RNSG 1215 Exam 1 Key Terms Questions and Answer

RNSG 1215 Exam 1 Key Terms Questions and Answer Objective data -Answer-What you as the health professional observe by inspecting, percussing, palpating and auscultating during the physical exam Database -Answer-Subjective data, objective data, the patient's record and laboratory studies form this From the database you: -Answer-Make a clinical judgment or diagnosis about the individual's health state, response to actual or potential health problems, and life processes Diagnostic reasoning -Answer-The process of analyzing health data and drawing conclusions to identify diagnoses Hypothetico-deductive process -Answer-Hypothesis forming and deductive reasoning -Has 4 major components: 1) Attending to initially available cues 2) Formulating diagnostic hypotheses 3) Gathering data relative to the tentative hypotheses 4) Evaluating each hypothesis with the new data collected, thus arriving at a final diagnosis Cue -Answer-Piece of information, sign or symptom or a piece of lab data Hypothesis -Answer-Tentative explanation for a cue or a set of cues that can be used as a basis for further investigation Nursing Process -Answer-1) Assessment 2) Diagnosis 3) Outcome identification 4) Planning 5) Implementation 6) Evaluation Novice -Answer-No experience with a specific patient population and uses rules to guide performance Competent -Answer-Takes 2-3 years in similar clinical situations to achieve this -You see actions in the context of arching goals or daily plans for patients Proficient -Answer-Understands a patient situations as a whole rather than as a list of tasks -You can see long-term goals for the patient Expert -Answer-Vault over the steps and arrive at a clinical judgment in one quick leap -Intuitive grasp of a clinical situation and zeroes in on the accurate solution -Has a storehouse of experience concerning which interventions have worked in the past Assessment -Answer--Collect data (review the clinical record, health history, physical exam, functional assessment, risk assessment, review of the literature) -Use EBA techniques -Document relevant data Diagnosis -Answer--Compare clinical findings with normal and abnormal variation and developmental events -Interpret data (identify clusters of cues, make hypotheses, test hypotheses, derive diagnoses) -Validate diagnoses -Document diagnoses Outcome identification -Answer--Identify expected outcomes -Individualize to the person -Culturally appropriate -Realistic and measurable -Include a timeline Planning -Answer--Establish priorities -Develop outcomes -Set timelines for outcomes -Identify interventions -Integrate evidence-based trends and research -Document plan of care Implementation -Answer--Implement in a safe and timely manner -Use evidence-based interventions -Collaborate with colleagues -Use community resources -Coordinate care delivery -Provide health teaching and health promotion -Document implementation and any modifications Evaluation -Answer--Progress toward outcomes