Assessment and Diagnosis

Question 1

Is a systematic, rational method of planning and providing individualized nursing care.

Answer 1

Nursing Process

Question 2

in the nursing process, the client may be a?

Answer 2

an individual, a family, a community, or a group.

Question 3

Enumerate the Purpose of the Nursing Process

Answer 3

To identify a client’s health status

To identify actual or potential health care problems or needs

To establish plans to meet the identified needs

To deliver specific nursing interventions to meet those needs.

Question 4

among the choices, which is not the purpose of the nursing process:

A. To identify a client’s health status

B. To identify actual or potential health care problems or needs

C. To establish rapport about the patient

D. To know the specific nursing interventions to meet those needs.

Answer 4

C

Question 5

enumerate the characteristics of the Nursing Process

Answer 5

1. Cyclic and dynamic nature
2. Client centeredness
3. Focus on problem solving
4. Decision making
5. Interpersonal and collaborative style
6. Universal applicability
7. Use of critical thinking
8. Use of clinical reasoning

Question 6

Characteristics of the Nursing Process where:
Data from each phase provide input into the next phase. Findings from the evaluation phase feed back into assessment. Hence, the nursing process is a regularly repeated event or sequence of events that is continuously changing rather than staying the same.

Answer 6

Cyclic and dynamic nature

Question 7

Characteristics of the Nursing Process where:
The nurse organizes the plan of care according to client problems rather than nursing goals.

Answer 7

Client Centeredness

Question 8

Characteristics of the Nursing Process where:
In the assessment phase, the nurse collects data to determine the client’s habits, routines, and needs, enabling the nurse to incorporate client routines into the care plan as much as possible.

Answer 8

Client Centeredness

Question 9

Characteristics of the Nursing Process where:
mental activity in which a problem is identified (unsteady state) and requires clarifying the nature of the problem and suggesting possible solutions.

Answer 9

Focus on Problem Solving

Question 10

Characteristics of the Nursing Process where:
Nurses can be highly creative in determining when and how to use data to make decisions.

Answer 10

Decision making

Question 11

Characteristics of the Nursing Process where:
It requires the nurse to communicate directly and consistently with clients and families to meet their needs. It also requires that nurses collaborate, as members of the health care team, in a joint effort to provide quality client care.

Answer 11

Interpersonal and collaborative style

Question 12

Characteristics of the Nursing Process where:
it is used as a framework for nursing care in all types of health care settings, with clients of all age groups.

Answer 12

Universal Applicability

Question 13

Characteristics of the Nursing Process where:
requires the nurse to think creatively, use reflection, and engage in analytical thinking

Answer 13

Use of Critical THinking

Question 14

Characteristics of the Nursing Process where:
By reflecting the nurse determines whether the outcome of care was appropriate.

Answer 14

use of clinical reasoning

Question 15

term “nursing process” was coined by ____ and ____ in _____

Answer 15

Lydia Hall and Dorothy Johnson in 1955

Question 16

were the first user with the series of phases describing the nursing process.

Answer 16

Orlando and Ernestein Weidenbach

Question 17

what year was the nursing process was formally introduced as a tool for nursing practice?

Answer 17

1967

Question 18

first to introduce the term nursing diagnosis.

Answer 18

Fry (1953)

Question 19

Is the first step in the nursing process.

Answer 19

Assessment

Question 20

Is the systematic & continuous collection, organization, validation and documentation of data or information

Answer 20

Assessment

Question 21

Is carried out during all phases of the nursing Process

Answer 21

Assessment

Question 22

Give the Four(4) type of assessment

Answer 22

Initial Assessment
Problem-focused assessment
Emergency assessment
Time-lapsed reassessment

Question 23

a type of assessment performed within a specified time after admission to healthcare facility

Answer 23

Initial Assessment

Question 24

type of assessment done to establish a complete database for problem identification, reference & future comparison.

Answer 24

Initial Assessment

Question 25

type of assessment performed to determine status of a specific problem identified in an earlier assessment

Answer 25

Problem-focused assessment

Question 26

type of assessment for the MIO

Answer 26

Problem-focused assessment

Question 27

assessment used to assess self-care ability (improved or worsened)

Answer 27

Problem-focused assessment

Question 28

assessment performed during physiologic or psychologic crisis of the client

Answer 28

Emergency assessment

Question 29

assessment used to identify life-threatening problems ,new or overlooked problems

Answer 29

emergency Assessment

Question 30

Assessment used for rapid assessment of client during a cardiac arrest

Answer 30

emergency assessment

Question 31

assessment done several months after initial assessment to compare the client’s status to baseline data previously obtained.

Answer 31

Time-lapsed reassessment

Question 32

used to assess Functional health patterns of client in a home or long term facility

Answer 32

Time=lapsed reassessment

Question 33

ASSESSMENT involves: (COVID)

Answer 33

C ollecting data. O rganizing data. V alidating data. I nterpreting data. D ocumenting data

Question 34

contains all the information about a client

Answer 34

Database

Question 35

fundamental data in which the nurse builds client care.

