ATI Clinical Judgement Process – The Nursing Process

100 question-and-answer flashcards reviewing key concepts, definitions, and examples related to the nursing process, clinical reasoning, diagnoses, planning, implementation, and evaluation from the ATI Clinical Judgement Process lecture.

1. What organization provides the professional definition of nursing referenced in the lecture?

The American Nurses Association (ANA).

2. According to the ANA, what kind of relationship facilitates health and healing?

A caring relationship between nurse and patient.

3. How has nursing evolved over time, as described in the lecture?

It has moved from task-oriented work to knowledgeable, competent, independent, collaborative, person-centered care.

4. What is meant by “thoughtful practice” in nursing?

Considerate, compassionate practice that promotes humanity, dignity, and patient well-being while using reflection to improve care.

5. Name three components of thoughtful person-centered practice.

The person, the professional nurse, and reflective practice leading to personal learning (other components include clinical reasoning/decision-making and appropriate nursing action).

6. List two personal attributes of a professional nurse highlighted in the lecture.

Open-mindedness and a profound sense of the value of the person (other examples: self-awareness, responsibility, motivation, leadership, bravery).

7. What disease-related knowledge must a nurse possess to develop sound clinical reasoning?

Epidemiology, pathophysiology mechanisms, signs and symptoms, and probable progression or outcomes of the disease.

8. How is critical thinking defined in nursing?

A systematic, disciplined, comprehensive, well-reasoned way to form and shape one’s thinking.

9. Give two characteristics of a nurse who thinks critically.

Effective communicator and logical thinker (others: independent, confident, prudent, sensitive to diversity).

10. What are technical competencies in nursing?

Mastery of intricate procedures and equipment with confidence and competence before performing them independently.

11. Why are interpersonal competencies essential for nurses?

They promote patient dignity and respect, build caring relationships, and enrich both patient and nurse.

12. What does being "accountable" mean for a nurse?

Being attentive and responsive to individual patients’ health-care needs and accepting responsibility for outcomes.

13. Distinguish critical thinking, clinical reasoning, and clinical judgment.

Critical thinking is broad reasoning; clinical reasoning is thinking about patient-care issues; clinical judgment is the conclusion or decision reached.

14. Why is trial-and-error problem solving not ideal in nursing practice?

It is inefficient and can be dangerous for patients.

15. The nursing process exemplifies which type of problem-solving method?

Scientific problem solving.

16. List the five key characteristics of the nursing process.

Systematic, dynamic, interpersonal, outcome-oriented, and universally applicable.

17. What are the five official steps of the nursing process (in order)?

Assessment, Diagnosis, Outcome Identification & Planning, Implementation, Evaluation.

18. What legal principle applies if a nursing action is not documented?

“If it wasn’t documented, it wasn’t done.”

19. State one benefit of the nursing process for patients.

It provides scientifically based, holistic, individualized care.

20. State one benefit of the nursing process for nurses.

It offers opportunities to collaborate with other health-care professionals.

21. Define the assessment phase of the nursing process.

Systematic, continuous collection, analysis, validation, and communication of patient data.

22. Differentiate objective data from subjective data.

Objective data are observable and measurable by others; subjective data are reported only by the patient.

23. Name the four types of nursing assessments.

Initial, Focused, Emergency, and Time-lapsed assessments.

24. Give two common sources of assessment data besides the patient.

Family/significant others and the patient record (others: lab reports, consultations, literature).

25. During assessment, why must a nurse identify assumptions and inconsistencies?

To detect bias and ensure information is accurate and reliable.

26. What is the primary focus of a nursing assessment compared to a medical assessment?

The patient’s responses to health problems affecting basic human needs (ADLs).

27. What are the three parts of an actual (problem-focused) nursing diagnosis?

Problem (diagnostic label), Etiology (related factors), and Defining characteristics (as evidenced by).

28. Provide the structure of a risk nursing diagnosis.

“Risk for” + problem + related factor (no defining characteristics because the problem has not occurred).

