2700 Exam #2 -
c c c
with complete solution 2022/2023
c c c
ClinicalcReasoningc&cClinicalcJudgementc-cANSWERc
Criticalcthinkingc-
cANSWERcCombinationcofcreasonedcthinking,copennessctocalternatives,cabilityctocreflect,c&
cdesirectocseekctruth.
CLOUDc-cANSWERcClear.cLogical.cObjective.cUnbiased.cDispassionate
Componentscofcthecnursingcprocess
(ADPPIE)c-cANSWERcAssessment
Diagnosis
Planningcoutcomesc
PlanningcInterventionsc
Implementationc
Evaluation
Assessmentcphasec-
cANSWERcObtainingcinformationcfromcmanycsourcesc(physicalcexam,clabctests,chealthchist
ory).
-Purposecisctocgathercdatacthatcyoucwillcusectocdrawcconclusionscaboutcpt'schealthcstatus
Diagnosiscphasec-
cANSWERcIdentifycthecpt'schealthcneedscbasedconcreviewcofcassessmentcdata.
Planningcoutcomescphasec-
cANSWERcWorkcw/cptctocdecidecgoalscforcthecpatient'scoutcome.
Planningcinterventioncphasec-
cANSWERcDevelopcaclistcofcpossiblecinterventionscbasedconcyourcnursingcknowledge.cThe
ncchoosectheconecmostclikelyctochelpcptcreachctheircstatedcgoals.cBestcinterventionscarecevid
encecbased.
Implementationcphasec-
cANSWERcActioncphase.cCarryingcoutcorcdelegatingcthecactionscyouchavecpreviouslycplann
ed.cDocumentcpt'scresponsectocthem
Evaluationcphasec-
cANSWERcDeterminecwhethercthecpt'scdesiredcoutcomeschavecbeencachieved.cModifyccar
ecplancascneeded.
ComprehensivecAssessmentc-cANSWERc-
Providescholisticcinformationcaboutcthecclient'scoverallchealthcstatus.c
-Includescsubjectivec&cobjectivecdatac
-Includescinformationcaboutcemotional/spiritualcstatus,cfamily,c&ccommunity
,2700 Exam #2 -
c c c
with complete solution 2022/2023
c c c
FocusedcAssessmentc-
cANSWERcObtainscdatacaboutcancactual,cpotential,corcpossiblecproblemcthatchascbeenciden
tifiedcorcsuspected.c
-
Focusesconcparticularctopic,cbodycpart,corcfunctionalcabilitycinsteadcofcoverallchealthcstatus/
Objectivecdatac-
cANSWERcGatheredcthroughcphysicalcassessment,clabctests,cothercdiagnosticctests.c
-Sometimescneedcobjectivecdatactocvalidatecsubjectivecdata
-Cancbecmeasuredcorcobservedcbycthecnursec
E.g.)cvitalcsigns,cx-ray,cskinccolorcurinecoutput
Subjectivecdatac-
cANSWERcInformationccommunicatedctocthecnursecbycthecclient,cfamily,corccommunity
-Revealscthecperspective,cthoughts,cfeelings,cbeliefs,c&csensations
Primarycdatac-
cANSWERcThecsubjectivec&cobjectivecdatacobtainedcfromcthecclient.cWhatcthecclientcsaysco
rcwhatcyoucobserve
Secondarycdatac-cANSWERcObtainedc"secondchand"c
-Fromcthecmedicalcrecordcorcanotherccaregiverc
-"Shecseemscmorecconfusedcthancusual"
Procescforcdeterminingcacnursingcdiagnosisc-cANSWERc-
Aftercgatheringcdata,cuseccriticalcthinkingcskillsctocanalyzec&cidentifycpatterns/drawcconclusi
onscaboutchealthcstatus.c
-
nursingcdiagnosisciscstatedcinctermscofchumancresponsesctocdisease/injury.cNOTctreatedcas
cacmedicalcdiagnosis.
*NursesctreatcthecPERCEPTIONcofcthecdisease*c-cANSWERc
5cTypescofcNursingcDiagnosis
*SuckcAcPcReallycWell*c-cANSWERc-Syndrome
-Actual
-Possible
-Risk
-Wellness
PatientcGoalc-
cANSWERcAcBROADcstatementcbasedconcthecnursingcdiagnosis.cMustcbecrealistic.
