nur 505 exam 1
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1. nursing process: assessment, diagnosis, outcome identification, planning, implementation, evaluation
2. assessment/data collection: involves the systematic collection of information about the health status
of clients to identify needs and additional data to collect. Nurses can collect data during an initial assessment (baseline
data), focused assessment, and ongoing assessments.
3. effective data collection: nurses must ask clients appropriate questions, listen carefully to responses,
and have excellent head-to-toe physical assessment skills. Nurses must employ clinical judgment and critical thinking
in accurately recognizing when to collect assessment data. They must recognize the need to collect assessment data
prior to interventions.
4. subjective data: Nurses collect subjective data (manifestations) during a nursing history. Subjective data
includes clients' feelings, perceptions, and descriptions of health status. Clients are the only ones who can describe
and verify their own manifestations.
5. objective data: Nurses observe and measure objective data (findings) during a physical examination. Nurses
feel, see, hear, and smell objective data through observation or physical assessment of the client.
6. Analysis/diagnosis /data collection requires nurses to look at the data and: -
-Identify patterns or trends.
-Compare the data with expected standards or reference ranges.
-Arrive at conclusions to guide nursing care.
7. Planning: When planning client care (RN) or contributing to a client's plan of care (PN), nurses must establish
priorities and optimal outcomes of care they can readily measure and evaluate. These established priorities and
outcomes direct nurses in selecting interventions to include in a plan of care to promote, maintain, or restore health of
clients.
8. three types of planning: -develop a comprehensive plan of care for clients based on comprehensive
assessments they complete, for example, on admission to a health care facility or to a home health organization.
-perform ongoing planning throughout the provision of care. While obtaining new information and evaluating respons-
es to care, they modify and individualize the initial plan of care.
-discharge planning is a process of anticipating and planning for clients' needs after discharge. To be effective,
discharge planning must begin during admission.
9. priority setting guideline example: maslows low to high: physiological, safety and
security, love and belonging, self-esteem, self-actualization
Principle: Lower-level needs (physiological) must be met before higher-level needs.
1/5
, nur 505 exam 1
Study online at https://quizlet.com/_isnleg
10. Nurse-initiated/independent interventions:: Nurses use evidence and scientific rationale to
take autonomous actions to benefit clients. They base these actions on identified problems and health care needs, and
make sure they are within their scope of practice. Nurses perform or delegate the interventions and are accountable
for them. An example is repositioning a client at least every 2 hr to prevent skin breakdown.
11. Provider-initiated/dependent interventions:: Interventions nurses initiate as a result of a
provider's prescription (written, standing, or verbal) or the facility's protocol (blood administration procedures).
12. Collaborative interventions:: Interventions nurses carry out in collaboration with other health care
team professionals (ensuring that a client receives and eats their evening snack).
13. The nursing care plan (NCP): the end product of the planning step. Nurses organize the NCP for quick
identification of problems, outcomes, and interventions to implement.
14. implementation: In this step, nurses must use problem-solving, clinical judgment, and critical thinking
to select and implement appropriate therapeutic interventions using nursing knowledge, priorities of care, and
planned goals or outcomes to promote, maintain, or restore health. Nurses also use interpersonal skills (therapeutic
communication) and technical skills (psychomotor performance) when implementing nursing interventions.
15. therapeutic interventions: include measures nurses take to minimize risk (wearing personal protective
equipment). Nurses intervene to respond to unplanned events (an observation of unsafe practice, a change in status,
or the emergence of a life-threatening situation).
16. During implementation, nurses: perform nursing actions, delegate tasks, supervise other health
care staff, and document delivery of care and clients' responses.
17. evaluation: evaluate clients' responses to nursing interventions and form a clinical judgment about the extent
to which clients have met the goals and outcomes;
continuously evaluate clients' progress toward outcomes and use clients' data to determine whether to modify the plan
of care;
determine the effectiveness of the nursing care plan. They compare client data to the planned outcome criteria to
determine what further actions to take.
18. evaluation questions to consider: -"Did the client meet the planned outcomes?"
-"Were the nursing interventions appropriate and effective?"
-"Should I modify the outcomes or interventions?"
