N302 Chapter 2

Nurse practice acts

legal documents developed at the state level that define professional nursing's scope of practice and outline nurses' rights, responsibilities, and licensing requirements in providing care to individual clients, families, and communities.

Scope of practice

a broad term that refers ot the legal and sthical boundaries of practice for professional nurses established by each stateand defined in written state statutes.


providing only that information needed to provide care for the client to other health professionals directly involved in the care of the client.

Informed consent

giving the client enough information on which to base a knowledgeable decision. This is another legal aspect. For a legal consent to be valid, it must include these three things:1. consent must be voluntary2. the client must have full disclosure about hte risks, benefits, cost, potential side effects or adverse reactions, and otehr alternatives to treatment3. the client must have the capacity and competency to understand the information and to make an informed choice.

What is HIPAA?

Health Insurance Portability and Accountability Actimplemented in 2003. designed to protect the privacy of client records.

Advance directive

written statement or document executed by a competent adult that is designed to provide medical personnel, family members, and others with information as to hte person's wishes regarding the nature and extent of medical care to be provided in the future shoud he or she lose decision-making capacity.

Subjective data

refers to the client's perception of data and what the client says about the data.

Objective data

refers to data that are directly obseravable or verifiable through physical examination or tests.


educated guess about the meaning of a behavior or statement. To make it factual, check it with the client.

health care outcome

"the change in health status between a baseline time point and a final time point"should be client-centered and describe in specific, measureable terms.

Outcomes should be.....

based on diagnosesdocumented in measureable termsdeveloped collaboratively with the client an dother health providersrealistic and achievable

Independent nursing interventions

interventions that nurses can provide without a physicians order or direction form another health professional. --ex: health education, health promotion strategies, and counseling

dependent nursing interventions

require an oral or a written order from a physician to implement.

What is the NIC?

Nursing interventions classification

What is the NOC?

nursing outcomes classification

What are NNN terminologies?

NANDA, NIC, and NOC classifications

clinical pathways

represent a standardized, integrated multidisciplinary care plan, which includes the assessment and care given by all disciplines involved with a client's care.