Review of Clinical Judgement, Nursing Process and Care Plans

Question 1

clinical judgement

Answer 1

interpretation or conclusion about a patient’s needs, concerns or health problems, and/or the decision to take action (or not), use or modify standard approaches, or develop new ones as deemed appropriate by the patient’s response (outcome)

Question 2

clinical reasoning

Answer 2

the processes by which nurses make judgments, including generating alternatives, weighing them against evidence, choosing the most appropriate; also involves recognizing patterns, using intuition, and tacit knowledge

Question 3

noticing

Answer 3

focused observation, recognizing deviations from expected patterns, information seeking

Question 4

interpreting

Answer 4

developing a sufficient understanding of the situation, involves using one or more reasoning patterns to interpret the meaning of the data and determine an appropriate course of action, making sense of and prioritizing data

Question 5

responding

Answer 5

deciding on a course of appropriate action for the situation

Question 6

reflecting

Answer 6

involves both reflection-in-action and reflection-on-action

Question 7

assessment

Answer 7

deliberate, systematic collection of subjective and objective data

Question 8

planning

Answer 8

nurse sets client-centred goals, outline expected outcomes, plans nursing interventions that will resolve the client’s problems

Question 9

implementation

Answer 9

similar to responding; requiring cognitive interpersonal and psychomotor skills

Question 10

evaluation

Answer 10

similar to reflection; enables you to determine the client’s response to nursing care

Question 11

Nursing Process: ADPIE

Answer 11

assessment, diagnosis, planning, implementation, evaluation

Question 12

what is a nursing care plan?

Answer 12

a step by step process that nurses use to provide appropriate and effective nursing care

Question 13

NANDA International

Answer 13

the authoritative organization for developing and approving nursing diagnoses

Question 14

subjective data

Answer 14

what a person says about him or herself; only clients provide subjective data

Question 15

objective data

Answer 15

data from a general survey, physical examination and laboratory or diagnostic studies

Question 16

primary data

Answer 16

comes from the client

Question 17

secondary data

Answer 17

family and s/o, HC team, medical records

Question 18

tertiary data

Answer 18

literature and nurses’ experience

Question 19

what does a nursing diagnosis do?

Answer 19

determines health problems within the domain of nursing

Question 20

what is a nursing diagnosis a clinical judgement about?

Answer 20

the individual, family, or community response to an actual or potential health problem, rather than on the physiological event complication or disease

Question 21

collaborative nursing diagnosis

Answer 21

nurses also encounter client problems that must be managed collaboratively w/ other personnel from other health disciplines

Question 22

what are the components of a nursing diagnosis?

Answer 22

diagnostic label (problem), the etiology identified from the pt’s data base (“related to”) and defining characteristics (supporting evidence)

Question 23

types of nursing diagnoses

Answer 23

actual client problem, health risk, health promotion challenge, wellness

Question 24

actual client problem

Answer 24

a problem the client actually has; sufficient assessment data are actually available to say this is a problem for the client

Question 25

health risk

Answer 25

a problem that could develop in a vulnerable individual

Question 26

health promotion challenge

Answer 26

a person expresses readiness to enhance specific health behaviours

Question 27

wellness

Answer 27

this represents a level of wellness the client has achieved, but the client could move to a higher level of wellness, improving the level of coping in a client

Question 28

who or what may you need to collaborate with in nursing planning?

Answer 28

the family, HC team, client and related literature

Question 29

priority setting

Answer 29

the ranking of nursing diagnoses or client issues, determining which problem is more important or urgent; establish a preferential order for nursing actions and requires critical thinking

Question 30

what consideration must be made in priority setting?

Answer 30

you must attend to the client's most important need first, considering their physiological condition; the order of priorities changes as a client's condition changes

Question 31

what questions must you consider when setting goals?

Answer 31

what do you plan to achieve? what specific client behaviours do you want to see? what specific physiological responses do you expect? how will you know you have achieved your goal?

Question 32

expected outcome

Answer 32

a specific measurable change in a client's status

Question 33

nursing intervention

Answer 33

any treatment based on clinical judgement and knowledge, to enhance client outcomes, and are evidence informed + based on client needs

Question 34

cognitive skills

Answer 34

the use of critical thinking

Question 35

interpersonal skills

Answer 35

the nurse has a trusting relationship, a caring attitude and communicated clearly with the client

Question 36

psychomotor skills

Answer 36

this is the integration of cognitive and motor activities