Nursing Exam 1 terms NURS 20040
Assessing collecting, validating, and communicating patient data
Cue A signal for something to happen
Data Facts and statistics collected together for reference or analysis
Database A collection of data organized in a manner that allows access, retrieval, and use of
that data
Emergency Assessment Life-threatening situations-ABC, suicidal thoughts, social conflict
leading to violent acts
Inference A logical interpretation based on prior knowledge and experience.
Initial assessment comprehensive nursing assessment resulting in baseline data that enables
the nurse to make a judgment about a patient's health status, ability to manage one's own health
care, and need for nursing, and to plan individualized, holistic health care for the patient
interview a meeting of people face to face, especially for consultation.
minimum data set a standard established by health care institutions that specifies the
information that must be collected from every patient
nursing history Identifies the patient's health status, strengths, health problems, health
risks, and need for nursing care.
objective data what the health professional observes by inspecting, palpating, percussing, and
auscultating during the physical examination
observation The act of noticing and describing events or processes in a careful, orderly way.
patient-centered assessment method (PCAM) a tool nurses can use to assess patient
complexity using the social determinants of health that often explain why some patients engage
and respond well in managing their health while others with similar health conditions do not
experience the same outcomes
physical assessment systematic examination of the patient for objective data to better define the
patient's condition and to help the nurse in planning care, usually performed in a head-to-toe
format; a collection of objective data about changes in the patient's body systems
Review of Systems (ROS) A systematic approach for collecting the patient's self-reported
data on all body systems.
subjective datainformation perceived only by the affected person
time lapse assessment Used to compare health data from the initial assessment. Typically used in
long term care patients.
validation act of confirming or verifying
collaborative problem Physiological complication that requires the nurse to use nursing- and
health care provider-prescribed interventions to maximize patient outcomes.
, data cluster a set of signs or symptoms gathered during assessment that you group together in
a logical way
diagnosing analysis of patient data to identify patient strengths and health problems that
independent nursing intervention can prevent or resolve
diagnostic error failure to detect an actual unhealthy behavior or condition
health problem condition related to health requiring intervention if disease or illness is to
be prevented or resolved and coping and wellness are to be promoted
medical diagnosis Identification of a disease condition based on specific evaluation of signs
and symptoms
Nursing Diagnosis used to evaluate the response of the whole person to actual or potential
health problems
nursing diagnosis used to evaluate the response of the whole person to actual or potential
health problems
problem-focused nursing diagnosis describes a clinical judgement concerning an undesirable
human response to a health condition/life process that exists in an individual, family, or
community
risk nursing diagnosis clinical judgment that a problem does not exist, but the presence of risk
factors indicates that a problem is likely to develop unless nurses intervene
standard exact, agreed-upon quantity used for comparison
syndrome A group of symptoms typical of a particular disease or condition
clinical pathways (critical pathways, CareMaps) case management tools used to
communicate the standardized, interdisciplinary plan of care for a particular group of patients;
care guidelines and outcomes are specified for each day of the patient's stay
collaborative interventions interdependent nursing actions performed jointly by nurses and
other members of the health care team
computerized plans of nursing care plan of patient care developed by computer software
programs that enable the nurse to call up screens listing causes, goals and related nursing
interventions for nursing diagnoses and medical diagnoses.
consultation process in which two or more individuals with varying degrees of experience and
expertise deliberate about a problem and its solution
criteria a principle or standard by which something may be judged or decided
discharge planning systematic process of preparing the patient to leave the health care facility
and for maintaining continuity of care
expected outcome specific, measurable criteria used to evaluate whether the patient goal has
been met
goal something you aim for that takes planning and work
initial planning planning that addresses each problem listed in the prioritized nursing
diagnoses and identifies appropriate patient goals and the related nursing care
nurse-initiated intervention independent nursing actions that involve carrying out nurse-
prescribed interventions written on the nursing plan of care, as well as any other actions that
nurses initiate without the direction or supervision of another health care professional and that
result from their assessment of patient needs
Nursing Interventions Classification (NIC) first comprehensive, validated list of nursing
interventions applicable to all settings that can be used by nurses in multiple specialties and
facilitates the work of identifying appropriate interventions
Assessing collecting, validating, and communicating patient data
Cue A signal for something to happen
Data Facts and statistics collected together for reference or analysis
Database A collection of data organized in a manner that allows access, retrieval, and use of
that data
Emergency Assessment Life-threatening situations-ABC, suicidal thoughts, social conflict
leading to violent acts
Inference A logical interpretation based on prior knowledge and experience.
