DETAILED ANSWERS|LATEST
Data clustering - ANSWER determining what out of all data is significant
Components that add to the ability to critically think - ANSWER knowledge,
experience, attitudes, and standards
Nursing process steps - ANSWER Assessment
Diagnosis
Planning
Implementation
Evaluation
Assessment - ANSWER observation, collection of information, and data which is
analyzed, validated organized, and documented
Primary, secondary, subjective, and objective data - ANSWER primary:patient
interview
Secondary: family, medical record
Subjective: symptoms
Objective: signs, labs, tests
Signs vs. Symptoms - ANSWER Signs = Objective information; can be seen, measured,
heard, or felt
- Color, pulse, edema
1
,Symptoms = Subjective information
- Dyspnea, pain, nausea
Nursing Diagnosis - ANSWER Analyze the data and identify actual and potential
problems. Create a clear statement of the problem.
Immediate Priorities - ANSWER abcs, Airway, Breathing, Circulation- think about
Maslow's Hierarchy of Needs
Actual health problem - ANSWER existing problems or concerns
Risk diagnosis - ANSWER increased potential or vulnerability of the patient for a
problem or complication
Health promotion diagnosis - ANSWER expression of desire to change health
Medical diagnosis vs nursing diagnosis - ANSWER Medical Diagnosis: is used to
evaluate the cause or etiology of disease
Nursing Diagnosis: clinical judements about a persons response to an actual or potential
health state
Planning - ANSWER develop a plan with realistic goals and effective interventions.
Types of planning - ANSWER Initial, Ongoing, Discharge
Goals of planning - ANSWER standardized and individualized care plans
2
, Overall goal - ANSWER overall goal of health for patient. Part of the planning process
and small SMART goals leading up to it
SMART goals - ANSWER Specific, Measurable, Attainable, Realistic, Timely
Wellness diagnosis - ANSWER expected outcomes that demonstrate health
maintenance or achievement of an even higher level of health
Interventions - ANSWER actions taken to correct or manage a patient's problems
Interventions are selected by - ANSWER theories, ANA standards, evidence-based
practice, clinical-practice guidelines, and knowledge
Independent nursing interventions - ANSWER actions that a nurse initiates without
supervision or direction from others
Interdependent nursing interventions - ANSWER In conjunction with an
interdisciplinary team member
Ex. Assist client with physical therapy exercises
Dependent nursing interventions - ANSWER actions that require an order from a
physician or another health care professional
Implementation - ANSWER doing, delegating, and recording
Evaluation - ANSWER collect data related to outcomes
Compare data with desired outcomes
Related nursing interventions to outcomes
Draw conclusions about problem status
3
Data clustering - ANSWER determining what out of all data is significant
Components that add to the ability to critically think - ANSWER knowledge,
experience, attitudes, and standards
Nursing process steps - ANSWER Assessment
Diagnosis
Planning
Implementation
Evaluation
Assessment - ANSWER observation, collection of information, and data which is
analyzed, validated organized, and documented
Primary, secondary, subjective, and objective data - ANSWER primary:patient
interview
Secondary: family, medical record
Subjective: symptoms
Objective: signs, labs, tests
Signs vs. Symptoms - ANSWER Signs = Objective information; can be seen, measured,
heard, or felt
- Color, pulse, edema
1
,Symptoms = Subjective information
- Dyspnea, pain, nausea
Nursing Diagnosis - ANSWER Analyze the data and identify actual and potential
problems. Create a clear statement of the problem.
Immediate Priorities - ANSWER abcs, Airway, Breathing, Circulation- think about
Maslow's Hierarchy of Needs
Actual health problem - ANSWER existing problems or concerns
Risk diagnosis - ANSWER increased potential or vulnerability of the patient for a
problem or complication
Health promotion diagnosis - ANSWER expression of desire to change health
Medical diagnosis vs nursing diagnosis - ANSWER Medical Diagnosis: is used to
evaluate the cause or etiology of disease
Nursing Diagnosis: clinical judements about a persons response to an actual or potential
health state
Planning - ANSWER develop a plan with realistic goals and effective interventions.
Types of planning - ANSWER Initial, Ongoing, Discharge
Goals of planning - ANSWER standardized and individualized care plans
2
, Overall goal - ANSWER overall goal of health for patient. Part of the planning process
and small SMART goals leading up to it
SMART goals - ANSWER Specific, Measurable, Attainable, Realistic, Timely
Wellness diagnosis - ANSWER expected outcomes that demonstrate health
maintenance or achievement of an even higher level of health
Interventions - ANSWER actions taken to correct or manage a patient's problems
Interventions are selected by - ANSWER theories, ANA standards, evidence-based
practice, clinical-practice guidelines, and knowledge
Independent nursing interventions - ANSWER actions that a nurse initiates without
supervision or direction from others
Interdependent nursing interventions - ANSWER In conjunction with an
interdisciplinary team member
Ex. Assist client with physical therapy exercises
Dependent nursing interventions - ANSWER actions that require an order from a
physician or another health care professional
Implementation - ANSWER doing, delegating, and recording
Evaluation - ANSWER collect data related to outcomes
Compare data with desired outcomes
Related nursing interventions to outcomes
Draw conclusions about problem status
3
