EXAM 1 Nursing Process Review

What key principles govern high-quality nursing documentation?

Documentation must be accurate, complete, timely (real-time charting), confidential (HIPAA), and objective (factual observations rather than personal opinions)

What is critical thinking in nursing?

The disciplined, systematic cognitive process of applying skillful reasoning to analyze information, question assumptions, evaluate evidence, and guide belief or action

What are clinical pathways?

Multidisciplinary, standardized guidelines based on evidence that outline the sequence and timing of care steps for specific clinical conditions

What is a health promotion diagnosis?

A diagnostic category based on patient’s expressed motivation and desire to enhance their overall well-being and actualize their health potential

What is clinical judgement?

The ultimate outcome of critical thinking and clinical reasoning, where the nurse synthesized all available information to make a final decision or take action regarding patient care

What is the Nurse’s role as a care coordinator?

Leads collaborative care planning by organizing patient needs and acting as communicator, educator, counselor, and interdisciplinary team member alongside the patient and family

What are dependent interventions?

Nursing actions carried out under the direct order or prescription of a licensed healthcare provider, such as administering medication or performing prescribed wound care

What are physical assessment techniques?

Inspection/Observation, Palpation, Percussion, Auscultation

What is clinical reasoning?

The cognitive process by which a nurse synthesizes clinical knowledge and patient data to generate hypotheses and make sense of a clinical situation

What is the PES structure of a nursing diagnosis?

A three-part diagnostic statement comprising: Problem category (NANDA), Etiology (‘related to’ factor causing the issue), Signs/Symptoms (‘as evidenced by’ defining characteristics)

What is the difference between primary and secondary data sources in nursing assessment?

Primary comes directly from the patient, secondary comes from family members/caretakers/medical records

What are independent nursing interventions?

Autonomous care actions initiated and performed by a nurse based on clinical judgement without needing a healthcare provider’s order (patient teaching, emotional support, etc)

What is a nursing assessment?

The systematic and dynamic collection and analysis of holistic data regarding a patient’s physical, psychological, social, emotional, and spiritual health status

What rules guide clinical prioritization when selecting nursing diagnoses to address first?

Prioritize life-threatening problems (ABCs) first, actual problems over potential/risk problems, acute over chronic conditions, and foundational physiological needs before higher-level needs (Maslow)

What is the cyclical nature of the nursing process?

The nursing process is not a linear checklist, it is a continuous and dynamic cycle where evaluation leads back to reassessment, allowing nurses to adapt care as patient conditions change

Why is the nursing process considered foundational to professional nursing practice?

It provides a systematic, evidence-based framework for critical thinking and clinical decision-making, ensuring individualized, safe, and competent patient-centered care aligned with ANA standards

What is syndrome diagnosis?

A clinical judgement describing a cluster of specific nursing diagnoses that occur together and are best addressed through combined, coordinated interventions

What are the four holistic domains of nursing assessment?

Physical (body systems, vital signs), Psychosocial (mental health, coping, social support), Emotional, Spiritual

How do short-term and long-term nursing goals differ in timeframe and purpose?

Short-term goals target immediate needs within hours to days, while long-term goals extend over weeks to months to improve overall quality of life or manage chronic conditions

How does a nursing diagnosis differ from a medical diagnosis?

A medical diagnosis identifies a specific disease process or pathology, nursing diagnoses focuses on the human response to health conditions and life processes (physiologically or psychologically)

What are SMART goals?

Specific, measurable, achievable, relatable/relevant, timely

What is quality assurance (QA)?

QA programs ensure existing care standards are maintained by auditing structure, process, and outcomes

What is Quality Improvement (QI)?

QI is a continuous framework using data analysis to actively improve system processes and patient outcomes

What are the three potential outcomes when evaluating a patient’s progress toward goals?

1. Goal Met: Continue the current plan of care

2. Goal Unmet/Partially Met: Reassess, review interventions, revise plan

3. Terminate: Discontinue interventions that are resolved, no longer relevant, or ineffective

What are interdependent interventions?

Collaborative actions requiring coordination and shared decision-making with other healthcare team members

What is a problem-focused nursing diagnosis?

A diagnosis that identifies an existing, undesirable human response to a health condition, supported by validated clinical signs and symptoms (defining characteristics)

What is a risk nursing diagnosis?

A clinical judgement identifying a patient’s vulnerability to developing an unwanted health problem when risk factors are present, before the problem actually occurs

What is ADPIE?

Assessment, Diagnosis, Planning, Implementation, and Evaulation

During an admission assessment, a nurse explores a patient’s coping mechanisms, mental health status, and family support systems. Which holistic domains is being assessed?

Psychosocial domain

Which NANDA-I category applies when a cluster of nursing diagnoses occurs together due to a specific life event or situation, such as post-traumatic stress?

Syndrome diagnosis

Which documentation structure organizes patient information around specific patient problems and utilizes the SOAP format (Subjective, Objective, Assessment, Plan)?

Problem-oriented documentation

How does clinical judgement differ from clinical reasoning within the cognitive framework of nursing?

Clinical judgement is the final synthesis and decision on action, whereas clinical reasoning is the process of combining knowledge and experience to generate hypotheses

A nurse formulates the nursing diagnosis: ‘Risk for Falls related to impaired mobility and history of falls.’ Which structural element is absent from this diagnosis?

Definition characteristics (‘as evidenced by’), risk diagnoses do not contain defining characteristics because the problem has not occurred yet

The five-step nursing process serves as the basis for approved standards of practice set by which professional organization?

American Nurses Association (ANA)

Which evidence-based practice tool provides multidisciplinary standardized guidelines to direct care for common medical conditions?

Clinical pathways

Administering a prescribed diuretic medication to manage fluid retention is an example of which type of intervention?

Dependent intervention