What are the steps in concept map care planning? (Select all 4)

4. Identify goals, outcomes, interventions, 5. Evaluate patient responses, 1. Develop a basic skeleton diagram, 2. Analyze/Categorize data, 3. Analyze nursing diagnosis/relationships between patient illnesses

What is the difference between a nursing diagnosis and a Collaborative problem?

Nursing - focuses on unhealthy response to health and illness, Collaborative - Diagnoses and treatment come from multiple disciplines

Alerts you to the fact that something may be wrong

What are the benefits to nursing diagnoses?

Individualizes patient care, Improves communication between nurses

What is the focused assessment?

A specific assessment meant to address the current problem

Determining the effectiveness of plan of care (patient goal achievement)

What is the difference between the nurse assessment and the medical/health assessment?

Medical - targets data pointing to pathologic conditions, Nursing - focuses on patient's response to health problems

What is objective data?

Observable/Measureable (Ex: Temperature or Blood Pressure)

What are critical thinking indicators (CTIs)? (Select all 4)

Ex: Self-aware, effective communicator, alert to context, open/fair-minded, Behaviors that promote development of critical thinking habits, Ex:Improvement-oriented, curious/inquisitive, reflective/logical/realistic, Evidence-based descriptions of behaviors often seen in critical thinkers

What is a critical pathway?

Based on physician's orders, A standardized plan of care, must be personalized for each patient

How is a nursing diagnosis written?

(Problem) related to (Etiology) as evidenced by (Defining Characteristics)

What are the four blended skills essential to nursing practice? (Select all 4)

Ethical/Legal - Personal moral code/Professional role responsibilities, Cognitive - Makes sense of the situation/what is necessary to achieve goals, Interpersonal - Establish caring relationships that help achieve goals, Technical - Manipulate equipment skillfully to produce desired outcome

What is an example of Interpersonal Skills?

Encouraging personal strengths of patients to achieve health goals

What is the comprehensive/initial assessment?

The initial head to toe assessment during admission

What is the nursing history of a patient?

Captures/records uniqueness of pt so care can be planned to meet needs, Identifies strengths/weaknesses, health risks, focus on getting to know pt

What is a collaborative problem?

Both the nurse and the physician work together to diagnose patient, Example: SNOWMOBILE ACCIDENT

What is the purpose of the nursing interview?

Verifies data gathered during patient history, yields new data, A planned communication that establishes a working relationship w/ the pt

What is an etiology in a nursing diagnosis?

The factors contributing/maintaining the unhealthy state

What are the characteristics of data?

Purposeful, Complete, Factual/Accurate, Relevant

Developing a plan of individualized care, specifying goals/interventions

What is the major concern and responsibility of nurses?

To monitor for changes in health status of patients

What is an inference?

A judgement you make about the situation

What is a nursing assessment?

Systematic and continuous collection of patient data

What is whistle-blowing?

A warning to the public concerning a danger covered up by an organization, A report to an appropriate law enforcement agency (outside the hospital), A warning from a past/present member of an organization to the public

What are the four assessment priorities? (Select all 4)

Need for Nursing - How much/little nursing care does the patient need?, Developmental Stage - What stage is the patient? Is this usual/unusual?, Practical Considerations - What care is appropriate for the patient?, Health Orientation - identify potential/actual health risks, pt's values

What are the sources of patient data?

Patient, Family, Records, Other Professionals, Nurse Literature

What are the limitations to nursing diagnoses?

Nursing practice may be restricted, Patients may be misdiagnosed leading to inappropriate care

What is critical thinking?

A systematic way to form one's thinking, Based on intellectual standards and is well-reasoned

What are the patient benefits to using the nursing process correctly?

Individualized patient care (Holistic Care), Continuity of Care, Clear, efficient, cost-effective plan of action

What is the purpose of the nursing physical assessment?

Verifies data gathered during patient history, yields new data, An exam of the patient for objective data that may define pt's condition

What are some examples of critical thinking? (Select all 4)

Identifying potential problems - Remedy pitfalls to sound reasoning (Bias), Critique of judgement - questioning decisions to ensure theyre appropriate, Adequacy of knowledge - judging if the info is accurate/factual, Identifying the purpose of your thinking/helps direct thoughts toward goal

Who published the first book on the nursing process? What year?

Helen Yura & Mary B. Walsh, 1967

Includes all pertinent info collected by RN/other health professionals, The patient's record

What are the four habits that assist in the development of technical skills? (Select all 4)

Familiarize yourself with new equipement, understand how it works, Don't be ashamed to ask for help/clarification, Practice skill until you feel confident before performing it on a patient, Identify technically expert nurses, ask them for tips/tricks

Which organization was the *FIRST* to identifry diagnosis as part of the legal domain of professional nursing?What year?

