ADPIE I Flashcards
A deliberate problem-solving approach for meeting people’s healthcare and nursing needs.
Nursing Process
These are the five key steps involved in the Nursing Process.
Evaluation
Implementation
Planning
Diagnosis
Assessment
These are the defining characteristics of the Nursing Process.
Confined to bed rest
Cyclic and dynamic
Planned
Uses problem-solving techniques
Client-centered
Provides the framework for care
The process of systematically collecting, organizing, validating, and documenting data to determine a patient’s health status and problems.
Assessment
These are the four types of assessment used in nursing practice.
Emergency Assessment
Episodic/Follow-up Assessment
Problem-based/Focused Assessment
Initial Comprehensive Assessment
A detailed history and physical examination performed at the onset of care in a primary care setting or upon hospital admission.
Initial Comprehensive Assessment
A history and physical examination limited to a specific problem or complaint (e.g., a sprained ankle).
Problem-based/Focused Assessment
An assessment performed when a patient follows up for a previously identified problem.
Episodic/Follow-up Assessment
An assessment done during a physiological or psychological crisis that requires immediate action.
Emergency Assessment
The process of gathering information about the client’s health status, which is essential for accurate diagnosis and intervention.
Data Collection
These are the three essential characteristics of data in nursing.
Relevant
Accurate
Complete
The main source of information about a patient’s health.
Primary Source of Data (Client)
Other sources of patient information, including family members, reports, test results, and medical records.
Secondary Sources of Data
Information that only the client can describe, such as pain, itching, and weakness.
Subjective Data
Information that can be observed or measured, such as blood pressure, redness, and cyanosis.
Objective Data
The three primary methods of data collection used in nursing practice.
Physical Assessment
Interview
Observation
The process of using senses (sight, hearing, touch, and smell) to gather data about a client’s health status.
Observation
A structured conversation used to collect subjective data about a client’s health history and concerns.
Interview
The examination of the client using techniques such as inspection, palpation, percussion, and auscultation.
Physical Assessment
The second step of the Nursing Process, which describes clinical judgments about individual, family, or community responses to health problems/life processes.
Diagnosis (Nursing Diagnosis)
These are the three components of a Nursing Diagnosis.
Signs and Symptoms
Etiology (Cause)
Problem
The diagnostic label that describes the client’s health problem or response.
Problem Component of Nursing Diagnosis
The identified cause or contributing factor of the health problem, written as “related to” in the diagnosis statement.
Etiology (Cause) Component of Nursing Diagnosis
The cluster of signs and symptoms that indicate the presence of a particular diagnosis, written as “as evidenced by” or “as manifested by.”
Signs and Symptoms Component of Nursing Diagnosis
The four types of Nursing Diagnoses.
Syndrome Diagnosis
Risk Diagnosis
Health Promotion Diagnosis
Actual Diagnosis
A problem that is present at the time of assessment, based on signs and symptoms.
Actual Diagnosis
A diagnosis that relates to the client’s readiness to improve their health condition and behaviors.
Health Promotion Diagnosis
A clinical judgment that a problem does not yet exist but may develop if no intervention is provided.
Risk Diagnosis
A diagnosis that represents a cluster of related problems that are expected to occur due to a certain situation or event.
Syndrome Diagnosis
The third step in the Nursing Process, where goals and interventions are planned.
Planning
These are the four main steps in the Planning phase of the Nursing Process.
Write nursing interventions
Select nursing interventions
Formulate goals/desired outcomes
Prioritize problems/diagnoses
The four key steps of the planning process in nursing care.
Writing individualized care plans
Selecting nursing interventions
Establishing client goals or desired outcomes
Setting priorities
Goals that are Specific, Measurable, Attainable, Relevant, and Time-Bound.
S.M.A.R.T Goals
The fourth step in the Nursing Process, where interventions are implemented.
Implementation
These are the five key steps in the Implementation phase of the Nursing Process.
Document nursing activities
Supervise delegated care
Implement nursing interventions
Determine the nurse’s need for assistance
Reassess the client
The three types of nursing interventions.
Collaborative
Dependent
Independent
Nursing actions that the nurse can perform autonomously without a physician’s order, such as patient education or repositioning.
