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Nur221 - Foundation of Nursing > test 2 > Flashcards

test 2 Flashcards

1
Q

Steps of nursing process in order

A
  1. Assessment
  2. Diagnosis (nursing)
  3. Planning
  4. Implementation
  5. Evaluation
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2
Q
  • Systemic problem-solving process that guides all nursing actions
  • Help nurse provide goal-directed, client centered care
A

Nursing Process

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3
Q
  • Systemic gathering of data and ongoing process
  • Categorizing data (cluster cues)
  • Recording data
A

Assessment

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4
Q
  • Identifying client’s actual or portentously health needs, problems, and strengths
  • Pt’s response to their illness
A

Diagnosis

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5
Q

Data about client’s motivation, family, and available resources help you and the client formulate realistic goals

A

Planning

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6
Q

Decide goals you want to achieve with your nursing activities, keep pt in mind

A

Planning outcomes

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7
Q

Assess data to choose interventions to help the client achieve stated goals

A

Planning interventions

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8
Q

Putting plan into action and making sure pt is able to do it
- gather data by observing the client’s response as interventions are performed

A

Implementation

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9
Q

Types of nursing knowledge

A

Theoretical, Practical, Self, and Ethical

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10
Q
  • Knowing “why”
  • EBP facts/theories from nursing and other disciplines
  • Understanding why you need to do something with research to back it up
A

Theoretical

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11
Q

Knowing “what to do and how to do it”
- basically what we’re doing in the skills lab

A

Practical

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12
Q

Knowing yourself and your beliefs, understanding your self
- Help decrease bias and errors in planning individual care

A

Self

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13
Q

Our obligation, knowing right from wrong
- Doing the right thing

A

Ethical

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14
Q

Assessment focused on disease and pathology; doctor does the orders
- Diseased process related

A

Medical diagnosis

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15
Q
  • Assessment that focus on client’s response to illness
  • Considered to be the symptoms, the nurse’s role is to make interventions to alleviate symptoms
A

Nursing diagnosis

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16
Q

The different types of assessment

A

Comprehensive, initial focused, and ongoing focused

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17
Q

Global, nursing/patient database, admission

A

Comprehensive assessment

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18
Q
  • Used to follow up on symptoms or findings from first examination
  • First time seeing and focusing on it
A

Initial focused assessment

19
Q

Evaluate the status of existing problems and goals

A

Ongoing focused assessment

20
Q

Maslow’s hierarchy of needs from bottom to top

A
  • Physiological
  • Safety
  • Love/belonging
  • Esteem
  • Self-actualization
21
Q

Breathing, food, water, sex, sleep, homeostasis, excretion

A

Physiological of Maslow’s Hierarchy

22
Q

Security of…
body, employment, resources, morality, family, health, and property

A

Safety of Maslow’s Hierarchy

23
Q

Friendship, family, and sexual intimacy

A

Love/belonging of Maslow’s Hierarchy

24
Q

Self-esteem, confidence, achievement, respect of others, respect BY others

A

Esteem of Maslow’s Hierarchy

25
Q

Morality, creativity, spontaneity, problem solving, lack of prejudice, acceptance of facts

A

Self-actualization of Maslow’s Hierarchy

26
Q

Grouping given data

A

Cluster cues

27
Q

Goal that needs to be achieved within a few hours or days
- By end of shift, end of day

A

Short-term

28
Q

Goal that needs to be achieved over a longer period of time (week, month, or more)
- by discharge

A

Long-term

29
Q

SMART goal

A

Specific - define goal as much as possible: who, what, where, why, and which
Measurable - track progress and measure outcome
Attainable/achievable - goal is reasonable enough to be accomplished; goal isn’t out of reach or below standard performance
Relevant - goal is worthwhile and will meet the needs
Timely - time limit; establish sense of urgency and prompt nurse for time management

30
Q

Why do we write and develop goals for the patient?

A

We want to have a positive change

31
Q
  • Within RN scope of practice/license
  • Doesn’t require order
  • Done in response to nursing dx
A

Independent interventions

32
Q
  • Ordered by doctor/provider, implement by RN
  • Nurse is still responsible for the assessment/evaluation of the dependent intervention — make sure order is safe for the pt
A

Dependent intervention

33
Q

Done with collaboration of health team members

A

Interdependent intervention

34
Q

How to communicate task with the 5 rights of delegation

A

Right…
- Task, Circumstances, Person, Direction/communication, Supervision

35
Q

5Rs - Delegable for a specific pt

A

Right Task

36
Q

5Rs - Appropriate pt setting, available resources, and other relevant factors considered

A

Right circumstances

37
Q

5Rs - Delegating the right task to the right person to be performed on the right person

A

Right person

38
Q

5Rs - Clear, concise description of the task, including its objective, limits, and expectations

A

Right direction/communication

39
Q

5Rs - Appropriate monitory, evaluation, intervention, and feedback

A

Right supervision

40
Q

Who is responsible for the evaluation of the task delegated?

A

Nurse

41
Q
  • Evaluation that hasn’t been met
  • Evaluation done while implementing care, immediately after care, and at each pt contact
A

Ongoing evaluation

42
Q

Evaluation at specified stages, time, or intervals

A

Intermittent evaluation

43
Q
  • Evaluation that has ended, mark it as met and take it off the care plane
  • The progress or status at discharge
  • Includes forms or special instructions
A

Terminal evaluation

Nur221 - Foundation of Nursing (3 decks)

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