ATI - Chapter 7

Question 1

The nursing process is a cyclical, critical thinking process that consists of ____ steps to follow in a purposeful, goal directed, systematic way to achieve optimal client outcomes.

Answer 1

5

Question 2

The nursing process is a variation of scientific reasoning that helps nurses organize nursing care and ____ the optimal available evidence to care care delivery.

Answer 2

apply

Question 3

The ____ is a dynamic, continuous, client-centered, problem-solving, and decision-making framework that is foundational to nursing practice.

Answer 3

nursing process

Question 4

The nursing process provides a framework throughout which nurses can apply knowledge, experience, judgement, and skills, as well as ______ of nursing practice to the formulation of a plan of nursing care.

Answer 4

established standards

Question 5

The nursing process helps nurses integrate critical thinking creatively to base ______ on reason.

Answer 5

nursing judgements

Question 6

The nursing process promotes the _____ of nursing while differentiating the practice of nursing from the practice of medicine and that of other health care professionals.

Answer 6

professionalism

Question 7

The nursing process includes sequential but overlapping steps (5)

Answer 7

assessment/data collection
analysis/data collection
planning
implementation
evaluation

Question 8

The accuracy and _____ of assessment/analysis/data/collection and planning have a direct impact on implementation and evaluation

Answer 8

throroughness

Question 9

Use of the nursing process results in a comprehensive, individualized, client-centered plan of nursing care that nurses can deliver in a ______ and reasonable manner.

Answer 9

timely

Question 10

_______ collection involves the systematic collection of information about clients’ present health status to identify needs and additional data to collect based on findings.

Answer 10

assessment/data collection

Question 11

Nurses can collect data during an initial assessment (_______), focused assessment, and ongoing assessments.

Answer 11

baseline data

Question 12

Methods of data collection include observation, __________, medical history, comprehensive or focused physical exams, diagnostic and laboratory reports, and collaboration with other members of the health care team.

Answer 12

interviews with clients and families

Question 13

To collect data effectively, nurses must ask clients appropriate questions, listen carefully to responses, and have excellent _______ skills.

Answer 13

head to toe physical assessment

Question 14

Nurses also must employ clinical judgment and critical thinking in accurately ______ when to collect assessment data. They also must recognize the need to collect assessment data prior to interventions.

Answer 14

recognizing

Question 15

Nurses collect ______ during a nursing history. They include clients’ feelings, perceptions, and descriptions of health status. Clients are the only one who can describe and _____ their own symptoms.

Answer 15

subjective data

verify

Question 16

Nurses observe and measure objective data (signs) during a physical exam. They feel, see, hear, and ____ objective data through observation or physical assessment of the client.

Answer 16

smell

Question 17

During this assessment/data collection, the nurse validates, interprets, and ______.

Answer 17

clusters data

Question 18

Documentation of the assessment data must be thorough, concise, and ____.

Answer 18

accurate

Question 19

My shoulder is really sore.

subjective or objective

Answer 19

subjective

Question 20

The client grimaces when attempting to brush her hair with her left arm.
subjective or objective

Answer 20

objective observation

Question 21

Analysis/data collection requires nurses to look at the data and recognize _______.

Answer 21

patterns or trends

Question 22

Analysis/data collection requires nurses to compare the data with expected standards or ____. Arrive at conclusions to guide nursing care.

Answer 22

reference ranges

Question 23

RNs make multiple analyses based on their interpertations of collected data. They decide, using reasoning and judgement, which data account for clients’ health status or ______.

Answer 23

problems

Question 24

When planning client care or contributing to a client’s plan of care, nurses must establish ______ and optimal outcomes of care they can readily measure and evaluate.

Answer 24

priorities

Question 25

The established priorities and outcomes of client care then direct nurses in selecting interventions to include in a plan of care to promote, _____, or restore health.

Answer 25

maintain

Question 26

Nurses do three types of planning. Initially they develop a ______ plan of care for clients based on comprehensive assessments they complete, for example, on admission to health care facility or to a home health organization.

Answer 26

comprehensive

Question 27

Nurses do ____ planning through the provision of care. While obtaining new info and evaluating responses to care, they modify and individualize the initial plan.

Answer 27

ongoing

Question 28

____ planning is a process of anticipating and planning for clients’ needs after discharge. To be effective, discharge planning must begin during admission.

Answer 28

discharge

Question 29

Throughout the planning process , nurses set priorities, determine client outcomes, and select specific nursing _____.

Answer 29

interventions

Question 30

Nurses participate in priority setting when thyey identify a preferential order of problems. This guides the delivery of nursing care. They can use guidelines to set priorities, such as _______.

Answer 30

Maslow’s hierarchy of basic needs.

Question 31

Nurses work with clients to identify _____, where as outcomes identify the observable criterion that will determine success or failure of the goal.

Answer 31

goals

Question 32

The goal must be ______, singular, observable, measurable, time-limited, mutually agreeable, and reasonable.

Answer 32

client-centered

Question 33

Concise, ______ goals helps nurses and clients evaluate progress through both short and long term goals to guide the client toward the ______ and determine the effectiveness of nursing care.

Answer 33

measurable

planned outcome

Question 34

________ interventions are when nurses use evident and scientific rationale to take autonomous actions to benefit clients. They base these actions on identified problems and health care needs, and make sure they are within their scope of practice. Nurses perform or delegate the interventions and are accountable for them.

Answer 34

nurse initated/independent interventions

Question 35

__________ are interventions nurses initiate as a result of a provider’s prescription or the facility’s protocol, such as blood administration procedures.

Answer 35

provider-initiated/dependent interventions

Question 36

______ interventions are carried out by nurses in collaboration with other health care team professionals.

Answer 36

collaborative interventions

Question 37

The _____ is the end product of the planning step. Nurses organize the ____ for quick identification of problems, outcomes, and interventions to implement.

Answer 37

Nursing Care Plane

NCP

Question 38

During implementation the nursing process, nurses base the care they provide on assessment data, analyses, and the plan of care they developed in the previous steps of the _____.

Answer 38

nursing process

Question 39

During implementation, they must use problem-solving, clinical judgment, and critical thinking to select and implement appropriate _______ using nursing knowledge, priorities of care, and planned goals or outcomes to promote, maintain or restore health.

Answer 39

therapeutic interventions

Question 40

Therapeutic interventions also include measures nurses take to minimize risk, such as wearing personal protective equipment. Nurses intervene to respond to unplanned events, a change in status, or the ______ of a life threatening situation.

Answer 40

emergence

Question 41

Nurses use evidence-based rationale for the selection and implementation of all _____. Caring and professional behavior should be at the center of all therapeutic nursing interventions

Answer 41

therapeutic interventions

Question 42

During implementation, nurses perform nursing actions, delegate tasks, supervise otehr health care staff, and document the care and _____.

Answer 42

client’s responses

Question 43

During the evaluation stage, nurses evaluate clients’ responses to nursing interventions and form a clinical judgment about the extent to which clients have met the ______ and outcomes.

Answer 43

goals

Question 44

Nurses continuously evaluate the client’s progress toward outcomes, and use the client data to determine whether or not to _____ the plan of care.

Answer 44

modify

Question 45

Nurses determine the ________ of the nursing care plan. They collect data based on the outcome criteria then compare what actually happened with the planned outcomes. This helps determine what further actions to take.

Answer 45

effectiveness

Question 46

Factors That can lead to lack of goal achievement

Answer 46

an incomplete database
unrealistic client outcomes
nonspecific nursing interventions
inadequate time for the client to achieve the outcomes

Question 47

Client outcomes in specific, measurable terms are easier to ____.

Answer 47

evaluate