off of your interaction with the client, what is your next step? |
Finalizing the diagnostic statement |
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(def) |
diagnostic label |
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(def) |
Related factors |
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What are the 3 purposes of "related factors" within the diagnostic statement? |
1. identify one or more probable causes of the health problems/diagnostic label |
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(def) |
Defining characteristics |
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In formulating a nursing diagnosis, what is the next step after you have determined your related factors and defining characteristics? |
You complete your nursing diagnosis |
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When completing your nursing diagnosis, what determines if you will use a two-part or three-part statement? |
You will use a two-part statement for risk diagnosis. (PE - will consist of the problems/diagnostic label and the etiology/related-to factors) |
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Correct the following diagnostic label and explain the reasoning for the correction: |
"Risk for aspiration" |
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Correct the following Nursing Diagnosis: |
Risk for injury R/T change in mental status |
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Correct the following diagnostic label and explain the reasoning for the correction: |
Impaired skin integrity R/T immobility. |
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Correct the following diagnostic label and explain the reasoning for the correction: |
Spiritual distress R/T inability to attend services. |
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Correct the following diagnostic label and explain the reasoning for the correction: |
Ineffective Breathing Pattern R/T increased airway secretions. |
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Correct the following diagnostic label and explain the reasoning for the correction: |
Risk for ineffective airway clearance R/T accumulation of lung secretions. |
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Correct the following diagnostic label and explain the reasoning for the correction: |
Deficient knowledge: purposes and need for cardiac monitoring R/T lack of exposure to information. |
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Correct the following diagnostic label and explain the reasoning for the correction: |
Diarrhea R/T intolerance to milk-based foods. |
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Correct the following diagnostic label and explain the reasoning for the correction: |
- Anxiety R/T difficulty in ambulating. |
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True/False: |
False- Although you can only have one problem, you can have one or more related factors. |
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When planning your care, the diagnoses you have identified are ranked by order of what? |
importance - higher priority items are placed at the top |
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What framework is often used to help determine priority of diagnoses? |
Maslow's hierarchy of needs |
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Would the following have a high, intermediate, or low priority: |
High Priority |
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Needs that required immediate attention are ranked a ______ priority. |
High |
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Needs that involve non-emergency, non-life threatening situations would be ranked a ______ priority. |
Intermediate |
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Needs that may not be directly related to a specific illness or prognosis, but may affect their future well-being would be ranked a _____ priority. |
low |
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When establishing your client's Expected Outcome, you will include both goals and outcome criteria. Describe each. |
Goals = broad statements reflecting resolution of the diagnostic label/problem |
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True/False: |
True |
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True/False: |
True |
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True/False: |
False- |
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True/False: |
True |
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Who should formulate the expected outcome? |
When possible, both the nurse and client should formulate the expected outcome. |
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What is the overall purpose of an expected outcome? |
It is used to provide direction to nursing interventions and measure the validity of the interventions. |
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True/False: |
False- an expected outcome would be the result of a nursing intervention. They are not one in the same. |
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(def) |
Nursing interventions |
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Nursing interventions are individually tailored to meet the specific needs of a client. They should be designed to resolve what? |
the "related factors" |
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True/False: |
False- |
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Nursing interventions reflect the prescribed care that is required to do what (3) things? |
- monitor a problem (assessing) |
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What is the goal of nursing interventions if the nursing diagnosis is "Risk for..."? |
They should provide protection or precautionary measures |
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The verbs used in a nursing intervention are specific ones that direct what? |
They direct the nurse's actions (for example, assess, instruct, place, observe, etc.) |
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How would YOU guarantee that others are able to follow your care plan when you are not available? |
Make sure that your nursing interventions are specific! Use specific times, frequencies, amounts, etc. |
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Nursing interventions can be what (3) types? |
1. Physician-Initiated |
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What is wrong with the following nursing intervention: |
It is not specific. A correctly stated nursing intervention would be - |
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True/False: |
False- you should be able to identify rationales for all nursing interventions. You can find rationales in your text books, notes, care plan books, etc. |
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What are critical pathways and computerized care plans? |
standard plans of care developed to set daily care priorities for specific diagnoses, promote timely achievement of outcomes, and reduce the length of hospital stays. |
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(def) |
Care Map |
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_________ is simply carrying out the plan of care. |
Implementing |
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What are the 4 components of evaluating the plan of care? |
1. Review outcome criteria |
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(def) |
Physician-Initiated interventions |
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(def) |
Nurse-Initiated interventions |
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(def) |
Collaborative interventions |