New York Nurse Practice Act - 1972

What is the relationship between a nurses sense of accountability and the patient's well-being?

Concern for the patient transcends whatever happens in your shift, Fatigue, anxiety, negativity can all affect a patient's well-being, Being attentive/responsive to needs of individuals can affect pt wellbeing

What is the nurse's responsibility for reporting incompetent/unethical/illegal practices?

Follow the hospital's policy for reporting incidents, Document detailed account in patient's chart

What are the five characteristics of the nursing process?

Systematic, Dynamic, Interpersonal, Outcome-Focus, Universally Applicable

What is a problem in a nursing diagnosis?

Identifies what is unhealthy or what patient wants to change

What are some common problems with data collection?

Omission of pertinent data/Inclusion of irrelevant data, Unorganized database/Failure to update database, Failure to establish a rapport with patient, pt not forthcoming with info

What guides the concept map development?

Nursing Diagnoses, Medical Diagnoses

Analyze data gathered from nursing assessment, Identify factors that contribute to a patient's health problem

What is the time-lapsed assessment?

An assessment where the RN performs an intervention & then reassesses later

What is subjective data?

Perceived only by affected person (Ex: Pain or Nausea)

What are the steps of the nursing process?

Assessment, Diagnosis, Planning, Implementation, Evaluation

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Maryville NURS 203 Ch 13, 14, 15 Test Study Guide

