Final Exam- NUR 114 latest complete
update A+ graded
The Nursing Process - Assessment (collect, validate, organize, and record data)
Diagnosis (determine client's health need, NURSING DIAGNOSIS: e.g. risk for fall)
Planning (establish priorities, expected outcomes, select interventions, communicate
plan of care)
Implementation (ACTION PHASE: doing, delegating, documenting)
Evaluation (determine outcomes of treatment/interventions and modify care plan prn)
Nursing Care Plan - includes nursing diagnoses, goals and/or expected outcomes,
specific nursing interventions, and a section for evaluation findings so any nurse is able
to quickly identify a patient's clinical needs and situation.
Nursing Diagnosis - describes a health problem that can be treated by nursing
measures
SMART - Specific, Measurable, Attainable, Realistic, Timely:
when making a care plan
QSEN - Quality and Safety Education for Nurses:
Patient Centered Care.
Teamwork and Collaboration.
Evidence-Based Practice.
Quality Improvement.
Safety.
Informatics.
,Subjective v. Objective Data - Subjective: observation/data communicated to nurse but
not witnessed or measurable by nurse
Objective: observations/data the nurse can observe/measure (e.g. assessments, labs,
and diagnostic test results)
Primary v. Secondary Data - Primary: what the client states about their condition or
what the nurse observes (e.g. patients tells nurse they are in pain or nurse sees painful
grimacing of patient)
Secondary: another person reports to nurse or from medical record (e.g. another
caregiver tells nurse that a patient is in pain, or medical record lists chronic pain)
Directive v. Nondirective Interviewing - Directive: closed-ended question (yes or no
questions)
Indirective: open-ended questions (e.g. can you describe the quality of your pain?)
Health History - includes...
biographical data (name, age, etc.), chief complaint, history of present illness, client's
perception of health status/expectations, past health history, family health history,
psychosocial/social history, health assessment, medications, review of body systems
Florence Nightingale - Founder of modern nursing
- established standards for hospital and sanitary management, nursing education,
recognized health and illness as the two components of nursing, recognized nutrition is
important to health
Morals v. Ethics - Morals: private, personal, or group standards of right and wrong (e.g.
stealing is wrong)
Ethics: systemic study of right and wrong conduct (e.g. is it still wrong to steal food if the
person was starving?)
Values v. Beliefs - Values: worth of something, vary person to person
Beliefs: something that one accepts as true
Attitudes: feelings toward a person, thing, or idea
Autonomy - right to choose/self-determination
Nonmaleficence - do no harm
Beneficence - promote and do good
Fidelity - faithfulness; keep promises
, Veracity - tell the truth
Justice - be fair and equal to all
Altruism - concern for others' wellbeing
Human Dignity - respect of uniqueness of individuals or a population
Integrity - acting w/ ethics
Social Justice - upholding moral, legal, and humanistic principles
Federal Laws Guiding Nursing Practice - Bill of Rights
Emergency Medical Treatment and Active Labor Act
Americans With Disabilities Act
Patient Self-Determination Act
Health Insurance Portability and Accountability Act (HIPAA)
State Laws Guiding Nursing Practice - Mandatory Reporting Laws (communicable
disease/abuse)
Good Samaritan Laws (protect from liability)
Nurse Practice Acts (credentialing, licensing, discipline)
Standards of Practice/Care - what a reasonable and prudent nurse would do in a given
situation
- Nurse Practice Acts, Joint Commission, and American Nurse Association (ANA)
Intentional Torts - Assault and battery, false imprisonment, fraud, invasion of privacy,
defamation, slander, libel
Unintentional Torts - Malpractice, negligence
Culture - shared system of beliefs, values, and behavioral expectations; defines roles
and ininteractions with others, in families, and communities
Ethnicity v. Race - Ethnicity: groups who share social and cultural heritage
(language/beliefs)
Race: groups who have biological similarities (alaskan native, asian, african american,
pacific islander, white, etc.)