,2700 Exam #2 -
c c c
with complete solution 2022/2023
c c c
PatientcOutcomesc-cANSWERcStepscthatcwillcallowcthecpatientctocreachctheircgoal
-Short-term
-Mustcbecmeasurablec
-Mustcbecrealisticc
-Patient-focused:c"patientcwill"
Processcforcgeneratingcnursingcinterventionsc-cANSWERc1.cSetcrealisticcinterventionsc
2.cBegincwithcwhoc"Nursecwill..."c
3.cChoosecacverbcorcactioncstatementc
4.cIdentifychow/whenc
5.cIncludecrationalecforceachcintervention
Processcforcevaluatingctheceffectivenesscofcacnursingccarecplanc-
cANSWERc1.cReassesscthecpatient:cgathercdatac
2.cComparecitctocthecpreviouscdatac
3.cDidcthecptcmakecprogressctowardscoutcome?c
4.cDocumentcpt'scresponsectocintervention
5.cDeterminecifcyoucwillccontinuecplancofccarecorcmodify/terminatecplan
*Legal,cEthics,c&cSocialcJustice*c-cANSWERc
Identifycfactorscthatccontributectocthecfrequencycofcnurse'scmoralcproblemsc-cANSWERc-
Technologicalcadvancesc
-Needscofcacmulticulturalcpopulation
-Costccontainmentc
-Naturecofcnursingcworkc
-Naturecofcthecnursingcprofession
-Complexcrelationships
Whatcarecthecethicalcissuesc&cprinciplescinvolvedcincanycgivencethicalcsituation?c-
cANSWERc-Informedcconsentc
-Privacyc&cconfidentialityc
-Nonmaleficence:cdocnocharm/preventcharm
-Respectcforcdignitiyc
-Beneficencec
-Fidelityc
-Veracity:ctellcthectruthc
-Justice
Dilemmac-cANSWERcNotcallcmoralcproblemscarecdilemmasc
-Whencacchoicecmustcbecmadecbetweenctwocequallycbadcactions
Whatcarecthecnurse'scobligationscincsocialcjusticecdecisions?c-cANSWERc-
Becawarec&csensitivectocissuesc
, 2700 Exam #2 -
c c c
with complete solution 2022/2023
c c c
-Takecresponsibilitycforcactionsc
-Becacteamcmember
-Supportcpt/familyc
-Supportcptscwhocarecnotcallowedctocdecidec
-Use/participatecethicsccommitteec
-Strivectocimprovecdecisioncmaking
Rolecofcthecnursecascancadvocatec-
cANSWERcSafeguardcclientscagainstcabusec&cviolationscofctheircrightsc
-Inform
-Supportc
-Communicate
HealthcInsurancecPortabilitycandcAccountabilitycActc(HIPAA)c-cANSWERc-
Protectschealthcinsurancecbenefitscofcworkerscwhoclose/changecjobs
-Protectccoveragectocpplcw/cpreexisitingcmedicalcconditionsc
-Establishcstandardsctocprotectcprivacycofchealthcinfo
-Allowcptsctocsee,cmakeccorrections,c&cobtainccopiescofctheircmedicalcrecords
Intentionalctortc-
cANSWERcActionctakencbyconecpersoncw/cintentconcharmingcanother.cHarmcdoescNOTchav
ectocbecviolent,chostile,corccausecsignificantcpain.cMaycbecprosecutedcunderccriminalclaw.
ExamplescofcIntentionalctortsc-
cANSWERcAssault,cBattery,cFalsecImprisonment,cInvasioncofcprivacy,cfraud
Assaultc-
cANSWERcNursecintentionallycplacescpatientcincimmediatecfearcofcviolencecorcoffensivecco
ntact.cMUSTcincludecwordscexpressingcintentctocharm.c"Icwillcslapcyou"
Batteryc-
cANSWERcWhencoffensivecorcharmfulcphysicalccontactciscmadectocpatientcwithoutcconsentc
orcunauthorizedctouchingcofcacperson'scbody.cTocavoidcbattery,calwayscobtaincinformedccon
sentcbeforecprovidingctreatmentc(e.g.ccatheter,cIV)
FalsecImprisonmentc-
cANSWERcThecrestrainingcofcacpersoncwithoutcproperclegalcauthorization
Invasioncofcprivacyc-cANSWERcViolatescacperson'scrightctocbecleftcalone
Fraudc-cANSWERcThecfalsecrepresentationcofcsignificantcfactscbycwordscorcconduct
Unintentionalctortsc-cANSWERcMostccommonctypeciscnegligencecorcmalpractice
c c c
with complete solution 2022/2023
c c c
ClinicalcReasoningc&cClinicalcJudgementc-cANSWERc
Criticalcthinkingc-
cANSWERcCombinationcofcreasonedcthinking,copennessctocalternatives,cabilityctocreflect,c&
cdesirectocseekctruth.