Independent Intervention
Nursing actions that require a physician’s order, such as administering medications or inserting a catheter.
Dependent Intervention
Nursing actions that involve working with other healthcare professionals, such as physical therapy or dietary planning.
Collaborative Intervention
The final step of the Nursing Process, which evaluates whether client goals were achieved.
Evaluation
These are the five steps in the Evaluation phase of the Nursing Process.
Continue, modify, or terminate the care plan
Draw conclusions about problem status
Relate nursing actions to client goals/outcomes
Compare data with outcomes
Collect data related to outcomes
The three possible outcomes of an evaluation.
Unmet
Partially Met
Goal Met
The client has achieved the desired outcome completely.
Goal Met
The client has made some progress toward the goal but has not fully achieved it.
Partially Met
The client has not achieved the goal, and further intervention is needed.
Unmet
- A nurse is conducting an initial assessment for a newly admitted patient with diabetes. What type of assessment should the nurse perform?
a) Problem-based/Focused Assessment
b) Initial Comprehensive Assessment
c) Episodic/Follow-up Assessment
d) Emergency Assessment
b) Initial Comprehensive Assessment
- During an assessment, a patient states, “I feel weak all over and have a tingling sensation in my fingers.” How should the nurse classify this data?
a) Subjective Data
b) Objective Data
c) Primary Data
d) Secondary Data
a) Subjective Data
- A patient with hypertension visits the clinic for a routine blood pressure check-up. What type of assessment should the nurse conduct?
a) Problem-based/Focused Assessment
b) Initial Comprehensive Assessment
c) Episodic/Follow-up Assessment
d) Emergency Assessment
c) Episodic/Follow-up Assessment
- A nurse is gathering data from a patient’s family members, laboratory reports, and past medical records. What type of data source is the nurse using?
a) Primary Source
b) Secondary Source
c) Subjective Data
d) Objective Data
b) Secondary Source
- A patient arrives at the emergency department unconscious. Who should the nurse obtain health history information from?
a) The patient
b) The patient’s family or significant other
c) The patient’s medical records only
d) The attending physician
b) The patient’s family or significant other
- A nurse identifies that a patient has a high risk of developing pressure ulcers due to immobility. What type of nursing diagnosis should be made?
a) Actual Diagnosis
b) Health Promotion Diagnosis
c) Risk Diagnosis
d) Syndrome Diagnosis
c) Risk Diagnosis
- A patient with pneumonia reports difficulty breathing, has a respiratory rate of 28 breaths per minute, and has a low oxygen saturation level. How should the nurse phrase this nursing diagnosis?
a) Ineffective Airway Clearance related to excessive mucus secretion as evidenced by abnormal lung sounds and cough
b) Risk for Infection related to pneumonia as evidenced by increased white blood cell count
c) Ineffective Breathing Pattern related to increased mucus production as evidenced by tachypnea and low oxygen saturation
d) Impaired Gas Exchange related to lung infection as evidenced by fever and general malaise
c) Ineffective Breathing Pattern related to increased mucus production as evidenced by tachypnea and low oxygen saturation
- A nurse is caring for a patient who is eager to learn about dietary management for diabetes. What type of nursing diagnosis should the nurse assign?
a) Risk Diagnosis
b) Syndrome Diagnosis
c) Actual Diagnosis
d) Health Promotion Diagnosis
d) Health Promotion Diagnosis
- Which of the following statements correctly represents a complete nursing diagnosis?
a) Impaired Physical Mobility
b) Impaired Physical Mobility related to muscle weakness
c) Impaired Physical Mobility related to muscle weakness as evidenced by inability to move independently
d) Patient has difficulty walking due to weak muscles
c) Impaired Physical Mobility related to muscle weakness as evidenced by inability to move independently
- A patient with stroke is unable to perform daily activities such as dressing and eating. How should the nurse classify this diagnosis?
a) Health Promotion Diagnosis
b) Syndrome Diagnosis
c) Risk Diagnosis
d) Actual Diagnosis
d) Actual Diagnosis
- A patient with severe abdominal pain and a blood pressure of 90/60 mmHg arrives at the emergency department. According to Maslow’s Hierarchy of Needs, which intervention should the nurse prioritize?
