Study your flashcards anywhere!

Download the official Cram app for free >

  • Shuffle
    Toggle On
    Toggle Off
  • Alphabetize
    Toggle On
    Toggle Off
  • Front First
    Toggle On
    Toggle Off
  • Both Sides
    Toggle On
    Toggle Off
  • Read
    Toggle On
    Toggle Off
Reading...
Front

How to study your flashcards.

Right/Left arrow keys: Navigate between flashcards.right arrow keyleft arrow key

Up/Down arrow keys: Flip the card between the front and back.down keyup key

H key: Show hint (3rd side).h key

A key: Read text to speech.a key

image

Play button

image

Play button

image

Progress

1/69

Click to flip

69 Cards in this Set

  • Front
  • Back
What are the 5 steps of the nursing process?
assessment
analysis
planning
implementation
evaluation
Define assessment?
gather objective and
subjective data
verify data
Define analysis?
interpret data
collect additional data when
necessary
identify and communicate
nursing diagnoses
determine health team's
ability to meet client's
needs
Define planning?
determine and prioritize
goals of care. Include
client, significant others,
and health team in setting
goals
develop and modify plan for
delivery of client's care
Define implementation?
organize and manage the
client's care
perform or assist in
performance of client's
care
counsel and teach client,
significant others, and
health team
provide care specifically
directed toward achieving
goals
Define evaluation?
compare actual outcomes with
expected outcomes
evaluate compliance with the
established regimen or plan
record and describe client's
response to plan
modify plan as indicated, and
set priorities
What are the 2 components of the nursing diagnosis?
response
etiology
The RESPONSE component of a nursing diagnosis is?
includes potential or actual
health response
describes measurable
outcomes that can be
derived
cites potential for changes
based on nursingn actions
example: alteration in
comfort, pain
The ETIOLOGY component of a nursing diagnosis is?
includes potential or actual
health response
addresses independent, inter-
dependent, and dependent
nursing functions
example: related to
fractured left
ankle
Name 13 NANDA-Approved Nursing Diagnoses?
activity/rest
circulation
elimination
emotional reactions
food/fluid
hygiene
neurologic
pain
relationship alterations
safety
sexuality
teaching/learning
ventilation
Name the Activity/Rest NANDA-Approved Nursing Diagnoses? (7)
Activity Intolerance
Activity Intolerance,
Potential
Disuse Syndrome, Potential
for
Diversional Activity Deficit
Fatigue
Physical Mobility, Impaired
Sleep Pattern Disturbance
Name the Circulation NANDA-Approved Nursing Diagnoses?
(3)
Decreased Cardiac Output
Tissue Perfusion, Altered
(Specify type: renal,
cerebral, cardiopulmonary,
GI, peripheral)
high risk for peripheral
neurovascular dysfunction
Name the Elimination NANDA-Approved Nursing Diagnoses?
(12)
Constipation
Constipation, Colonic
Constipation, Perceived
Diarrhea
Incontinence, Bowel
Incontinence, Functional
Incontinence, Reflex
Incontinence, Stress
Incontinence, Total
Incontinence, Urge
Urinary Elimination, Altered
Urinary Retention
Name the Emotional Reactions NANDA-Approved Nursing Diagnoses?
(22)
Adjustment, Impaired
Anxiety
Body Image Disturbance
Individual Coping,
Ineffective
Defensive Coping
Denial, Ineffective
Decisional Conflict (Specify)
Fear
Grieving, Anticipatory
Grieving, Dysfunctional
Hopelessness
Post-Trauma Response
Powerlessness
Personal Identity Disturbance
Rape-Trauma Response
Rape-Trauma Syndrome
Rape-Trauma Syndrome:
Compound Reaction
Rape-Trauma Syndrome: Silent
Reaction
Relocation Stress Syndrome
Self-Esteem, Chronic Low
Self-Esteem, Situational Low
Spiritual Distress
Name the Food/Fluid NANDA-Approved Nursing Diagnoses?
(12)
Breastfeeding, Ineffective
Interrupted Breastfeeding
Fluid Volume, Excess
Fluid Volume Deficit,
Potential
Nutrition Less than Body
Requirements, Altered
Nutrition More than Body
Requirements, Altered
Nutrition, Potential for more
than Body Requirements,
Altered
Oral Mucous Membrane, Altered
Swallowing, Impaired
Ineffective Infant Feeding
Pattern
Name the Hygiene NANDA-Approved Nursing Diagnoses?
(2)
Health-Seeking Behaviors
(Specify)
Self-Care Deficit:
---Bathing/Hygiene
---Toileting
---Feeding
---Dressing/Grooming
Name the Neurologic NANDA-Approved Nursing Diagnoses?
(5)
Communications, Impaired
