2700 Exam #2 -with complete solution 2022/2023

Clinical Reasoning & Clinical Judgement - ANSWER Critical thinking - ANSWER Combination of reasoned thinking, openness to alternatives, ability to reflect, & desire to seek truth. CLOUD - ANSWER Clear. Logical. Objective. Unbiased. Dispassionate Components of the nursing process (ADPPIE) - ANSWER Assessment Diagnosis Planning outcomes Planning Interventions Implementation Evaluation Assessment phase - ANSWER Obtaining information from many sources (physical exam, lab tests, health history). -Purpose is to gather data that you will use to draw conclusions about pt's health status Diagnosis phase - ANSWER Identify the pt's health needs based on review of assessment data. Planning outcomes phase - ANSWER Work w/ pt to decide goals for the patient's outcome. Planning intervention phase - ANSWER Develop a list of possible interventions based on your nursing knowledge. Then choose the one most likely to help pt reach their stated goals. Best interventions are evidence based. Implementation phase - ANSWER Action phase. Carrying out or delegating the actions you have previously planned. Document pt's response to them Evaluation phase - ANSWER Determine whether the pt's desired outcomes have been achieved. Modify care plan as needed. Comprehensive Assessment - ANSWER -Provides holistic information about the client's overall health status. -Includes subjective & objective data -Includes information about emotional/spiritual status, family, & community Focused Assessment - ANSWER Obtains data about an actual, potential, or possible problem that has been identified or suspected. -Focuses on particular topic, body part, or functional ability instead of overall health status/ Objective data - ANSWER Gathered through physical assessment, lab tests, other diagnostic tests. -Sometimes need objective data to validate subjective data -Can be measured or observed by the nurse E.g.) vital signs, x-ray, skin color urine output Subjective data - ANSWER Information communicated to the nurse by the client, family, or community -Reveals the perspective, thoughts, feelings, beliefs, & sensations Primary data - ANSWER The subjective & objective data obtained from the client. What the client says or what you observe Secondary data - ANSWER Obtained "second hand" -From the medical record or another caregiver -"She seems more confused than usual" Proces for determining a nursing diagnosis - ANSWER -After gathering data, use critical thinking skills to analyze & identify patterns/draw conclusions about health status. -nursing diagnosis is stated in terms of human responses to disease/injury. NOT treated as a medical diagnosis. *Nurses treat the PERCEPTION of the disease* - ANSWER 5 Types of Nursing Diagnosis *Suck A P Really Well* - ANSWER -Syndrome -Actual -Possible -Risk -Wellness Patient Goal - ANSWER A BROAD statement based on the nursing diagnosis. Must be realistic. Patient Outcomes - ANSWER Steps that will allow the patient to reach their goal -Short-term -Must be measurable -Must be realistic -Patient-focused: "patient will" Process for generating nursing interventions - ANSWER 1. Set realistic interventions 2. Begin with who "Nurse will..." 3. Choose a verb or action statement