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Answers

1
What are the steps in concept map care planning? (Select all 4)
4. Identify goals, outcomes, interventions
5. Evaluate patient responses
1. Develop a basic skeleton diagram, 2. Analyze/Categorize data
3. Analyze nursing diagnosis/relationships between patient illnesses
2
What is the difference between a nursing diagnosis and a Collaborative problem?
Nursing - Diganoses and treatment come from multiple disciplines
Nursing - focuses on unhealthy response to health and illness
Collaborative - Focuses on unhealthy responses to health and illness
Collaborative - Diagnoses and treatment come from multiple disciplines
3
What is a cue?
Alerts you to the fact that something may be wrong
A judgement you make about the situation
4
What are the benefits to nursing diagnoses?
Individualizes patient care
Gives nurses total authority over patients
Improves communication between nurses
Nurses can freely diagnose and treat patients
5
What is the focused assessment?
An assessment where the RN performs an intervention & then reassesses later
A specific assessment meant to address the current problem
An assessment performed during a trauma/code
The initial head to toe assessment during admission
6
What is Evaluation?
Identifying patient strengths and actual/potential problems
Developing a plan of individualized care, specifying goals/interventions
Determining the effectiveness of plan of care (patient goal achievement)
Systematically collecting patient data, determining need for nursing care
7
What is the difference between the nurse assessment and the medical/health assessment?
Medical - targets data pointing to pathologic conditions
Medical - focuses on patien'ts response to health problems
Nursing - focuses on patient's response to health problems
Nursing - targets data pointing to pathologic conditions
8
What is objective data?
Observable/Measureable (Ex: Temperature or Blood Pressure)
Perceived only by affected person (Ex: Pain or Nausea)
9
What are critical thinking indicators (CTIs)? (Select all 4)
Ex: Self-aware, effective communicator, alert to context, open/fair-minded
Behaviors that promote development of critical thinking habits
Ex:Improvement-oriented, curious/inquisitive, reflective/logical/realistic
Evidence-based descriptions of behaviors often seen in critical thinkers
10
What is a critical pathway?
Based on physician's orders
A standardized plan of care, must be personalized for each patient
Based on nursing diagnoses
A standardized plan of care, generalized according to each problem
11
How is a nursing diagnosis written?
(Problem) related to (Etiology) as evidenced by (Defining Characteristics)
(Problem) caused by (Medical Diagnosis) as shown by (Subjective Data)
(Etiology) related to (Defining Characteristics) related to (Problem)
(Etiology + Defining Characteristics) caused by (Problem)
12
What are the four blended skills essential to nursing practice? (Select all 4)
Ethical/Legal - Personal moral code/Professional role responsibilities
Cognitive - Makes sense of the situation/what is necessary to achieve goals
Interpersonal - Establish caring relationships that help achieve goals
Technical - Manipulate equipment skillfully to produce desired outcome
13
What is an example of Interpersonal Skills?
Offer scientific rationale for patient plan of care
Acting as effective patient advocates, promoting accountability
Creatively adapt equipment to needs of patients in diverse situations
Encouraging personal strengths of patients to achieve health goals
14
Who was the first organizaction to utilize the nursing process? What year?
AACN - 1982
AACN - 1974
ANA - 1982
ANA - 1974
15
What is the comprehensive/initial assessment?
The initial head to toe assessment during admission
An assessment where the RN performs an intervention & then reassesses later
An assessment performed during a trauma/code
A specific assessment meant to address the current problem
16
What is the nursing history of a patient?
Captures/records uniqueness of pt so care can be planned to meet needs
Identifies strengths/weaknesses, health risks, focus on getting to know pt
A list of all the times the patient has previously been in a hospital
The patient's previous medical diagnoses
17
What is the primary source of information in an assessment?
The Doctor
The Nurse
The Patient
The Objective Data
18
What is a collaborative problem?
Both the nurse and the physician work together to diagnose patient
A diagnosis made by the physician carried out by the nurse
A diagnosis made by the nurse to treat the patient as a whole
Example: SNOWMOBILE ACCIDENT
19
When was the term "nursing diagnosis" used first? By whom?
1973 - V. Fry
1973 - Gabbie & Levin
1953 - V. Fry
1953 - Gabbie & Levin
20
What is the purpose of the nursing interview?
An exam of the patient for objective data that may define pt's condition
Verifies data gathered during patient history, yields new data
Conscious/deliberate use of 5 senses to gather data, used in each pt visit
A planned communication that establishes a working relationship w/ the pt
21
What is an etiology in a nursing diagnosis?
The factors contributing/maintaining the unhealthy state
Identifies what is unhealthy or what patient wants to change
The subjective/objective data that signals the existence of a disease
22
What are the characteristics of data?
Private, Encompasing, Accurate, Purposeful
Intentional, Accurate, Honest, Respectful
Subjective, Objective, Emotional, Social
Purposeful, Complete, Factual/Accurate, Relevant
23
What is Planning?
Identifying patient strengths and actual/potential problems
Systematically collecting patient data, determining need for nursing care
Determining the effectiveness of plan of care (patient goal achievement)
Developing a plan of individualized care, specifying goals/interventions
24
What is the major concern and responsibility of nurses?
To assist doctors in implementing medical care
To monitor for changes in health status of patients
To assist patients in all activities of daily life
To diagnose medical issues
25
What is an inference?
Alerts you to the fact that something may be wrong
A judgement you make about the situation
26
What is a nursing assessment?
The goals implemented by the nurse to assist in patient health
Systematic and continuous collection of patient data
Documenting patients vitals in their chart
