Module 1: Nursing Process, Critical Thinking, Health Assessment, and Infection Control (NUR 152)

A set of Q&A style flashcards covering key concepts from the nursing process, data types, diagnoses, planning and evaluation, CJMM, health assessment, vital signs, infection control, and related topics from the lecture notes.

What are the five steps of the nursing process (ADPIE)?

Assessment, Diagnosis, Planning, Implementation, and Evaluation.

Define subjective data in nursing assessment.

Symptoms reported by the patient; information obtained from the patient (primary source).

Define objective data in nursing assessment.

Signs observed or measured during assessment (e.g., vital signs, physical findings, diagnostic results).

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

Medical diagnosis identifies a disease or medical condition; nursing diagnosis describes a patient’s response to a health problem and guides nursing interventions.

What is a collaborative problem in nursing?

A health issue requiring combined nursing and medical/other professional actions; nurses monitor and intervene while physicians address medical aspects.

According to the NCSBN Clinical Judgment Measurement Model (CJMM), what are the four steps to interpret data?

Recognize cues, Analyze cues, Prioritize hypotheses, Generate solutions (then take actions and evaluate outcomes).

Name the four types of nursing diagnoses listed in the notes.

Actual, Risk for, Health Promotion (Readiness for Enhanced), Syndrome.

What are the three parts of a complete nursing diagnosis in PES format?

Problem (P), Etiology/Related to (E), and Signs/Symptoms or Defining Characteristics (S) for actual diagnoses; risk diagnoses do not have S.

What are the three levels of priority in nursing care as guided by the ABCs?

Airway (first), Breathing (second), Circulation (third); followed by safety, pain, and other needs.

What does SMART stand for in planning outcomes?

Specific, Measurable, Achievable, Realistic, Timely.

What does RUMBA stand for in planning outcomes?

Relevant, Understandable, Measurable, Behavioral, Achievable.

What are the three elements of planning (as described in the notes)?

Priorities/outcomes, patient-centered goals/outcomes, and nursing interventions.

What is the difference between direct and indirect nursing actions?

Direct actions involve interacting with the patient; indirect actions are carried out away from the patient (e.g., documentation, advocacy, coordination of care).

What occurs in the evaluation phase of the nursing process?

Assess whether goals were met, determine if the plan should be modified, and continue the nursing process cycle.

What does the CJMM stand for and what is it used for?

Clinical Judgment Measurement Model; it guides clinical judgment through recognizing cues, analyzing cues, prioritizing hypotheses, generating solutions, taking action, and evaluating outcomes.

Which organization developed the CJMM framework?

National Council of State Boards of Nursing (NCSBN).

What is the purpose of the Five Moments for Hand Hygiene?

To reduce the risk of infection by performing hand hygiene at key moments of patient care (before patient contact, before aseptic tasks, after body-fluid exposure, after patient contact, after contact with patient surroundings).

List common healthcare-associated infections (HAIs) mentioned in the notes.

CAUTI, SSI, CLABSI, MRSA infections, C. diff, CRE, VRE, VISA/VRSA, CRAB.

What does PERRLA stand for in eye assessment?

Pupils Equal, Round, Reactive to Light and Accommodation.

Name the four abdominal quadrants.

RUQ, LUQ, RLQ, LLQ.

What is the typical exam order for abdominal assessment and why?

Inspect, Auscultate, Percuss, Palpate (IAPP); auscultation before palpation/percussion to avoid disturbing bowel sounds.

What is capillary refill time considered normal?

Less than 3 seconds.

What is the auscultation mnemonic used for heart sounds (to remember locations)?

Aortic, Pulmonic, Erb’s point, Tricuspid, Mitral (often recalled as A-P-E-T-O-M-A-N or similar mnemonics); S1 and S2 are the heart sounds (“lub-dub”).

What are the typical adult vital signs ranges (approximate)?

Temperature about 98.6°F (37°C); Pulse 60–100 bpm; Respirations 12–20 per minute; Blood pressure around 120/80 mmHg (values vary by individual).

What are the two components of a health assessment and their purpose?

Health History and Physical Examination; together they establish baseline data, guide care, and support safe, effective nursing practice.

What is the purpose of PPE donning and doffing training in the notes?

To protect the clinician and prevent the spread of infection by correct sequence and technique when putting on and removing protective equipment.

What are Maslow’s hierarchy elements used for in nursing prioritization?

Helping prioritize patient needs from physiological and safety needs up to love/belonging, esteem, and self-actualization when planning care.

What is the main difference between a health promotion (readiness for enhanced) diagnosis and an actual diagnosis?

Health promotion focuses on readiness to enhance well-being and does not have defining symptoms yet; actual diagnoses describe current patient problems with defining symptoms.