Nursing Process & Clinical Judgment – Review Flashcards

What are the two primary actions nurses perform with data?

Collect it and analyze it.

Which phase immediately follows Assessment in the nursing process?

Diagnosis.

What single keyword summarizes the Diagnosis phase?

Identifying.

In the nursing process, what does Implementation involve?

Putting care into action through interventions to meet patient needs.

How many basic types of nursing interventions exist?

Two.

Name the two types of nursing interventions.

Direct-care interventions and indirect-care interventions.

Give one example of an indirect-care intervention.

Advocating for the patient (other possible answers: charting, patient education, consulting the physician).

Give one example of a direct-care intervention.

Repositioning the patient for comfort (other possible answers: administering medication, assisting with hygiene).

Why is the nursing process called cyclical?

Because nurses continually reassess and repeat the steps to address actual or potential problems.

What must a nurse always do before implementing any intervention?

Assess the patient.

Define clinical judgment in nursing.

Using experience and learned knowledge to make decisions about patient care.

How many cognitive skills make up the Clinical Judgment Model?

Six.

When a patient shows obvious shortness of breath, what is the nurse’s FIRST action?

Assess the patient’s airway and breathing status.

In ABC prioritization, what do the letters A, B, and C stand for?

Airway, Breathing, Circulation.

Besides ABC, what two other priorities are often added for test questions?

Safety and Pain.

In an NCLEX-style question, recognition cues usually appear as what?

Key words or phrases that signal the main issue.

In a real patient, recognition cues are better known as what?

Signs and symptoms.

What is the universal sign of choking?

The patient grasping their throat with both hands.

List the three parts of an ACTUAL nursing diagnosis.

Problem, related factors, and evidence (major assessment findings).

How does a POTENTIAL (risk) nursing diagnosis differ in structure from an actual one?

It has only two parts: “Risk for …” followed by the evidence or risk factors.

Give a sample risk diagnosis for a fresh surgical patient.

Risk for infection as evidenced by tenderness at the incision site.

What does the SMART acronym stand for in goal-setting?

Specific, Measurable, Attainable, Relevant, Time-bound.

Write a SMART goal aimed at reducing post-op pain.

“Client will report pain level of 4 or less on a 0-10 scale within 48 hours.”

Name a direct-care action (non-pharmacologic) to reduce abdominal pain.

Reposition the patient or provide supportive pillows.

Define Activities of Daily Living (ADLs).

Basic self-care tasks normally performed each day, such as bathing and eating.

Give two examples of ADLs.

Bathing and toileting (others: eating, dressing, ambulating).

What does the “I” in IADLs stand for?

Instrumental.

Give two examples of Instrumental Activities of Daily Living (IADLs).

Shopping for groceries and paying bills (others: cooking, managing medications, house cleaning).

During the Evaluation phase, what key question is asked?

Were the expected outcomes and goals met?

List the four core components of critical thinking mentioned in lecture.

Knowledge, standards, attitudes, and experience.

Under Knowledge, what do nurses need to understand about diseases?

Underlying disease processes and normal growth & development.

Which professional body publishes the Scope & Standards of Practice for nurses?

The American Nurses Association (ANA).

Name two professional attitudes vital for nurses.

Fairness and integrity (others: confidence, creativity, perseverance).

Why is therapeutic communication important in nursing?

It ensures information is delivered in a way the patient can understand and trust.

Give one developmental milestone typical for an infant.

Learning to hold up the head or developing gross motor control.

Can a registered nurse prescribe medications?

No, unless the nurse is licensed as a Nurse Practitioner (NP).

In an emergency, should the nurse call the physician before doing an appropriate assessment?

No, the nurse must assess and intervene within scope first.

Which priority framework is commonly used in exam questions besides ABC?

Airway, Breathing, Circulation, and Safety (sometimes Pain).

Name one quick nursing intervention for a supine patient in respiratory distress.

Elevate the head of the bed.

What label begins every risk nursing diagnosis?

“Risk for …”

What does the Planning step of the nursing process answer?

What outcomes are desired and how they will be achieved.

Provide one example of an indirect nursing intervention related to pain management.

Documenting the next pain-medication time on the room whiteboard.

Why did many new nurses graduating during COVID struggle with clinical judgment?

They lacked in-person clinical practice to apply classroom learning.

Failure to act appropriately can lead to what legal issue?

Malpractice lawsuits against the nurse.

What does ANA stand for?

American Nurses Association.

List two non-verbal cues indicating pain.

Facial grimacing and guarding/holding the affected area.

Why might some male patients under-report pain?

Cultural or personal beliefs about expressing discomfort.

Is it ethical for a nurse to withhold abortion information due to personal beliefs?

No; the nurse must provide unbiased information