An initial intake evaluation of a patient on admission
27
Who used the term "nursing process" first? What year?
Lydia Hall, 1955
Lydia Hall, 1967
Helen Yura & Mary B. Walsh, 1967
Helen Yura & Mary B. Walsh, 1955
28
What is whistle-blowing?
A warning to the public concerning a danger covered up by an organization
A warning of impending danger to the public as a whole
A report to an appropriate law enforcement agency (outside the hospital)
A warning from a past/present member of an organization to the public
29
What are the four assessment priorities? (Select all 4)
Need for Nursing - How much/little nursing care does the patient need?
Developmental Stage - What stage is the patient? Is this usual/unusual?
Practical Considerations - What care is appropriate for the patient?
Health Orientation - identify potential/actual health risks, pt's values
30
When does the nurse need to report significant patient data?
As soon as possible
Within 24 hours
When the doctor asks for it
At the end of their shift
31
What are the sources of patient data?
Patient, Family, Friends, Peers, Other Nurses
Patient, Family, Records, Other Professionals, Nurse Literature
Patient, Doctor, Nurse, Medical Record, Patient History
Patient, Family, Teachers, Friends, Peers
32
What are the limitations to nursing diagnoses?
Nursing practice may be restricted
Doctors may reject nurse's opinions
Patient's may not trust nursing diagnoses
Patients may be misdiagnosed leading to inappropriate care
33
What is critical thinking?
A generalized guide on how to think/act
Based on emotional standards and empathetic research
A systematic way to form one's thinking
Based on intellectual standards and is well-reasoned
34
What are the patient benefits to using the nursing process correctly?
The ability to have a nurse on call 24/7
Individualized patient care (Holistic Care)
Continuity of Care
Clear, efficient, cost-effective plan of action
35
What is the purpose of the nursing physical assessment?
Conscious/deliberate use of 5 senses to gather data, used in each pt visit
Verifies data gathered during patient history, yields new data
A planned communication that establishes a working relationship w/ the pt
An exam of the patient for objective data that may define pt's condition
36
What are some examples of critical thinking? (Select all 4)
Identifying potential problems - Remedy pitfalls to sound reasoning (Bias)
Critique of judgement - questioning decisions to ensure theyre appropriate
Adequacy of knowledge - judging if the info is accurate/factual
Identifying the purpose of your thinking/helps direct thoughts toward goal
37
Who published the first book on the nursing process? What year?
Lydia Hall, 1967
Helen Yura & Mary B. Walsh, 1955
Helen Yura & Mary B. Walsh, 1967
Lydia Hall, 1955
38
What is a database?
Includes all pertinent info collected by RN/other health professionals
A collection of medical practitioners/documents negligence
The patient's record
A helpful system nurses can use to look up information on procedures
39
What are the four habits that assist in the development of technical skills? (Select all 4)
Familiarize yourself with new equipement, understand how it works
Don't be ashamed to ask for help/clarification
Practice skill until you feel confident before performing it on a patient
Identify technically expert nurses, ask them for tips/tricks
40
Which organization was the *FIRST* to identifry diagnosis as part of the legal domain of professional nursing?What year?
New York Nurse Practice Act - 1973
ANA Standards of Practice - 1973
ANA Standards of Practice - 1972
New York Nurse Practice Act - 1972
41
What is the relationship between a nurses sense of accountability and the patient's well-being?
Concern for the patient transcends whatever happens in your shift
Nurses must hold patient's accountable to the patient bill of rights
Fatigue, anxiety, negativity can all affect a patient's well-being
Being attentive/responsive to needs of individuals can affect pt wellbeing
42
What is the nurse's responsibility for reporting incompetent/unethical/illegal practices?
Follow the hospital's policy for reporting incidents
RNs are obligated to report all unethical practices to the police
Document detailed account in patient's chart
RNs are required to report all incompetent practices to the state boards
43
What are the five characteristics of the nursing process?
Dynamic, Emotional, Holistic, Universally Applicable, Patient-Focused
Systematic, Dynamic, Interpersonal, Outcome-Focus, Universally Applicable
Systematic, Ethical, Legal, Social, Universally Applicable
Sympathy, Empathy, Universally Applicable, Emotional, Social
44
What is a problem in a nursing diagnosis?
Identifies what is unhealthy or what patient wants to change
The subjective/objective data that signals the existence of a disease
The factors contributing/maintaining the unhealthy state
45
When did Board Exams start using the nursing process as an organizing concept?
1967
1974
1955
1982
46
What are some common problems with data collection?
Omission of pertinent data/Inclusion of irrelevant data
Unorganized database/Failure to update database
Patients lying during interview process to acquire medications
Failure to establish a rapport with patient, pt not forthcoming with info
47
What guides the concept map development?
Patient Diagnoses
Nursing Diagnoses
Medical Diagnoses
Physical Diagnoses
48
What is diagnosing?
Analyze data gathered from nursing assessment
Stating what the actual disease process is to assist physician
Identify factors that contribute to a patient's health problem
Implementing a plan of care
49
What is the time-lapsed assessment?
A specific assessment meant to address the current problem
An assessment performed during a trauma/code
An assessment where the RN performs an intervention & then reassesses later
The initial head to toe assessment during admission
50
What is subjective data?
Perceived only by affected person (Ex: Pain or Nausea)
Observable/Measureable (Ex: Temperature or Blood Pressure)
51
What are the steps of the nursing process?
Assessment, Diagnosis, Planning, Implementation, Evaluation
Assessment, Direction, Prevention, Instruction, Empathy
Assignment, Direction, Planning, Intervention, Evaluation
Assignment, Diagnosis, Prevention, Intervention, Ejection
52
What is an example of Ethical/Legal Skills?
Encouraging personal strengths of patients to achieve health goals