Answer 35

Database

Question 36

– referred to as the baseline information of the client

Answer 36

Database

Question 37

Collecting Data includes the ___, ___, ____, ____

Answer 37

1. nursing health history 2. physical examination 3. laboratory & diagnostic test results 4. material contributed by other health personnel

Question 38

types of Sources of data

Answer 38

Primary and secondary sources

Question 39

all but one is considered as the secondary source of data: Support people Health care providers The patient themselves Client records Relevant literature All sources other than the client

Answer 39

The patient themselves

Question 40

Also called signs or overt data. Observable and measurable data obtained through physical examination and laboratory and diagnostic testing.

Answer 40

Objective data

Question 40

Referred to as symptoms or covert data Data from client’s (and sometimes family’s) point of view. Includes feelings, perceptions, and concerns. Collected through interview.

Answer 40

Subjective data

Question 41

Methods of collecting data:

Answer 41

1. interview 2. observation 3. physical examination

Question 42

type of interview wherein the profile of the client/health history is created

Answer 42

initial formal interview

Question 43

type of interview informally taken during N-P interaction

Answer 43

on-going review

Question 44

Models or Frameworks used in Organizing Data

Answer 44

Gordon’s 11 Functional Health Pattern Framework Orem’s Self-care Model Roy’s Adaptation Model

Question 45

type of model where outlines the data to be collected classified the observable behavior into four categories: physiological, self-concept, role function, and interdependence

Answer 45

Roy’s Adaptation Model

Question 46

The model describes the client’s need for adequate nutrition, normal elimination, and adequate rest to promote normal human functioning and development.

Answer 46

Orem’s Self-care Model

Question 47

The eleven functional health patterns are health perception and management, nutritional, metabolic, elimination, activity, sleep, cognitive, self perception and concept, role relationship, sexuality, coping and stress, and value belief systems.

Answer 47

Gordon’s 11 Functional Health Pattern Framework

Question 48

Double-checking” or verifying data to confirm that it is accurate and factual

Answer 48

Validating Data

Question 49

Accurate and complete recording of assessment data is essential for communicating information to health care team.

Answer 49

Documenting data

Question 50

In this phase, nurses use critical thinking skills to interpret assessment data and identify client strengths and problems

Answer 50

Nursing diagnosis

Question 51

refers to the reasoning process

Answer 51

Diagnosing

Question 52

statement or conclusion regarding the nature of a phenomenon

Answer 52

Diagnosis

Question 53

standardized NANDA names for the diagnoses

Answer 53

Diagnostic labels

Question 54

causal relationship between the problem & its related or risk factors

Answer 54

Etiology

Question 55

A medical diagnosis is a ___________ by the physician that determines a specific disease, condition or pathological state.

Answer 55

clinical judgment

Question 56

T or F A nursing diagnosis is a clinical judgment about individual, family, or community responses to actual or potential health problems/life processes.

Answer 56

True

Question 57

NANDA meaning

Answer 57

North American Nursing Diagnosis Association (NANDA),

Question 58

what is the purpose of NANDA?

Answer 58

to define, refine, and promote a taxonomy of nursing diagnostic terminology of general use to professional nurses

Question 59

Types of Nursing Diagnoses

Answer 59

Actula diagnosis Risk diagnosis Wellness diagnosis

Question 60

type of nursing diagnosis that shows a a client problem at the time of assessment Ex. Ineffective Breathing Pattern and Anxiety

Answer 60

Actual diagnosis

Question 61

problem does not exist but the presence of risk factors indicates that a problem is likely to develop if unattended. Ex. Risk for Infection

Answer 61

Risk Diagnosis

Question 62

human responses to levels of wellness in an individual, family or community that have a readiness for enhancement . Ex. Readiness for Enhanced Nutrition

Answer 62

Wellness diagnosis

Question 63

Making a nursing diagnosis is the scientific identification of the client’s needs. It requires:

Answer 63

(1) use of judgment (2) identification of stresses in the external & internal environment (3) awareness of client’s reactions to stress

Question 64

Nursing Diagnosis is a _________ Statement

Answer 64

one-, two- or three-part

Question 66

Consists of a NANDA label only Ex. Ineffective airway clearance Acute pain Impaired skin integrity Fluid volume deficit Impaired Gas exchange Hyperthermia Sleep pattern disturbance

Answer 66

One part statement

Question 67

the related cause or primary factors contributing to the problem. relarionshio of problem and its related risk factors

Answer 67

Etiology

Question 68

Nursing Diagnosis where it hincludes first two parts of Two-Part Statement: the diagnostic label and the etiology.

Answer 68

Basic three-part statement (PES format)

Question 69

what statements are these? Ineffective Breathing Pattern related to pain Anxiety related to stress Acute Pain related to decreased myocardial flow Impaired Skin Integrity related to pressure over bony prominence

Answer 69

Two-part statement (PE format)

Question 70

Characteristics of a Nursing Diagnosis

Answer 70

Clear & concise statement Specificity Patient-centered data Accuracy No inclusion of medical data No inclusion of value judgment Supported by S/S within the database that reflect at least the major defining characteristics of that diagnosis