Verbal
Dysreflexia
Unilateral Neglect
Sensory/Perceptual
Alterations (Specify
type: visual, auditory,
kinesthetic, gustatory,
tactile, olfactory)
Thought Process, Altered
Name the Pain Nanda-Approved Nursing Diagnoses?
(2)
Pain
Pain, Chronic
Name the Relationship Alterations NANDA-Approved Nursing Diagnoses? (13)
Family Coping: Compromised,
Ineffective
Family Coping: Disabling,
Ineffective
Family Process, Altered
Parental Role Conflict
Parenting, Altered
Role Performance, Altered
Self-Esteem, Chronic Low
Self-Esteem, Situational Low
Self-Esteem Disturbance
Social Interaction, Impaired
Social Isolation
Caregiver Role Strain
High Risk for Caregiver Role
Name the Safety NANDA-Approved Nursing Diagnoses? (17)
Body Temperature, Potential
Altered
Health Maintenance, Altered
Home Maintenance
Management, Impaired
Hyperthermia
Hypothermia
Infection, Potential for
Injury, Potential for
Poisoning, Potential for
Suffocation, Potential for
Trauma, Potential for
Skin Integrity, Impaired
Skin Integrity, Potential
Impaired
Thermoregulation, Ineffective
Tissue Integrity, Impaired
Violence, Potential for:
Self-directed or directed
at others
High Risk for Self-Mutilation
Name the Sexuality NANDA-Approved Nursing Diagnoses?
(2)
Sexual Dysfunction
Sexual Patterns, Altered
Name the Teaching/Learning NANDA-Approved Nursing Diagnoses? (5)
Growth and development,
altered
Knowledge deficit (specify)
Noncompliance (specify)
Ineffective management of
therapeutic regimen
(individuals)
Therapeutic regimen:
(community, families):
ineffective management
Name the Ventilation NANDA-Approved Nursing Diagnoses?
(6)
Airway clearance, ineffective
Aspiration, potential for
Breathing pattern,
ineffective
Gas exchange
Dysfunctional ventilatory
weaning response
Inability to sustain
spontaneous ventilation
Name Maslow's Hierarchy of Needs in order. (6)
Physiologic
Safety
Love and Belonging
Esteem and Recognition
Self-Actualization
Aesthetic
What is the definition of Maslow's Physiologic?
Biologic needs for food, shelter, water, sleep, oxygen, sexual expression
What is the definition of Maslow's Safety?
Avoiding harm; attaining security, order, and physical safety
What is the definition of Maslow's Love and Belonging?
Giving and receiving affection; companionship; and identification with a group
What is the definition of Maslow's Esteem and Recognition?
Self-esteem and respect of others; success in work; prestige
What is the definition of Maslow's Self-Actualization?
Fulfillment of unique potential
What is the definition of Maslow's Aesthetic?
Search for beauty and spiritual goals
The priority biologic need is?
breathing i.e. open airway
Ensuring that the client's environment is 1____ is a priority, e.g., teaching an older client to remove throw rugs which pose a safety hazard when ambulating would have a greater priority than teaching how to use a walker - FIRST priority is 2____, then 3____ skills.
1 SAFE
2 safety
3 coping
Which action has a higher priority...assisting the client in becoming a part of a support group...or assisting him/her in developing self-esteem?
sense of belonging comes first, and such a sense might help in developing self-esteem
What provides the laws that control the practice of nursing in each state?
Nurse Practice Acts
A tort is an act involving injury or damage to another (except 1_____ of contract) resulting in 2_____ liability (i.e. the victim can sue) instead of 3_____ liability (see crime).
1 breech
2 civil
3 criminal
Two unintentional torts are?
negligence
malpractice
Negligence is a form of ______ tort whereby performing an act that a reasonable and prudent person would not do. Measure of negligence is "_____" (i.e. would a reasonable and prudent nurse act in the same manner under the same circumstance?)
unintentional
reasonableness
Malpractice is a form of ______ tort whereby there is negligence of professional _____, e.g., professional misconduct, or unreasonable lack of skill in carrying out professional duties.
unintentional
misconduct
What four elements are necessary to prove negligence/malpractice and if any element is missing, it cannot be proved?
duty
breach of duty
injury/damages
causation
What is DUTY? (one of the four elements that proves negligence/malpractice and cannot be missing)
The obligation to use due care (what a reasonable, prudent nurse would do)