Offer scientific rationale for patient plan of care
Acting as effective patient advocates, promoting accountability
Creatively adapt equipment to needs of patients in diverse situations
53
What are the four steps involved in data interpretation and analysis? (Select all 4)
Identify strengths and problems
Recognize patterns or clusters
Reach conclusions (Sometimes there isn't a problem)
Recognize significant data
54
What is Diagnosing?
Systematically collecting patient data, determining need for nursing care
Determining the effectiveness of plan of care (patient goal achievement)
Identifying patient strengths and actual/potential problems
Developing a plan of individualized care, specifying goals/interventions
55
What are the guidelines for writing nursing diagnoses?
Use non-judgemental language
Use non-specific language (Ex: good, normal)
Avoid using medical diagnoses
Must have problem and etiology, can include defining characteristics
56
What are the five types of nursing diagnoses?
Problem, Genuine, Definite, Wellness, Risk
Potential, Problematic, Risk, Wellness, Syndrome
Actual, Possible, Potential, Desireable, Opportunistic
Actual, Risk, Possible, Wellness, Syndrome
57
What is a concept map?
An instructional strategy that visually displays relationships for illness
Assists RN students to develop a care plan based on individual problems
A map for a patient's entire stay in the hospital, admission to discharge
A map for the patient to follow to encourage wellness
58
When does data need to be verified?
When the doctor asks the RN to
When there is a discrepancy between what the pt says and what the RN sees
When the patient asks for it
When there is a difference in what the pt says & what their friend says
59
When was the first National Conference on Nursing Diagnoses? Who called it? (Eventually became NANDA)
1953 - Gabbie & Levin
1973 - V. Fry
1953 - V. Fry
1973 - Gabbie & Levin
60
When was the ANA Congress? What was established there?
1973 - Nurse Practioner steps were legitimized, standards of practice
1982 - Board exams established, began using nursing process to organize
1973 - Board exams established, began using nursing process to organize
1982 - Nurse Practioner steps were legitimized, standards of practice
61
What is the emergency assessment?
A specific assessment meant to address the current problem
An assessment performed during a trauma/code
An assessment where the RN performs an intervention & then reassesses later
The initial head to toe assessment during admission
62
What is the purpose of a nursing diagnosis?
Stating what the actual disease process is to assist physician
Focuses on patient's response to medical interventions
Identifying issues that can be fixed with independant nursing intervention
Changes as the patient's responses change
63
What is the purpose of a medical diagnosis?
Changes as the patient's responses change
Identifying issues that can be fixed with independant nursing intervention
Focuses on patient's response to medical interventions
A diagnosis made by a physician to direct treatment of pathologic issues
64
What are the four stages of a patient interview?
Introduction, Interview, Evaluate, Document
Preparatory, Introduction, Working Phase, Termination
Prepare, Intervene, Implement, Evaluate
Prepare, Interview, Working Phase, Transcribe
65
Who made nursing diagnosis a separate step of the nursing process? What year?
Yura & Walsh, 1974
Yura & Walsh, 1967
Gabbie & Lavin, 1967
Gebbie & Lavin, 1974
66
What is the purpose of nursing observation?
A planned communication that establishes a working relationship w/ the pt
An exam of the patient for objective data that may define pt's condition
Verifies data gathered during patient history, yields new data
Conscious/deliberate use of 5 senses to gather data, used in each pt visit
67
What is an example of Cognitive Skills?
Acting as effective patient advocates, promoting accountability
Creatively adapt equipment to needs of patients in diverse situations
Encouraging personal strengths of patients to achieve health goals
Offer scientific rationale for patient plan of care
68
What is an example of Technical Skills?
Acting as effective patient advocates, promoting accountability
Creatively adapt equipment to needs of patients in diverse situations
Encouraging personal strengths of patients to achieve health goals
Offer scientific rationale for patient plan of care
69
What does the nursing history include? (Select all 4)
Patient strengths and weaknessess
Cultural considerations, developmental histories
Perceptions of health status and current health habits/patterns
Patient/Family educational needs or willingness to participate in careplan
70
What are the nurse benefits to using the nursing process correctly?
The opportunity to go back to school to specialize in a certain field
Opportunity to work collaboratively with other healthcare workers
Opportunity to grow professionally
Satisfaction of making a difference in the lives of patients
71
What are definining characteristics in a nursing diagnosis?
Identifies what is unhealthy or what patient wants to change
The factors contributing/maintaining the unhealthy state
The subjective/objective data that signals the existence of a disease
72
What is Assessment?
Identifying patient strengths and actual/potential problems
Systematically collecting patient data, determining need for nursing care
Developing a plan of individualized care, specifying goals/interventions
Determining the effectiveness of plan of care (patient goal achievement)
73
What are the characteristics of interpersonal skills? (Select all 4)
Establishing caring relationships
Preparing attention/intention prior to each clinical encounter
Enjoying the rewards of mutual exchange
Promoting human dignity/respect
74
How should a nurse document significant patient data?
Include their own person judgements about the patient's situation
Avoid non-specific terms (Ex: good, feeling better)
Use patient's own words whenever possible
Summarize objective/subjective in a concise, comprehensive way
75
What are the four methods used to collect data during the physical assessment?
Inspection, Interview, Objective, Subjective
Inspection, Auscultation, nursing diagnosis, medical diagnosis
See, Hear, Feel, Interview
Inspection, Auscultation, Palpation, Percussion

Maryville NURS 203 Ch 13, 14, 15 Test Study Guide Flashcards | StudBud