a) Provide emotional support to reduce anxiety
b) Assist the patient with deep breathing exercises
c) Administer prescribed pain medication and fluids
d) Educate the patient about stress management
c) Administer prescribed pain medication and fluids
- A nurse is setting goals for a patient recovering from a stroke. Which of the following goals follows the S.M.A.R.T criteria?
a) The patient will improve mobility soon
b) The patient will walk independently
c) The patient will walk 10 feet using a walker within one week
d) The patient will try to move daily
c) The patient will walk 10 feet using a walker within one week
- A nurse is writing an individualized care plan for a patient with pneumonia. What should the nurse focus on?
a) Generalized interventions used for all patients with pneumonia
b) The patient’s specific needs, signs, and symptoms
c) The physician’s diagnosis and treatment plan only
d) The nurse’s past experiences with similar patients
b) The patient’s specific needs, signs, and symptoms
- A patient with diabetes is at risk for developing foot ulcers due to decreased sensation. Which of the following is an appropriate nursing goal?
a) The patient will prevent injury by inspecting feet daily for any cuts or wounds within the next month.
b) The nurse will check the patient’s feet at every visit.
c) The patient will take medications as prescribed.
d) The physician will order wound care treatment if an ulcer develops.
a) The patient will prevent injury by inspecting feet daily for any cuts or wounds within the next month.
A patient with a history of falls is admitted to the hospital. Which intervention should the nurse implement first?
a) Educate the patient on the importance of using the call light
b) Place the bed in the lowest position with side rails up
c) Obtain an order for a sedative to keep the patient calm
d) Place the patient’s walker at the foot of the bed
b) Place the bed in the lowest position with side rails up
- A nurse is assessing a patient who recently had a stroke and has difficulty swallowing. What is the most appropriate nursing diagnosis?
a) Risk for Aspiration related to impaired swallowing
b) Impaired Verbal Communication related to neurological deficits
c) Risk for Falls related to unsteady gait
d) Ineffective Breathing Pattern related to muscle weakness
a) Risk for Aspiration related to impaired swallowing
- A nurse is caring for a patient with heart failure who has 3+ pitting edema in both legs. What type of data is this?
a) Subjective Data
b) Objective Data
c) Secondary Data
d) Historical Data
b) Objective Data
- A nurse is prioritizing care for four patients. Which patient should the nurse assess first?
a) A patient who reports nausea after taking pain medication
b) A post-operative patient with a blood pressure of 80/50 mmHg
c) A patient who needs assistance ambulating to the restroom
d) A patient requesting discharge instructions
b) A post-operative patient with a blood pressure of 80/50 mmHg
- A nurse is developing a care plan for a patient who has difficulty managing their medications at home. What is the most appropriate nursing diagnosis?
a) Ineffective Health Maintenance related to lack of knowledge
b) Deficient Fluid Volume related to medication side effects
c) Risk for Aspiration related to swallowing difficulty
d) Impaired Mobility related to medication side effects
a) Ineffective Health Maintenance related to lack of knowledge
- A nurse is teaching a patient how to properly use an incentive spirometer after surgery. What type of nursing intervention is this?
a) Independent
b) Dependent
c) Collaborative
d) Diagnostic
a) Independent
- A patient with pneumonia is receiving oxygen therapy. Which intervention should the nurse implement to promote effective airway clearance?
a) Encourage deep breathing and coughing exercises
b) Increase oxygen levels without a physician’s order
c) Limit fluid intake to prevent congestion
d) Keep the patient in a supine position for comfort
a) Encourage deep breathing and coughing exercises
- A nurse is reviewing a patient’s lab results and notes an elevated white blood cell count. What should the nurse do next?
a) Notify the physician immediately
b) Reassess the patient for signs of infection
c) Document findings and continue monitoring
d) Administer antibiotics without an order
b) Reassess the patient for signs of infection
- A nurse is implementing a care plan for a patient at risk for skin breakdown. Which intervention is most appropriate?