CLOUDc-cANSWERcClear.cLogical.cObjective.cUnbiased.cDispassionate
Componentscofcthecnursingcprocess
(ADPPIE)c-cANSWERcAssessment
Diagnosis
Planningcoutcomesc
PlanningcInterventionsc
Implementationc
Evaluation
Assessmentcphasec-
cANSWERcObtainingcinformationcfromcmanycsourcesc(physicalcexam,clabctests,chealthchist
ory).
-Purposecisctocgathercdatacthatcyoucwillcusectocdrawcconclusionscaboutcpt'schealthcstatus
Diagnosiscphasec-
cANSWERcIdentifycthecpt'schealthcneedscbasedconcreviewcofcassessmentcdata.
Planningcoutcomescphasec-
cANSWERcWorkcw/cptctocdecidecgoalscforcthecpatient'scoutcome.
Planningcinterventioncphasec-
cANSWERcDevelopcaclistcofcpossiblecinterventionscbasedconcyourcnursingcknowledge.cThe
ncchoosectheconecmostclikelyctochelpcptcreachctheircstatedcgoals.cBestcinterventionscarecevid
encecbased.
Implementationcphasec-
cANSWERcActioncphase.cCarryingcoutcorcdelegatingcthecactionscyouchavecpreviouslycplann
ed.cDocumentcpt'scresponsectocthem
Evaluationcphasec-
cANSWERcDeterminecwhethercthecpt'scdesiredcoutcomeschavecbeencachieved.cModifyccar
ecplancascneeded.
ComprehensivecAssessmentc-cANSWERc-
Providescholisticcinformationcaboutcthecclient'scoverallchealthcstatus.c
-Includescsubjectivec&cobjectivecdatac
-Includescinformationcaboutcemotional/spiritualcstatus,cfamily,c&ccommunity
,2700 Exam #2 -
c c c
with complete solution 2022/2023
c c c
FocusedcAssessmentc-
cANSWERcObtainscdatacaboutcancactual,cpotential,corcpossiblecproblemcthatchascbeenciden
tifiedcorcsuspected.c
-
Focusesconcparticularctopic,cbodycpart,corcfunctionalcabilitycinsteadcofcoverallchealthcstatus/
Objectivecdatac-
cANSWERcGatheredcthroughcphysicalcassessment,clabctests,cothercdiagnosticctests.c
-Sometimescneedcobjectivecdatactocvalidatecsubjectivecdata
-Cancbecmeasuredcorcobservedcbycthecnursec
E.g.)cvitalcsigns,cx-ray,cskinccolorcurinecoutput
Subjectivecdatac-
cANSWERcInformationccommunicatedctocthecnursecbycthecclient,cfamily,corccommunity
-Revealscthecperspective,cthoughts,cfeelings,cbeliefs,c&csensations
Primarycdatac-
cANSWERcThecsubjectivec&cobjectivecdatacobtainedcfromcthecclient.cWhatcthecclientcsaysco
rcwhatcyoucobserve
Secondarycdatac-cANSWERcObtainedc"secondchand"c
-Fromcthecmedicalcrecordcorcanotherccaregiverc
-"Shecseemscmorecconfusedcthancusual"
Procescforcdeterminingcacnursingcdiagnosisc-cANSWERc-
Aftercgatheringcdata,cuseccriticalcthinkingcskillsctocanalyzec&cidentifycpatterns/drawcconclusi
onscaboutchealthcstatus.c
-
nursingcdiagnosisciscstatedcinctermscofchumancresponsesctocdisease/injury.cNOTctreatedcas
cacmedicalcdiagnosis.
*NursesctreatcthecPERCEPTIONcofcthecdisease*c-cANSWERc
5cTypescofcNursingcDiagnosis
*SuckcAcPcReallycWell*c-cANSWERc-Syndrome
-Actual
-Possible
-Risk
-Wellness
PatientcGoalc-
cANSWERcAcBROADcstatementcbasedconcthecnursingcdiagnosis.cMustcbecrealistic.