Failure to care for and/or to protect others against unreasonable risk.
DUTY (one of four elements of negligence/malpractice) must _______ foreseeable risks.
Example: If a floor has water on it, the nurse is responsible for anticipating the risk to the client of falling.
ANTICIPATE
What is BREACH OF DUTY? (one of the four elements that proves negligence/malpractice and cannot be missing)
Failure to perform according to the established standard of conduct in providing nursing care.
What is INJURY/DAMAGES? (one of the four elements that proves negligence/malpractice and cannot be missing)
Failure to meet standard of care, which causes actual injury or damage to the client, either physical or mental.
What is CAUSATION? (one of the four elements that proves negligence/malpractice and cannot be missing)
A connection exists between conduct and the resulting injury referred to as "proximate cause" or "remoteness of damage"
Hospital policies provide a guide for nursing 1_____.
They are NOT 2____, but courts generally rule against nurses who have violated the employer's policies. Hospitals can be liable for poorly formulated or poorly implemented policies.
1 actions
2 laws
What alerts administration to possible liability claims and the need for investigation; they do NOT _____ against legal action being taken for negligence or malpractice.
Incident report
protect
Burning a client with a hot water bottle or heating pad is an example of?
negligence/malpractice
Two forms of intentional tort are?
assault
battery
What is the term used for mental or physical threat, e.g., forcing (without touching) a client to take a medication or treatment?
assault
What is the term used when touching, with or without the intent to do harm, e.g., hitting or striking a client. If a mentally competent adult is forced to have a treatment and has refused, this occurs?
battery
Leaving sponges or instruments in a client in surgery is an example of?
negligence/malpractice
What is the term for encroachment or trespassing on another's body and/or personality?
invasion of privacy
Confinement without authorization?
false imprisonment
Exposure or discussion of the client's case. After death, the client has a right to be unobserved, excluded from unwarranted operations, and protected from unauthorized touching of the body?
exposure of a person
Performing incompetent assessments is an example of?
negligence/malpractice
Divulgence of privileged information or communication, e.g., from charts, conversations, or observations?
defamation
Failing to heed warning signs of shock or impending MI is an example of?
negligence/malpractice
Willful and purposeful misrepresentation that could cause, or has caused, loss or harm to a person or property?
fraud
Ignoring signs and symptoms of bleeding is an example of?
negligence/malpractice
Presenting false credentials for the purpose of entering nursing school, obtaining a license, or obtaining employment is termed?
fraud
A legal term meaning the accused is not criminally responsible for the unlawful act committed due to mental illness?
insanity
Forgetting to give a medication or giving the wrong medication is an example of?
negligence/malpractice
An act contrary to a criminal statute. Wrongs punishable by the state, committed against the state, with intent usually present.
crime
Legal hearing that is held to determine a person's capability to make responsible decisions about self, dependent, or property?
competency hearing
Persons declared incompetent have the legal status of a minor, i.e., they cannot? (5)
vote
make contracts or wills
drive a car
sue or be sued
hold a professional license
If a person is incompetent, a _____ is appointed. Declaring a person incompetent can be initiated by the ____ or family.
guardian
state
An admission whereby any adult may apply for another. However, medical or judicial approval is required to detain anyone beyond 24 hours.
emergency admmission
Emergency admissions allow persons held against their will to file a ____ _____ to try and get the court to hear their case and release them.
habeas corpus
With emergency admissions, the court determines the ____ and alleged unlawful restraint of a person.
sanity