19. factors that can lead to lack of goal achievement: -An incomplete database
-Unrealistic client outcomes
2/5
Study online at https://quizlet.com/_isnleg
1. nursing process: assessment, diagnosis, outcome identification, planning, implementation, evaluation
2. assessment/data collection: involves the systematic collection of information about the health status
of clients to identify needs and additional data to collect. Nurses can collect data during an initial assessment (baseline
data), focused assessment, and ongoing assessments.
3. effective data collection: nurses must ask clients appropriate questions, listen carefully to responses,
and have excellent head-to-toe physical assessment skills. Nurses must employ clinical judgment and critical thinking
in accurately recognizing when to collect assessment data. They must recognize the need to collect assessment data
prior to interventions.
4. subjective data: Nurses collect subjective data (manifestations) during a nursing history. Subjective data
includes clients' feelings, perceptions, and descriptions of health status. Clients are the only ones who can describe
and verify their own manifestations.
5. objective data: Nurses observe and measure objective data (findings) during a physical examination. Nurses
feel, see, hear, and smell objective data through observation or physical assessment of the client.
6. Analysis/diagnosis /data collection requires nurses to look at the data and: -
-Identify patterns or trends.
-Compare the data with expected standards or reference ranges.
-Arrive at conclusions to guide nursing care.
7. Planning: When planning client care (RN) or contributing to a client's plan of care (PN), nurses must establish
priorities and optimal outcomes of care they can readily measure and evaluate. These established priorities and
outcomes direct nurses in selecting interventions to include in a plan of care to promote, maintain, or restore health of
clients.
8. three types of planning: -develop a comprehensive plan of care for clients based on comprehensive
assessments they complete, for example, on admission to a health care facility or to a home health organization.
-perform ongoing planning throughout the provision of care. While obtaining new information and evaluating respons-
es to care, they modify and individualize the initial plan of care.
-discharge planning is a process of anticipating and planning for clients' needs after discharge. To be effective,
discharge planning must begin during admission.
9. priority setting guideline example: maslows low to high: physiological, safety and
security, love and belonging, self-esteem, self-actualization
Principle: Lower-level needs (physiological) must be met before higher-level needs.
1/5
, nur 505 exam 1
Study online at https://quizlet.com/_isnleg
10. Nurse-initiated/independent interventions:: Nurses use evidence and scientific rationale to
take autonomous actions to benefit clients. They base these actions on identified problems and health care needs, and
make sure they are within their scope of practice. Nurses perform or delegate the interventions and are accountable
for them. An example is repositioning a client at least every 2 hr to prevent skin breakdown.
11. Provider-initiated/dependent interventions:: Interventions nurses initiate as a result of a
provider's prescription (written, standing, or verbal) or the facility's protocol (blood administration procedures).
12. Collaborative interventions:: Interventions nurses carry out in collaboration with other health care
team professionals (ensuring that a client receives and eats their evening snack).
13. The nursing care plan (NCP): the end product of the planning step. Nurses organize the NCP for quick
identification of problems, outcomes, and interventions to implement.
14. implementation: In this step, nurses must use problem-solving, clinical judgment, and critical thinking
to select and implement appropriate therapeutic interventions using nursing knowledge, priorities of care, and
planned goals or outcomes to promote, maintain, or restore health. Nurses also use interpersonal skills (therapeutic
communication) and technical skills (psychomotor performance) when implementing nursing interventions.
15. therapeutic interventions: include measures nurses take to minimize risk (wearing personal protective
equipment). Nurses intervene to respond to unplanned events (an observation of unsafe practice, a change in status,
or the emergence of a life-threatening situation).
16. During implementation, nurses: perform nursing actions, delegate tasks, supervise other health
care staff, and document delivery of care and clients' responses.
17. evaluation: evaluate clients' responses to nursing interventions and form a clinical judgment about the extent
to which clients have met the goals and outcomes;
continuously evaluate clients' progress toward outcomes and use clients' data to determine whether to modify the plan
of care;
determine the effectiveness of the nursing care plan. They compare client data to the planned outcome criteria to
determine what further actions to take.
18. evaluation questions to consider: -"Did the client meet the planned outcomes?"
-"Were the nursing interventions appropriate and effective?"
-"Should I modify the outcomes or interventions?"
19. factors that can lead to lack of goal achievement: -An incomplete database
-Unrealistic client outcomes
2/5
