Clinical Judgment in Nursing - Unit 1

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Questions and Answers

Which of the following describes an aspect of evaluating nursing interventions?

  • Developing a new nursing care plan for each patient
  • Assessing a patient's vital signs to determine effectiveness (correct)
  • Ignoring patient feedback on treatment
  • Using subjective data exclusively for assessment

What is the most appropriate initial step in the nursing process?

  • Collect objective and subjective data (correct)
  • Determine the patient's understanding of their condition
  • Review the patient's family history
  • Implement nursing interventions immediately

Which type of immunity is characterized by the body building defenses after exposure to pathogens?

  • Acquired immunity (correct)
  • Autoimmune response
  • Innate immunity
  • Passive immunity

What should a nurse do first if nursing interventions were not effective?

<p>Evaluate the care plan and assessment data (C)</p> Signup and view all the answers

In which stage of infection do symptoms typically start to appear?

<p>Prodromal stage (B)</p> Signup and view all the answers

Which of the following is NOT a link in the chain of infection?

<p>Patient education (A)</p> Signup and view all the answers

Which assessment method would be most appropriate for validating patient data?

<p>Checking the electronic health records (D)</p> Signup and view all the answers

Which of the following describes a localized infection?

<p>Is restricted to a specific area of the body (D)</p> Signup and view all the answers

How should a nurse prioritize patient care when faced with competing needs?

<p>Using clinical judgment to evaluate which need is most critical (B)</p> Signup and view all the answers

Which of the following represents subjective data in patient assessment?

<p>Patient reports feeling dizzy (B)</p> Signup and view all the answers

Flashcards

Assessment

Involves collecting information about the patient, both what they say (subjective data) and what you observe (objective data). Helps build a picture of the patient's health.

Planning

Developing a plan of action tailored to the patient's needs, based on the assessment findings. Includes setting goals and choosing interventions.

Implementation

Putting the plan into action, performing the chosen interventions to help the patient achieve their goals.

Evaluation

Evaluating whether the plan is working and if the patient is making progress towards their goals.

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Innate Immunity

Innate immunity is the body's first line of defense, acting as a barrier against infection. Examples: skin, mucous membranes, cilia.

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Acquired Immunity

Acquired immunity develops over time as the body encounters and learns to fight specific pathogens through exposure or vaccinations. Examples: antibodies, T lymphocytes.

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Immune Response

A natural defense mechanism involving blood cells (leukocytes) that target specific pathogens. There are two types: humoral and cell-mediated.

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Aseptic Technique

Involves using sterile techniques to prevent the spread of infection, such as hand hygiene, wearing gloves, and disinfecting surfaces.

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Chain of Infection

The chain of infection refers to the six necessary links that must be present for an infection to occur. These links include the infectious agent, reservoir, portal of exit, mode of transmission, portal of entry, and susceptible host.

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Critical Pathways

They are specialized plans outlining care for specific conditions or patient needs. They provide standardized guidelines for interventions, promoting consistency and efficiency in care.

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Study Notes

Unit 1: Clinical Judgment

  • Learning Objectives: Describe how clinical judgment guides decision-making during the nursing process, and identify strategies for collecting valid assessment data.
  • Clinical Judgement and Nursing Process:
    • Steps in clinical judgment process: subjective and objective data, generate solutions, interventions
    • Importance of patient-centered care
    • Nursing process steps: assessment, diagnosis, planning, implementation, evaluation
  • Data Collection:
    • Methods of data collection by nurses
    • Validating data collection methods
  • Prioritizing Nursing Care:
    • Prioritizing patient care based on needs
    • Identifying patients needing immediate attention
    • Prioritization of nursing interventions
  • Planning Patient Care:
    • Methods of patient care planning
    • Use of clinical care plans, critical pathways, clinical judgment models to guide the development of nursing care plans
    • Specific assessments and interventions for patient plans
  • Evaluating Nursing Interventions:
    • Methods for evaluating intervention effectiveness
    • Actions if interventions are not effective
    • Determining if the patient understands instructions

Unit 2: Asepsis and Infection Control

  • Learning Objectives: Differentiate between the body's natural defenses, identify factors increasing infection risk, and compare types of infections.
  • Body's Natural Defenses:
    • Components of the body's three primary defenses against infection
    • Different types of immunity
  • Infection Risk Factors:
    • Factors increasing risk for infection development
  • Infection Stages:
    • Five stages of infection
    • Description of what happens in each infection stage
  • Types of Infections:
    • Comparing localized and systemic infections
  • Infection Classifications:
    • Different classifications of infection types
  • Chain of Infection:
    • Six links in the chain of infection
    • Nursing interventions to prevent infection spread
  • Infection Control Techniques:
    • Standard Precautions and Transmission-Based Precautions
    • Medical and Surgical Asepsis
    • Practicing medical and surgical asepsis
    • Identifying compromised sterility.
    • Emerging pathogens, infectious diseases, nurse's role
  • Signs and Symptoms of Infections
    • Differentiating between signs and symptoms of localized vs systemic infections
  • Medical Math:
    • Dosage calculation study guide (additional information).

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