Religion - order system of beliefs regarding cause, nature, purpose of the universe
related to God/gods
update A+ graded
The Nursing Process - Assessment (collect, validate, organize, and record data)
Diagnosis (determine client's health need, NURSING DIAGNOSIS: e.g. risk for fall)
Planning (establish priorities, expected outcomes, select interventions, communicate
plan of care)
Implementation (ACTION PHASE: doing, delegating, documenting)
Evaluation (determine outcomes of treatment/interventions and modify care plan prn)
Nursing Care Plan - includes nursing diagnoses, goals and/or expected outcomes,
specific nursing interventions, and a section for evaluation findings so any nurse is able
to quickly identify a patient's clinical needs and situation.
Nursing Diagnosis - describes a health problem that can be treated by nursing
measures
SMART - Specific, Measurable, Attainable, Realistic, Timely:
when making a care plan
QSEN - Quality and Safety Education for Nurses:
Patient Centered Care.
Teamwork and Collaboration.
Evidence-Based Practice.
Quality Improvement.
Safety.
Informatics.
,Subjective v. Objective Data - Subjective: observation/data communicated to nurse but
not witnessed or measurable by nurse
Objective: observations/data the nurse can observe/measure (e.g. assessments, labs,
and diagnostic test results)
Primary v. Secondary Data - Primary: what the client states about their condition or
what the nurse observes (e.g. patients tells nurse they are in pain or nurse sees painful
grimacing of patient)
Secondary: another person reports to nurse or from medical record (e.g. another
caregiver tells nurse that a patient is in pain, or medical record lists chronic pain)
Directive v. Nondirective Interviewing - Directive: closed-ended question (yes or no
questions)
Indirective: open-ended questions (e.g. can you describe the quality of your pain?)
Health History - includes...
biographical data (name, age, etc.), chief complaint, history of present illness, client's
perception of health status/expectations, past health history, family health history,
psychosocial/social history, health assessment, medications, review of body systems
Florence Nightingale - Founder of modern nursing
- established standards for hospital and sanitary management, nursing education,
recognized health and illness as the two components of nursing, recognized nutrition is
important to health
Morals v. Ethics - Morals: private, personal, or group standards of right and wrong (e.g.
stealing is wrong)
Ethics: systemic study of right and wrong conduct (e.g. is it still wrong to steal food if the
person was starving?)
Values v. Beliefs - Values: worth of something, vary person to person
Beliefs: something that one accepts as true
Attitudes: feelings toward a person, thing, or idea
Autonomy - right to choose/self-determination
Nonmaleficence - do no harm
Beneficence - promote and do good
Fidelity - faithfulness; keep promises
, Veracity - tell the truth
Justice - be fair and equal to all
Altruism - concern for others' wellbeing
Human Dignity - respect of uniqueness of individuals or a population
Integrity - acting w/ ethics
Social Justice - upholding moral, legal, and humanistic principles
Federal Laws Guiding Nursing Practice - Bill of Rights
Emergency Medical Treatment and Active Labor Act
Americans With Disabilities Act
Patient Self-Determination Act
Health Insurance Portability and Accountability Act (HIPAA)
State Laws Guiding Nursing Practice - Mandatory Reporting Laws (communicable
disease/abuse)
Good Samaritan Laws (protect from liability)
Nurse Practice Acts (credentialing, licensing, discipline)
Standards of Practice/Care - what a reasonable and prudent nurse would do in a given
situation
- Nurse Practice Acts, Joint Commission, and American Nurse Association (ANA)
Intentional Torts - Assault and battery, false imprisonment, fraud, invasion of privacy,
defamation, slander, libel
Unintentional Torts - Malpractice, negligence
Culture - shared system of beliefs, values, and behavioral expectations; defines roles
and ininteractions with others, in families, and communities
Ethnicity v. Race - Ethnicity: groups who share social and cultural heritage
(language/beliefs)
Race: groups who have biological similarities (alaskan native, asian, african american,
pacific islander, white, etc.)
Religion - order system of beliefs regarding cause, nature, purpose of the universe
related to God/gods
