Basic Nursing and Clinical Judgment Practice Flashcards

Practice flashcards in question and answer format covering clinical judgment, nursing process steps, vital signs assessment and norms, legal accountability, nursing history, and mobility principles.

What is the definition of critical thinking in nursing?

Purposeful, analytical thinking that results in a reasoned decision through a combination of reasoned thinking, openness to alternatives, the ability to reflect, and a desire to seek truth.

A newly employed hospital nurse questions a standard of client care that does not seem to follow evidence-based practice. Which critical thinking attitude is being demonstrated?

Intellectual autonomy.

How do the steps of the traditional Nursing Process align with the cognitive processes of the NCSBN Clinical Judgment Measurement Model (NCJMM)?

Assessment aligns with Recognizing Cues; Diagnosis aligns with Analyzing Cues; Planning aligns with Prioritizing Hypotheses and Generating Solutions; Implementation aligns with Taking Action; Evaluation aligns with Evaluating Outcomes.

What is the primary difference between a medical diagnosis and a nursing diagnosis?

A medical diagnosis focuses on disease and pathology, whereas a nursing diagnosis focuses on the client's human responses to illness or health problems.

Which components of the nursing process can an RN delegate to unlicensed assistive personnel (UAP) or LPNs?

An RN may delegate data collection tasks (such as measuring vital signs, pain reports, and fingerstick blood glucose levels), but cannot delegate tasks requiring assessment, interpretation, or independent decision-making.

What are the three components of a three-part NANDA-I nursing diagnosis statement?

1. Problem (the NANDA-I diagnostic label), 2. Etiology (the cause or related factor, preceded by "related to"), and 3. Signs and Symptoms (the subjective/objective data evidence, preceded by "as evidenced by").

According to this decision tree, how are nursing diagnoses categorized based on assessment findings?

Diagnoses are categorized as Actual (if sufficient defining characteristics are present), Risk/Potential (if risk factors are present without symptoms), Possible (if symptoms indicate possibility but lack certainty), or Wellness (if health promotion interventions are needed).

According to Maslow's Hierarchy of Needs, which level of human needs takes highest priority in nursing care?

Physiological needs (such as food, air, water, temperature regulation, elimination, rest, sex, and physical activity).

What components must be included in a measurable patient goal/outcome statement?

Subject ("Patient will…"), Action, Performance criteria, Target time, and Special conditions.

What are the three categories of goal-directed nursing interventions?

Take (data to collect or assess), Treat (actions to perform to reach the goal), and Teach (education provided to the patient and family).

What are the average normal adult findings for oral temperature, pulse, respirations, and blood pressure?

Oral temperature is $36.7^\circ\text{C}-37^\circ\text{C}$ ($98^\circ\text{F}-98.6^\circ\text{F}$); Pulse range is $60-100\,\text{beats/min}$ (average $80\,\text{beats/min}$); Respirations range is $12-20\,\text{breaths/min}$; Blood Pressure is $<120\,\text{mm Hg}$ systolic and $<80\,\text{mm Hg}$ diastolic.

What are the average normal vital sign findings for a newborn?

Axillary temperature average $36.8^\circ\text{C}$ ($98.2^\circ\text{F}$), Pulse range $130\,\text{beats/min}$ ($80-180\,\text{beats/min}$), Respirations range $30-60\,\text{breaths/min}$, and average Blood Pressure $80/40\,\text{mm Hg}$.

What are the four physical mechanisms by which body heat is lost or transferred?

Radiation (electromagnetic waves), Convection (currents of air or water), Evaporation (conversion of water to vapor via perspiration or breathing), and Conduction (direct contact between warm and cool surfaces).

What are the temperature thresholds for Pyrexia, Hyperpyrexia, and Hypothermia?

Pyrexia (fever) is body temperature greater than $100^\circ\text{F}$ ($37.8^\circ\text{C}$); Hyperpyrexia is fever greater than $105.8^\circ\text{F}$ ($41.0^\circ\text{C}$); Hypothermia is core temperature below $95^\circ\text{F}$ ($35^\circ\text{C}$).

How is cardiac output calculated, and how does fever affect heart rate?

Cardiac output = Stroke volume $\times$ Pulse rate. Heart rate increases by approximately $10\,\text{beats/min}$ for every $1^\circ\text{F}$ increase in body temperature.