29. Why do risk diagnoses omit defining characteristics?

Because the undesirable response has not yet happened.

30. Define a health-promotion nursing diagnosis.

A judgment concerning a patient’s motivation and desire to increase well-being and actualize health potential.

31. What does NANDA-I stand for?

North American Nursing Diagnosis Association International.

32. Which NANDA domain covers “Risk for infection”?

Domain 11: Safety/Protection.

33. Under which NANDA domain is “Acute pain” classified?

Domain 12: Comfort.

34. Name two example diagnoses in Domain 4 (Activity/Rest).

Impaired physical mobility and Ineffective sleep pattern (others include impaired walking ability).

35. What is the primary purpose of outcome identification and planning?

To design a care plan that prevents, reduces, or resolves health problems and meets patient expectations.

36. List four planning activities nurses perform with patients and families.

Establish priorities, identify/write expected outcomes, select nursing interventions, and communicate the care plan.

37. Distinguish a goal from an expected outcome.

A goal is a broad aim; an expected outcome is a specific, measurable criterion for evaluating goal achievement.

38. When should discharge planning start?

At the time of patient admission.

39. Name three guides used to set nursing priorities.

Maslow’s hierarchy of needs, patient preference, and anticipation of future problems.

40. Give a correctly written example of a short-term outcome.

“Patient will report pain below 3/10 one hour after oral hydrocodone.”

41. What does SMART stand for when writing outcomes?

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

42. From which part of a nursing diagnosis are nursing interventions derived?

The etiology (related factors) of the diagnosis.

43. Define a nurse-initiated intervention.

An autonomous, evidence-based action the nurse performs without a provider order to benefit the patient.

44. Provide an example situation that requires a nursing consultation.

Patient cannot afford insulin; nurse consults a social worker for assistance.

45. What is the main purpose of the implementation step?

To carry out planned interventions to help the patient achieve desired health outcomes.

46. State one reason for implementing the care plan.

To determine the patient’s continuing need for nursing assistance.

47. Why must student nurses know the rationale for each intervention?

To justify actions with scientific evidence and ensure safe, effective care.

48. Define evaluation in the nursing process.

Measuring how well patient outcomes were achieved and deciding whether to terminate, modify, or continue the care plan.

49. Name the four outcome domains used in evaluation.

Cognitive, Psychomotor, Affective, and Physiologic outcomes.

50. What are “criteria” and “standards” in the evaluation phase?

Criteria are measurable qualities; standards are accepted levels of performance.

51. What three judgments can an evaluative statement make about a goal?

Goal met, goal partially met, or goal not met.

52. Give an example of an evaluative statement for a partially met goal.

“6/8/20 – Goal partially met; patient ambulated to bathroom once with assistance.”

53. Why are nursing care plans individualized?

To address each patient’s unique problems, needs, and preferences.

54. What does the acronym ADPIE represent?

Assess, Diagnose, Plan, Implement, Evaluate – the steps of the nursing process.

55. In a nursing diagnosis, what does the etiology identify?

The factors causing or maintaining the unhealthy state.

56. Give two defining characteristics of a bathing self-care deficit.

Strong body and urine odor and patient’s statement of fearing a fall in the tub.

57. Why should nurses avoid relying on family members as interpreters?

Potential privacy breaches and inaccuracies; professional interpreters should be used per protocol.

58. What does "universally applicable" mean regarding the nursing process?

It serves as a framework for all nursing activities in any setting or specialty.

59. What is considered a nurse’s primary legal safeguard?

Competent practice within the legal boundaries of the Nurse Practice Act.

60. Define "reflective practice" for nurses.

Deliberately analyzing daily experiences to learn and improve future care.

61. When might a nurse use intuitive problem solving?

Experienced nurses use intuition for quick understanding based on prior knowledge and observation.

62. Provide an example of a technical competency.

Proficiently setting up and programming an infusion pump before independent use.

63. Which nursing process step includes validating collected data?

Assessment.

64. What is the first action when creating a care plan for acute pain?

Formulate the nursing diagnosis “Acute Pain related to…” based on assessment data.