,2700 Exam #2 -
c c c
with complete solution 2022/2023
c c c
PatientcOutcomesc-cANSWERcStepscthatcwillcallowcthecpatientctocreachctheircgoal
-Short-term
-Mustcbecmeasurablec
-Mustcbecrealisticc
-Patient-focused:c"patientcwill"
Processcforcgeneratingcnursingcinterventionsc-cANSWERc1.cSetcrealisticcinterventionsc
2.cBegincwithcwhoc"Nursecwill..."c
3.cChoosecacverbcorcactioncstatementc
4.cIdentifychow/whenc
5.cIncludecrationalecforceachcintervention
Processcforcevaluatingctheceffectivenesscofcacnursingccarecplanc-
cANSWERc1.cReassesscthecpatient:cgathercdatac
2.cComparecitctocthecpreviouscdatac
3.cDidcthecptcmakecprogressctowardscoutcome?c
4.cDocumentcpt'scresponsectocintervention
5.cDeterminecifcyoucwillccontinuecplancofccarecorcmodify/terminatecplan
*Legal,cEthics,c&cSocialcJustice*c-cANSWERc
Identifycfactorscthatccontributectocthecfrequencycofcnurse'scmoralcproblemsc-cANSWERc-
Technologicalcadvancesc
-Needscofcacmulticulturalcpopulation
-Costccontainmentc
-Naturecofcnursingcworkc
-Naturecofcthecnursingcprofession
-Complexcrelationships
Whatcarecthecethicalcissuesc&cprinciplescinvolvedcincanycgivencethicalcsituation?c-
cANSWERc-Informedcconsentc
-Privacyc&cconfidentialityc
-Nonmaleficence:cdocnocharm/preventcharm
-Respectcforcdignitiyc
-Beneficencec
-Fidelityc
-Veracity:ctellcthectruthc
-Justice
Dilemmac-cANSWERcNotcallcmoralcproblemscarecdilemmasc
-Whencacchoicecmustcbecmadecbetweenctwocequallycbadcactions
Whatcarecthecnurse'scobligationscincsocialcjusticecdecisions?c-cANSWERc-
Becawarec&csensitivectocissuesc
, 2700 Exam #2 -
c c c
with complete solution 2022/2023
c c c
-Takecresponsibilitycforcactionsc
-Becacteamcmember
-Supportcpt/familyc
-Supportcptscwhocarecnotcallowedctocdecidec
-Use/participatecethicsccommitteec
-Strivectocimprovecdecisioncmaking
Rolecofcthecnursecascancadvocatec-
cANSWERcSafeguardcclientscagainstcabusec&cviolationscofctheircrightsc
-Inform
-Supportc
-Communicate
HealthcInsurancecPortabilitycandcAccountabilitycActc(HIPAA)c-cANSWERc-
Protectschealthcinsurancecbenefitscofcworkerscwhoclose/changecjobs
-Protectccoveragectocpplcw/cpreexisitingcmedicalcconditionsc
-Establishcstandardsctocprotectcprivacycofchealthcinfo
-Allowcptsctocsee,cmakeccorrections,c&cobtainccopiescofctheircmedicalcrecords
Intentionalctortc-
cANSWERcActionctakencbyconecpersoncw/cintentconcharmingcanother.cHarmcdoescNOTchav
ectocbecviolent,chostile,corccausecsignificantcpain.cMaycbecprosecutedcunderccriminalclaw.
ExamplescofcIntentionalctortsc-
cANSWERcAssault,cBattery,cFalsecImprisonment,cInvasioncofcprivacy,cfraud
Assaultc-
cANSWERcNursecintentionallycplacescpatientcincimmediatecfearcofcviolencecorcoffensivecco
ntact.cMUSTcincludecwordscexpressingcintentctocharm.c"Icwillcslapcyou"
Batteryc-
cANSWERcWhencoffensivecorcharmfulcphysicalccontactciscmadectocpatientcwithoutcconsentc
orcunauthorizedctouchingcofcacperson'scbody.cTocavoidcbattery,calwayscobtaincinformedccon
sentcbeforecprovidingctreatmentc(e.g.ccatheter,cIV)
FalsecImprisonmentc-
cANSWERcThecrestrainingcofcacpersoncwithoutcproperclegalcauthorization
Invasioncofcprivacyc-cANSWERcViolatescacperson'scrightctocbecleftcalone
Fraudc-cANSWERcThecfalsecrepresentationcofcsignificantcfactscbycwordscorcconduct
Unintentionalctortsc-cANSWERcMostccommonctypeciscnegligencecorcmalpractice
