Podcast
Questions and Answers
Which type of question gives the client less opportunity to decide whether the answer is true or not?
Which type of question gives the client less opportunity to decide whether the answer is true or not?
Why should nurses avoid asking 'Why' questions?
Why should nurses avoid asking 'Why' questions?
During which phase of an interview does the client communicate what he/she thinks, feels, knows, and perceives?
During which phase of an interview does the client communicate what he/she thinks, feels, knows, and perceives?
Which technique is NOT used to conduct a physical examination?
Which technique is NOT used to conduct a physical examination?
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What is the purpose of the closing phase of an interview in nursing?
What is the purpose of the closing phase of an interview in nursing?
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When may the use of probing and direct questioning be appropriate during an interview?
When may the use of probing and direct questioning be appropriate during an interview?
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What is the main method used in physical assessment?
What is the main method used in physical assessment?
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In data collection methods, which aspect is considered most important when observing?
In data collection methods, which aspect is considered most important when observing?
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What is the purpose of a focused interview in nursing practice?
What is the purpose of a focused interview in nursing practice?
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When is interviewing mainly used in the nursing process?
When is interviewing mainly used in the nursing process?
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Which source provides additional information regarding standards, cultural practices, and assessment data for specific client conditions?
Which source provides additional information regarding standards, cultural practices, and assessment data for specific client conditions?
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During the nursing process, what occurs whenever the nurse is in contact with the client or support persons?
During the nursing process, what occurs whenever the nurse is in contact with the client or support persons?
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What is the main purpose of the phase 'Implementing' in the nursing process?
What is the main purpose of the phase 'Implementing' in the nursing process?
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What is the primary purpose of the 'Evaluating' phase in the nursing process?
What is the primary purpose of the 'Evaluating' phase in the nursing process?
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In the nursing process, what does the 'Diagnosing' phase primarily involve?
In the nursing process, what does the 'Diagnosing' phase primarily involve?
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What is the purpose of the 'Assessing' phase in the nursing process?
What is the purpose of the 'Assessing' phase in the nursing process?
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During which type of assessment is the main purpose to identify new or overlooked problems?
During which type of assessment is the main purpose to identify new or overlooked problems?
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What is the goal of the 'Diagnosing' phase in the nursing process?
What is the goal of the 'Diagnosing' phase in the nursing process?
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Which action is NOT typically associated with the 'Implementing' phase in the nursing process?
Which action is NOT typically associated with the 'Implementing' phase in the nursing process?
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'Analyzing and synthesizing data' is a key activity in which phase of the nursing process?
'Analyzing and synthesizing data' is a key activity in which phase of the nursing process?
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'Selecting nursing strategies/interventions' is a primary activity in which phase of the nursing process?
'Selecting nursing strategies/interventions' is a primary activity in which phase of the nursing process?
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'Measuring the degree goals/outcomes have been achieved' is a primary focus in which phase of the nursing process?
'Measuring the degree goals/outcomes have been achieved' is a primary focus in which phase of the nursing process?
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Study Notes
Sources of Data
- Client records, including demographic profiles, medical records, and laboratory records
- Healthcare professionals, such as nurses, social workers, primary care providers, and physiotherapists
- Literature, which provides additional information on standards, cultural and social health practices, spiritual beliefs, and assessment data
Data Collection Methods
- Observing, which occurs whenever the nurse is in contact with the client or support persons
- Interviewing, used mainly when taking the nursing health history, and includes focused interviews to collect specific information
- Examining, a major method used in physical assessment, which involves observing, inspecting, auscultating, palpating, and percussing
Interviewing
- A planned communication with a purpose, used to collect information related to the client's problem
- Anchored on the belief that well-reasoned thinking will lead to trustworthy conclusions
- Curiosity, setting priorities, and developing rationales are essential components of clinical reasoning
Clinical Reasoning
- Developing rationales, which explains priority setting and nursing interventions
- Acts as a check for potential errors, justifies nursing actions, and contributes to client safety
- Learning how to act, which involves understanding relevant medical and nursing information and translating it into a plan of care
- Clinical reasoning in transition, which involves recognizing changes in the client's condition over time
Nursing Process
- Collecting, organizing, validating, and documenting client data to establish a database about the client's response to health concerns or illnesses
- Diagnosing, which involves analyzing and synthesizing data to identify client strengths and health problems
- Planning, which involves developing an individualized care plan that specifies client goals and related nursing interventions
- Implementing, which involves carrying out planned nursing interventions to assist the client in meeting desired goals
- Evaluating, which involves measuring the degree to which goals have been achieved and identifying factors that positively or negatively influence goal achievement
Phases of the Nursing Process
- Assessing, which involves collecting, organizing, validating, and documenting client data
- Diagnosing, which involves analyzing and synthesizing data to identify client strengths and health problems
- Planning, which involves developing an individualized care plan that specifies client goals and related nursing interventions
- Implementing, which involves carrying out planned nursing interventions to assist the client in meeting desired goals
- Evaluating, which involves measuring the degree to which goals have been achieved and identifying factors that positively or negatively influence goal achievement
Types of Assessment
- Initial assessment, which is performed within a specified time after admission to a healthcare agency
- Problem-focused assessment, which is an ongoing process integrated with nursing care
- Emergency assessment, which is done during any physiological or psychological crisis of the client
- Time-lapsed assessment, which is done several months after initial assessment
Nurse's Role in Health Assessment
- The goal of medical practice is to diagnose and treat disease, whereas the nurse's role is to identify client strengths and health problems
Planning the Interview
- Setting, including time, place, seating arrangement, and distance
- Language, including open-ended and closed questions
- Avoiding leading questions, as they can create problems if the client gives inaccurate answers
Stages of an Interview
- Opening, which involves establishing rapport and orientation
- Body, which involves the client communicating what they think, feel, know, and perceive in response to questions from the nurse
- Closing, which involves offering to answer questions, concluding, providing a summary, and thanking the client
Examining
- Physical examination or physical assessment, which involves systematic data collection using observation to detect health problems
- Techniques used in examination include inspection, auscultation, palpation, and percussion
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Description
Explore the key components of clinical reasoning in nursing, including examining traditions, setting priorities, developing rationales, and learning how to act based on well-reasoned thinking. Understand the importance of trustworthy conclusions and client safety.