a) Reposition the patient every two hours
b) Limit fluid intake to prevent incontinence
c) Keep the patient in one position for stability
d) Encourage the patient to ambulate without assistance
a) Reposition the patient every two hours
- A patient with a fever and chills is prescribed acetaminophen (Tylenol). What type of nursing intervention is administering the medication?
a) Independent
b) Dependent
c) Collaborative
d) Preventive
b) Dependent
- A nurse is reviewing a patient’s progress after implementing a fall prevention plan. The patient states, “I feel safer and haven’t fallen since the plan started.” How should the nurse document this evaluation?
a) Goal Met
b) Goal Partially Met
c) Goal Unmet
d) Intervention Not Effective
a) Goal Met
- A patient recovering from surgery is reluctant to get out of bed due to pain. What is the best intervention?
a) Encourage early ambulation with pain management
b) Allow the patient to rest in bed until they feel ready
c) Administer pain medication and reassess after 24 hours
d) Inform the patient that staying in bed will delay recovery
a) Encourage early ambulation with pain management
- A nurse is educating a patient about managing hypertension. What is an example of a collaborative intervention?
a) Encouraging the patient to take their medication
b) Working with a dietitian to create a low-sodium meal plan
c) Checking the patient’s blood pressure daily
d) Teaching relaxation techniques
b) Working with a dietitian to create a low-sodium meal plan
- A patient reports that they have not been taking their prescribed medications at home. What should the nurse do first?
a) Report the patient for noncompliance
b) Assess the patient’s understanding of the medication regimen
c) Tell the patient they must follow the doctor’s orders
d) Increase the medication dose to compensate
b) Assess the patient’s understanding of the medication regimen
- A nurse is preparing to administer IV antibiotics to a patient. What type of nursing intervention is this?
a) Independent
b) Dependent
c) Collaborative
d) Diagnostic
b) Dependent
- A patient has a nursing diagnosis of “Risk for Falls.” What would be an appropriate goal for this patient?
a) The patient will remain free from falls during hospitalization
b) The patient will use a walker at home
c) The patient will understand the risks of falling
d) The patient will request help when needed
a) The patient will remain free from falls during hospitalization
- A nurse evaluates a patient’s response to pain management interventions. The patient states that the pain is still at a level 7 out of 10. What should the nurse do next?
a) Continue with the current pain management plan
b) Notify the physician and suggest alternative pain management
c) Tell the patient to wait longer for the medication to work
d) Encourage the patient to ignore the pain
b) Notify the physician and suggest alternative pain management
- A patient is reluctant to participate in physical therapy after surgery. How should the nurse respond?
a) Explain the benefits of movement for recovery
b) Allow the patient to refuse therapy indefinitely
c) Tell the patient that physical therapy is mandatory
d) Discharge the patient from therapy
a) Explain the benefits of movement for recovery
- A nurse is evaluating a patient’s fluid balance. Which finding indicates dehydration?
a) Pale, moist skin
b) Blood pressure of 140/90 mmHg
c) Dark, concentrated urine
d) Weight gain of 2 kg in one day
c) Dark, concentrated urine
- A patient is admitted with a diagnosis of pneumonia. Which nursing diagnosis is the highest priority?
a) Ineffective Airway Clearance related to excessive mucus production
b) Risk for Imbalanced Nutrition related to loss of appetite
c) Activity Intolerance related to fatigue
d) Risk for Social Isolation related to hospitalization
a) Ineffective Airway Clearance related to excessive mucus production
- A nurse is providing discharge instructions to a patient with diabetes. Which statement by the patient indicates the need for further teaching?
a) “I will check my blood sugar levels regularly.”
b) “I should avoid walking barefoot to prevent injury.”
c) “I can eat anything I want as long as I take my insulin.”
d) “I will schedule regular checkups with my doctor.”
c) “I can eat anything I want as long as I take my insulin.”
- A patient recovering from surgery reports a pain level of 9/10. The nurse administers the prescribed pain medication. What should the nurse do next?
a) Document that the medication was given
b) Reassess the patient’s pain level after a set time
c) Encourage the patient to wait for the next dose
d) Tell the patient to relax and take deep breaths
b) Reassess the patient’s pain level after a set time