Initial assessment comprehensive nursing assessment resulting in baseline data that enables
the nurse to make a judgment about a patient's health status, ability to manage one's own health
care, and need for nursing, and to plan individualized, holistic health care for the patient
interview a meeting of people face to face, especially for consultation.
minimum data set a standard established by health care institutions that specifies the
information that must be collected from every patient
nursing history Identifies the patient's health status, strengths, health problems, health
risks, and need for nursing care.
objective data what the health professional observes by inspecting, palpating, percussing, and
auscultating during the physical examination
observation The act of noticing and describing events or processes in a careful, orderly way.
patient-centered assessment method (PCAM) a tool nurses can use to assess patient
complexity using the social determinants of health that often explain why some patients engage
and respond well in managing their health while others with similar health conditions do not
experience the same outcomes
physical assessment systematic examination of the patient for objective data to better define the
patient's condition and to help the nurse in planning care, usually performed in a head-to-toe
format; a collection of objective data about changes in the patient's body systems
Review of Systems (ROS) A systematic approach for collecting the patient's self-reported
data on all body systems.
subjective datainformation perceived only by the affected person
time lapse assessment Used to compare health data from the initial assessment. Typically used in
long term care patients.
validation act of confirming or verifying
collaborative problem Physiological complication that requires the nurse to use nursing- and
health care provider-prescribed interventions to maximize patient outcomes.
, data cluster a set of signs or symptoms gathered during assessment that you group together in
a logical way
diagnosing analysis of patient data to identify patient strengths and health problems that
independent nursing intervention can prevent or resolve
diagnostic error failure to detect an actual unhealthy behavior or condition
health problem condition related to health requiring intervention if disease or illness is to
be prevented or resolved and coping and wellness are to be promoted
medical diagnosis Identification of a disease condition based on specific evaluation of signs
and symptoms
Nursing Diagnosis used to evaluate the response of the whole person to actual or potential
health problems
nursing diagnosis used to evaluate the response of the whole person to actual or potential
health problems
problem-focused nursing diagnosis describes a clinical judgement concerning an undesirable
human response to a health condition/life process that exists in an individual, family, or
community
risk nursing diagnosis clinical judgment that a problem does not exist, but the presence of risk
factors indicates that a problem is likely to develop unless nurses intervene
standard exact, agreed-upon quantity used for comparison
syndrome A group of symptoms typical of a particular disease or condition
clinical pathways (critical pathways, CareMaps) case management tools used to
communicate the standardized, interdisciplinary plan of care for a particular group of patients;
care guidelines and outcomes are specified for each day of the patient's stay
collaborative interventions interdependent nursing actions performed jointly by nurses and
other members of the health care team
computerized plans of nursing care plan of patient care developed by computer software
programs that enable the nurse to call up screens listing causes, goals and related nursing
interventions for nursing diagnoses and medical diagnoses.
consultation process in which two or more individuals with varying degrees of experience and
expertise deliberate about a problem and its solution
criteria a principle or standard by which something may be judged or decided
discharge planning systematic process of preparing the patient to leave the health care facility
and for maintaining continuity of care
expected outcome specific, measurable criteria used to evaluate whether the patient goal has
been met
goal something you aim for that takes planning and work
initial planning planning that addresses each problem listed in the prioritized nursing
diagnoses and identifies appropriate patient goals and the related nursing care
nurse-initiated intervention independent nursing actions that involve carrying out nurse-
prescribed interventions written on the nursing plan of care, as well as any other actions that
nurses initiate without the direction or supervision of another health care professional and that
result from their assessment of patient needs
Nursing Interventions Classification (NIC) first comprehensive, validated list of nursing
interventions applicable to all settings that can be used by nurses in multiple specialties and
facilitates the work of identifying appropriate interventions
