and Study Guide
What is subjective data? - ANS ✔✔What patient says about him/herself during history taking.
For example: dizziness, nausea, etc.
What is objective data? - ANS ✔✔Observed when inspecting, percussing, palpating, and
auscultating patient during physical examination.
For example: abnormal breath sounds
What is a data base? - ANS ✔✔formed from subjective/objective data, plus patient's record and
laboratory studies
What are the levels of nursing experience? - ANS ✔✔Novice, proficient, and expert
What is diagnostic reasoning? - ANS ✔✔the process of analyzing health data and drawing
conclusions to identify diagnoses
What is part of the nursing process? - ANS ✔✔ADPIE:
-Assessment
-Diagnosis
-Planning
-Implementation
-Evaluation
What is a cue? - ANS ✔✔piece of information, a sign or symptom, or a piece of laboratory data
,What is a hypothesis? - ANS ✔✔tentative explanation for cues used as a basis for further
investigation
What is the process of diagnostic reasoning? - ANS ✔✔Attend to initially available cues,
formulate diagnostic hypotheses, gather data relative to tentative hypotheses, and evaluate
each hypothesis with new data collected to arrive at final diagnosis
What is included in the assessment portion of the nursing process? - ANS ✔✔Collecting data.
Review of clinical record, interview, health history, physical exam, functional assessment,
cultural & spiritual assessment, consultation, and review of literature.
What is included in the diagnosis portion of the nursing process? - ANS ✔✔Interpreting data
(identify clusters of cues & make inferences)
Validate inferences
Compare clusters of cues with definitions and defining characteristics
Identify related factors
Document the diagnosis.
What is included in the planning portion of the nursing diagnosis? - ANS ✔✔Establish priorities
Develop outcomes
Set time frames for outcomes
Identify interventions
Document plan of care
What is included in the implementation portion of the nursing diagnosis? - ANS ✔✔Determine
patient readiness
Review planned interventions
Collab with other team members
, Supervise by delegating appropriate responsibilities
Counsel person and significant others
Involve person in health care
Refer for continuing care
Document care provided
What is included in the evaluation portion of the nursing process? - ANS ✔✔Refer to
established outcomes
Evaluate individual's condition and compare actual outcomes with expected outcomes
Summarize results of evaluation
Identify reasons for failure to achieve expected outcomes
Take corrective action to modify plan of care
Document evaluation in plan of care
Critical thinking: identifying assumptions - ANS ✔✔recognize info taken for granted or fact
without evidence for it
Critical thinking: organized approach - ANS ✔✔use an organized, systemic assessment format
Critical thinking: validation - ANS ✔✔Check and corroborate accuracy and reliability of data
Critical thinking: normal and abnormal - ANS ✔✔Distinguish when identifying signs and
symptoms
Critical thinking: inferences or drawing conclusions - ANS ✔✔interpreting data and deriving
correct conclusions