Final Exam NUR 206 already pass
What factors play a role in a nurses' ability to think critically in a healthcare setting? -
ANSWERS-Experience and Knowledge
-Knowing the patient
-Context of clinical situations
What are the four steps of Tanner's Clinical Judgement Model? - ANSWERS-Noticing
-Interpreting
-Responding
-Reflecting
What is the nurse doing during the Noticing step? - ANSWERS-Reviewing medical
record before providing care
-Seeing the patient for the first time
What is the nurse doing during the interpreting step? - ANSWERS-What does clinical
data mean?
What is the nurse doing during the responding step? - ANSWERS-Planning and
intervention
-What is the appropriate response?
What is the nurse doing during the reflecting step? - ANSWERS-Did the patient
respond as expected?
When you collect assessment data, it is important to do what? - ANSWERS-Verify and
validate what you see for accuracy
What or who is the best source of assessment data? - ANSWERS-Primary source AKA
the patient
What are reason you might have to use secondary sources? - ANSWERS-Too ill
-Too young
-Confusion
-Mentally Ill
-Developmental issues
What are some common issues that might make a patient unreliable about their heal
history? - ANSWERS-Confusion
-Lack of knowledge
-Distraction
-Uncooperative
-Disinterested
-No family or caregiver available
, What are some common issues an older person might have that complicate a patient
assessment? - ANSWERS-Sensory problems
-Tire more easily
-Mental health
-Disinterest
-Tactile issues
How could you adapt the assessment to help? - ANSWERS-Go at a slower pace
-Speak clearly
-Be attentive
-Could use caregiver or family
What is subjective data? - ANSWERS-A patient's verbal description of their
health/health problems
What is objective data? - ANSWERS-Findings resulted from direct observation
Name five ways to promote therapeutic communication - ANSWERS-Be prepared
-Being courteous
-Comfort
-Connection
-Confirmation
What is the best way to know about your patient's specific cultural needs? -
ANSWERS-Ask
Give an example of how to document a chief complaint for a patient - ANSWERS-Pt
complains of right lower quadrant abdominal pain and is reason for seeking care.
An emergency situation, what are the three most important assessments? -
ANSWERS-Airway
-Breathing
-Circulation
-Addition of: Disability and exposure
Name three rules about charting/documenting care. - ANSWERS-If you did not chart it,
it was not done
-Clear and concise
-Use appropriate medical terminology
What are the three types of nursing diagnoses/diagnostic statements? - ANSWERS-
Problem-focused
-Risk diagnosis
-Health promotion
, What are the three parts of a problem-focused diagnoses? - ANSWERS-Diagnostic
label
-Related factors
-Major defining characteristics
What is an etiology? - ANSWERS-The cause/pathophysiology, circumstances, facts,
influences
-THEY ARE NOT THE DISEASE
What are two parts of a risk diagnosis? - ANSWERS-diagnostic label with risk factors
-Risk factors
What are the two parts of a health promotion diagnosis? - ANSWERS-Diagnostic label
-Major defining characteristics
Name three errors made when creating a nursing diagnoses statement? - ANSWERS-
Errors in data collection
-Analysis and interpretation of data
-misuse of diagnostic statement
What is a circular statement (errors in creating a nursing diagnoses statement)? -
ANSWERS-A diagnosis with no actual evidence or reason for diagnosis
All of our nursing care should be? - ANSWERS-Patient-centered
Which type of nursing diagnosis takes priority over the others? - ANSWERS-Problem
focused diagnoses over risk
-Risk over health promotion
Which is generally of higher priority, short-term or long-term problems? - ANSWERS-
Short term
What are the highest priority patient needs? - ANSWERS-Nursing diagnoses that if
untreated can result in harm to the patient
What needs do we usually act on last? - ANSWERS-Nursing diagnoses that are not
always directly related to a specific illness or prognosis, but affect a patient's future well-
being
What is a nursing goal? - ANSWERS-A broad statement that describes the desired
change in a patient's condition, perceptions, or behavior with a time frame
When is an outcome or goal short term? - ANSWERS-Usually less than a week
When is an outcome or goal long term? - ANSWERS-Usually over weeks or months
, Who should always be involved in the planning of patient care? - ANSWERS-The
patient
What is an expected outcome? - ANSWERS-Measurable changes to aim to that goal
What are the parts of a patient expected outcome, using the SMART acronym? -
ANSWERS-S: Specific
-M: Measurable
-A: Attainable
-R: Realistic
-T: Timeframe
Care plans should be what for each patient? - ANSWERS-Individualized
What factors should you consider when you select nursing interventions to use with
your patient? - ANSWERS-Present level of health
-Patients desires
-Evidence Based Support
-Feasibility
-Your own competency
What is an independent nursing intervention? - ANSWERS-Nurse initiated
What is a dependent nursing intervention? - ANSWERS-HCP initiated
What is a direct care intervention? - ANSWERS-Treatments nurses provide through
direct interactions
What is an indirect care intervention? - ANSWERS-Treatments performed away from
the patient
All nursing interventions should be ______ and within the ______ of practice and nurse
practice ______ - ANSWERS-Evidence Based
-Scope
-Act
What is a care bundle? - ANSWERS-A group of interventions related to a disease
process or condition
What is a clinical practice guideline? - ANSWERS-A systemically developed set of
statements about appropriate health care
The entire the patient is in your care, you should be frequently ______ them and
adjusting the care plan based on your findings - ANSWERS-Re-assessing
What factors play a role in a nurses' ability to think critically in a healthcare setting? -
ANSWERS-Experience and Knowledge
-Knowing the patient
-Context of clinical situations
What are the four steps of Tanner's Clinical Judgement Model? - ANSWERS-Noticing
-Interpreting
-Responding
-Reflecting
What is the nurse doing during the Noticing step? - ANSWERS-Reviewing medical
record before providing care
-Seeing the patient for the first time
What is the nurse doing during the interpreting step? - ANSWERS-What does clinical
data mean?
