FUNDAMENTALS SKILLS NR-224 QUESTIONS AND
ANSWERS/ A+ GRADE
Clinical Judgement
conclusion about a patients needs or health problems and/or the decision to take or
avoid action, use or modify standard approaches, or create new approaches based on
the patient's response
inductive reasoning
A type of logic in which generalizations are based on a large number of specific
observations to general
deductive reasoning
reasoning in which a conclusion is reached by stating a general principle and then
applying that principle to a specific case (The sun rises every morning; therefore, the
sun will rise on Tuesday morning.)
Clinical decision
separates professional nurses from assistive personal (AP). RNs:
>Observe
>Collects data
>Recognizes and identifies
>Takes action
Critical thinking and critical judgement skills (table)
Reflection mnemonic
Review your practice experiences to:
Describe
Analyze
Evaluate
Recall
Examine your responses
Feelings (acknowledge feelings)
Learn
Explore options
Create
Time (seta time for plan of care to be completed
Critical thinking
model
Nursing Process
The nursing process is a five-step clinical decision-making approach
ADPIE
Assess
Diagnosis
Planning
Evaluation
, Nursing Process chart
Assessment
Deliberate systematic collection of information about a patient
2 part
1.Collection of information
2.Interpretation of data
Why do we assess?
To establish a database about the patient's perceived needs, health problems, and
responses to these problems.
Types of Assesment
>Patient (interview, observation, physical examination)—the best source of information
subjective vs objective data
Subjective- What the patient tells you
Objective- what you detect during exam
Types of questions for data collection
Open-ended
•You want the patient to use their own words.
Back Channeling
•Use active listening and phrases such as:
•"all right," "go on," or "uh huh"
Probing
•Trying to get the patient to open up more by asking them "Is there anything else you
can tell me?"
Closed-ended
•One or two word answers
Nursing health history
Data documentation
-The last component of a complete assessment
-Legal and professional responsibility
-Requires accurate and approved terminology and abbreviations
Components of Nursing Diagnosis
Diagnostic Label:
Describes the patient's response to a health condition in as few words as possible
Related Factors:
The reason the patient is displaying the nursing diagnosis. It is not cause and effect. It
indicates etiology that contributes to the diagnosis.
PES format
the three essential components of nursing diagnostic statements including the terms
describing the problem, the etiology of the problem, and the defining characteristics or
cluster of signs and symptoms
PES Format
P= Problem, use NANDA-I label
E= Etiology or related factor
S= Symptoms or defining characteristics
Types of Nursing Diagnoses
ANSWERS/ A+ GRADE
Clinical Judgement
conclusion about a patients needs or health problems and/or the decision to take or
avoid action, use or modify standard approaches, or create new approaches based on
the patient's response
inductive reasoning
A type of logic in which generalizations are based on a large number of specific
observations to general
deductive reasoning
reasoning in which a conclusion is reached by stating a general principle and then
applying that principle to a specific case (The sun rises every morning; therefore, the
sun will rise on Tuesday morning.)
Clinical decision
separates professional nurses from assistive personal (AP). RNs:
>Observe
>Collects data
>Recognizes and identifies
>Takes action
Critical thinking and critical judgement skills (table)
Reflection mnemonic
Review your practice experiences to:
Describe
Analyze
Evaluate
Recall
Examine your responses
Feelings (acknowledge feelings)
Learn
Explore options
Create
Time (seta time for plan of care to be completed
Critical thinking
model
Nursing Process
The nursing process is a five-step clinical decision-making approach
ADPIE
Assess
Diagnosis
Planning
Evaluation
, Nursing Process chart
Assessment
Deliberate systematic collection of information about a patient
2 part
1.Collection of information
2.Interpretation of data
Why do we assess?
To establish a database about the patient's perceived needs, health problems, and
responses to these problems.
Types of Assesment
>Patient (interview, observation, physical examination)—the best source of information
subjective vs objective data
Subjective- What the patient tells you
Objective- what you detect during exam
Types of questions for data collection
Open-ended
•You want the patient to use their own words.
Back Channeling
•Use active listening and phrases such as:
•"all right," "go on," or "uh huh"
Probing
•Trying to get the patient to open up more by asking them "Is there anything else you
can tell me?"
Closed-ended
•One or two word answers
Nursing health history
Data documentation
-The last component of a complete assessment
-Legal and professional responsibility
-Requires accurate and approved terminology and abbreviations
Components of Nursing Diagnosis
Diagnostic Label:
Describes the patient's response to a health condition in as few words as possible
Related Factors:
The reason the patient is displaying the nursing diagnosis. It is not cause and effect. It
indicates etiology that contributes to the diagnosis.
PES format
the three essential components of nursing diagnostic statements including the terms
describing the problem, the etiology of the problem, and the defining characteristics or
cluster of signs and symptoms
PES Format
P= Problem, use NANDA-I label
E= Etiology or related factor
S= Symptoms or defining characteristics
Types of Nursing Diagnoses