What cardiovascular pressures and wave values are identified on this arterial pulse curve?

The peak wave is Systolic pressure, the trough is Diastolic pressure, the difference between peak and trough is Pulse Pressure, and MAP represents Mean Arterial Pressure.

Which major peripheral pulse points are depicted on this anatomical diagram?

Temporal, facial, carotid, brachial, radial, femoral, popliteal, posterior tibial, and dorsalis pedis arteries.

Where is the Point of Maximal Impulse (PMI) located for assessing an adult apical pulse?

At the intersection of the fifth intercostal space and the left midclavicular line.

How are Wheezes and Stridor distinguished during breath sound assessment?

Wheezes are high-pitched continuous musical sounds usually heard on expiration, whereas Stridor is a piercing, high-pitched sound heard primarily during inspiration.

What are the adult blood pressure thresholds for Elevated, Stage 1 Hypertension, and Stage 2 Hypertension?

Elevated: Systolic $120-129\,\text{mm Hg}$ AND Diastolic $<80\,\text{mm Hg}$; Stage 1 HTN: Systolic $130-139\,\text{mm Hg}$ OR Diastolic $80-89\,\text{mm Hg}$; Stage 2 HTN: Systolic $\ge 140\,\text{mm Hg}$ OR Diastolic $\ge 90\,\text{mm Hg}$.

In criminal law, what distinguishes a felony from a misdemeanor?

A felony is a major crime punishable by more than $1\,\text{year}$ in jail (such as murder, assisted suicide, sexual assault, or felony abuse), whereas a misdemeanor is a minor charge.

What four elements are required to establish liability and collect damages in a nursing malpractice lawsuit?

1. Existence of duty, 2. Breach of duty, 3. Causation, and 4. Damages.

What examples constitute intentional torts in nursing practice?

Assault and battery (such as performing a procedure without consent), false imprisonment (restraining a patient against their will), invasion of privacy, breach of confidentiality, and fraud.

What contributions were made to professional nursing by Florence Nightingale, Clara Barton, and Mary Mahoney?

Florence Nightingale established nursing education and emphasized sanitation and environment; Clara Barton founded the American Red Cross; Mary Mahoney was the first African American licensed professional nurse in the United States.

What are the five stages of clinical skill acquisition described in Patricia Benner's model?

Stage 1: Novice, Stage 2: Advanced Beginner, Stage 3: Competence, Stage 4: Proficient, Stage 5: Expert.

What are the six QSEN (Quality and Safety Education for Nurses) competencies?

1. Patient-Centered Care, 2. Teamwork and Collaboration, 3. Evidence-Based Practice, 4. Quality Improvement, 5. Safety, and 6. Informatics.

In Continuous Quality Improvement (CQI), how do process reviews differ from outcome reviews?

Process reviews examine how care is delivered and whether safe practices are followed, whereas outcome reviews examine the results of care to determine if those practices improved patient outcomes.

How are physical activity, physical fitness, and exercise distinguished?

Physical activity is bodily movement produced by skeletal muscles expending energy above baseline; Physical fitness is the ability to carry out ADLs with energy and alertness without fatigue; Exercise is planned, structured, repetitive, and purposeful physical activity to improve or maintain fitness.

How does stance width affect body balance and stability?

A broader base of support (wide stance) keeps the center of gravity closer to the base of support, making balance easier to maintain, whereas a narrow stance makes the body less stable.

Which structures of the motor nervous system control voluntary movement, coordination, and proprioception?

The Cerebral cortex initiates voluntary movement; the Cerebellum coordinates movement and controls proprioception (position sense); the Basal ganglia assists with movement coordination.

What are the differences between isometric, isotonic, and isokinetic exercises?

Isometric involves muscle contraction without movement against an immovable surface; Isotonic involves movement of a joint during muscle contraction (e.g., free weights); Isokinetic uses specialized machines to provide variable resistance through movement.

What body mechanics principles should nurses follow to protect their back from injury?

Obtain adequate assistance based on patient size and ability, avoid manual lifting by using assistive devices (following the ANA Handle With Care program), maintain a clutter-free environment, lock equipment wheels, avoid slippery surfaces, and wear supportive shoes with non-slip soles.