What is the nurse doing during the responding step? - ANSWERS-Planning and
intervention
-What is the appropriate response?
What is the nurse doing during the reflecting step? - ANSWERS-Did the patient
respond as expected?
When you collect assessment data, it is important to do what? - ANSWERS-Verify and
validate what you see for accuracy
What or who is the best source of assessment data? - ANSWERS-Primary source AKA
the patient
What are reason you might have to use secondary sources? - ANSWERS-Too ill
-Too young
-Confusion
-Mentally Ill
-Developmental issues
What are some common issues that might make a patient unreliable about their heal
history? - ANSWERS-Confusion
-Lack of knowledge
-Distraction
-Uncooperative
-Disinterested
-No family or caregiver available
, What are some common issues an older person might have that complicate a patient
assessment? - ANSWERS-Sensory problems
-Tire more easily
-Mental health
-Disinterest
-Tactile issues
How could you adapt the assessment to help? - ANSWERS-Go at a slower pace
-Speak clearly
-Be attentive
-Could use caregiver or family
What is subjective data? - ANSWERS-A patient's verbal description of their
health/health problems
What is objective data? - ANSWERS-Findings resulted from direct observation
Name five ways to promote therapeutic communication - ANSWERS-Be prepared
-Being courteous
-Comfort
-Connection
-Confirmation
What is the best way to know about your patient's specific cultural needs? -
ANSWERS-Ask
Give an example of how to document a chief complaint for a patient - ANSWERS-Pt
complains of right lower quadrant abdominal pain and is reason for seeking care.
An emergency situation, what are the three most important assessments? -
ANSWERS-Airway
-Breathing
-Circulation
-Addition of: Disability and exposure
Name three rules about charting/documenting care. - ANSWERS-If you did not chart it,
it was not done
-Clear and concise
-Use appropriate medical terminology
What are the three types of nursing diagnoses/diagnostic statements? - ANSWERS-
Problem-focused
-Risk diagnosis
-Health promotion
, What are the three parts of a problem-focused diagnoses? - ANSWERS-Diagnostic
label
-Related factors
-Major defining characteristics
What is an etiology? - ANSWERS-The cause/pathophysiology, circumstances, facts,
influences
-THEY ARE NOT THE DISEASE
What are two parts of a risk diagnosis? - ANSWERS-diagnostic label with risk factors
-Risk factors
What are the two parts of a health promotion diagnosis? - ANSWERS-Diagnostic label
-Major defining characteristics
Name three errors made when creating a nursing diagnoses statement? - ANSWERS-
Errors in data collection
-Analysis and interpretation of data
-misuse of diagnostic statement
What is a circular statement (errors in creating a nursing diagnoses statement)? -
ANSWERS-A diagnosis with no actual evidence or reason for diagnosis
All of our nursing care should be? - ANSWERS-Patient-centered
Which type of nursing diagnosis takes priority over the others? - ANSWERS-Problem
focused diagnoses over risk
-Risk over health promotion
Which is generally of higher priority, short-term or long-term problems? - ANSWERS-
Short term
What are the highest priority patient needs? - ANSWERS-Nursing diagnoses that if
untreated can result in harm to the patient
What needs do we usually act on last? - ANSWERS-Nursing diagnoses that are not
always directly related to a specific illness or prognosis, but affect a patient's future well-
being
What is a nursing goal? - ANSWERS-A broad statement that describes the desired
change in a patient's condition, perceptions, or behavior with a time frame
When is an outcome or goal short term? - ANSWERS-Usually less than a week
When is an outcome or goal long term? - ANSWERS-Usually over weeks or months
, Who should always be involved in the planning of patient care? - ANSWERS-The
patient
What is an expected outcome? - ANSWERS-Measurable changes to aim to that goal
What are the parts of a patient expected outcome, using the SMART acronym? -
ANSWERS-S: Specific
-M: Measurable
-A: Attainable
-R: Realistic
-T: Timeframe
Care plans should be what for each patient? - ANSWERS-Individualized
What factors should you consider when you select nursing interventions to use with
your patient? - ANSWERS-Present level of health
-Patients desires
-Evidence Based Support
-Feasibility
-Your own competency
What is an independent nursing intervention? - ANSWERS-Nurse initiated
What is a dependent nursing intervention? - ANSWERS-HCP initiated
What is a direct care intervention? - ANSWERS-Treatments nurses provide through
direct interactions
What is an indirect care intervention? - ANSWERS-Treatments performed away from
the patient
All nursing interventions should be ______ and within the ______ of practice and nurse
practice ______ - ANSWERS-Evidence Based
-Scope
-Act
What is a care bundle? - ANSWERS-A group of interventions related to a disease
process or condition
What is a clinical practice guideline? - ANSWERS-A systemically developed set of
statements about appropriate health care
The entire the patient is in your care, you should be frequently ______ them and
adjusting the care plan based on your findings - ANSWERS-Re-assessing
