02 Clinical Judgment and Nursing Care Planning Free Online FlashCards

What is clinical judgment in nursing?

Clinical judgment is reasoned decision-making that turns patient information into safe, timely care. It is a repeating process that changes as new findings or treatment responses emerge.

What should take priority over routine care?

Address immediate threats to life, such as airway, breathing, circulation, severe bleeding, or rapidly declining consciousness, before less urgent needs.

What does ADPIE stand for?

ADPIE stands for Assessment, Diagnosis/analysis, Planning, Implementation, and Evaluation.

What does SBAR stand for?

Situation, Background, Assessment, Recommendation/request.

What makes nursing documentation objective?

Document objective, specific observations and distinguish the patient’s statements from what you observe. Avoid vague or judgmental wording.

What does a patient handoff transfer?

A handoff transfers patient-specific information and responsibility to another caregiver, including what has changed, what has been done, and what remains to be done.

What are the six steps of clinical judgment?

Recognize cues, analyze cues, prioritize hypotheses, generate solutions, take action, and evaluate outcomes.

How should a nurse analyze patient cues?

Compare findings with the patient’s baseline and connect patterns, trends, or inconsistencies. Do not interpret one number in isolation.

When prioritizing, which patient generally comes first: unstable or stable?

A new, worsening, or unexpected change generally takes priority over a controlled, expected, or chronic problem.

What makes a nursing outcome measurable?

An outcome should be measurable and patient-centered, stating what will change and when—for example, a target pain level within a specified time after an intervention.

What does the evaluation step determine?

Evaluation compares the patient’s response with the expected outcome. Continue, modify, or report the plan as indicated; evaluation may reveal a need for more data or a different intervention.

How does closed-loop communication work?

The receiver repeats the key information, and the sender confirms or corrects it. This helps verify that critical instructions were understood.