65. In Maslow’s hierarchy, which needs are the highest priority?

Physiologic needs such as airway, breathing, and circulation.

66. How does documentation facilitate interdisciplinary communication?

It makes patient data, diagnoses, and plans accessible to all team members in the record.

67. During evaluation, should focus be on nurse activity or patient response?

Patient response and outcome achievement.

68. What is the purpose of a standardized care plan?

To provide common diagnoses, outcomes, and interventions for a typical patient population or problem.

69. Define a time-lapsed assessment.

An assessment conducted to compare a patient's current status with earlier baseline data.

70. How can a nurse reduce bias during data collection?

Assess systematically and verify the credibility of information sources.

71. What distinguishes a medical diagnosis from a nursing diagnosis?

Medical diagnoses name diseases; nursing diagnoses describe patient responses nurses can treat independently.

72. Provide an example of a syndrome nursing diagnosis.

Chronic pain syndrome.

73. What does the abbreviation “AEB” stand for in nursing diagnoses?

As Evidenced By.

74. Why is patient and family involvement crucial in goal setting?

It enhances realism, cooperation, and adherence to the care plan.

75. What is the purpose of anchoring an NG tube with tape as a nursing intervention?

To prevent tube displacement and reduce aspiration risk.

76. Describe one nurse-initiated intervention for imbalanced nutrition.

Provide foods tailored to the patient’s preferences to help stimulate appetite.

77. State one sign of impaired skin integrity around a surgical drain.

Redness and irritation of the skin surrounding the drain site.

78. In a “Risk for aspiration” diagnosis, why elevate the head of bed 30°?

To prevent reflux and aspiration during and after feedings.

79. What does a “deficient knowledge” diagnosis indicate?

The patient lacks necessary information or skills for effective health management.

80. Which competency involves bravery to question the “system” for patient advocacy?

Ethical/legal competency combined with personal bravery.

81. What element of critical thinking involves checking adequacy of knowledge?

Developing cognitive competencies.

82. Explain the term “blended competencies.”

The integration of cognitive, technical, interpersonal, and ethical/legal skills required for effective nursing.

83. What type of data is the patient report “I feel dizzy”?

Subjective data.

84. Give one example of physiologic outcome evaluation.

Assessing and comparing wound healing progress on physical examination.

85. What does independent thinking mean for nurses?

Forming logical judgments without undue influence while considering evidence.

86. When should a care plan be modified?

When outcomes are difficult to achieve or the patient’s condition or needs change.

87. What is the purpose of including rationales in student care plans?

To link each intervention to scientific evidence and sound reasoning.

88. Per the lecture example, when should pain be reassessed after oral analgesic?

One hour after the medication is given.

89. In dressing assessments, what does “CDI” stand for?

Clean, Dry, Intact.

90. Define "readiness for enhanced health management."

Patient expresses willingness and ability to improve control over health behaviors.

91. Provide one example of affective outcome evaluation.

Observing a patient attend a support group, indicating acceptance of illness.

92. Why are baseline data important in nursing care?

They allow comparison over time to judge changes and plan appropriate care.

93. Which evaluation decision is made when a goal is fully achieved?

Terminate the care plan for that problem.

94. Name a potential problem category during diagnostic reasoning.

Possible problem requiring more data to confirm or rule out.

95. What should a nurse do when a patient problem is beyond nursing scope?

Consult and collaborate with the appropriate health-care professional.

96. Why must interventions comply with professional standards and facility protocols?

To ensure legal, safe, and high-quality patient care.

97. Explain the term “scope and standards of practice.”

Authoritative guidelines detailing acceptable nursing roles and performance expectations.

98. What does a BMI of 16.8 indicate in the lecture’s nutrition example?

The patient is underweight, supporting an imbalanced nutrition diagnosis.

99. Why should patient outcomes include a target time?

To establish a timeframe for evaluating progress toward the goal.

100. How does pairing intuitive and logical thinking benefit nursing practice?

It balances experience-based insights with systematic analysis to enhance clinical reasoning.