Berman Links (part 2) Flashcards
Which of the following behaviors is most representative of the nursing diagnosis phase of the nursing process?
a. ) Identifying major problems or needs.
b. ) Organizing data in the client’s family history.
c. ) Establishing short-term and long-term goals.
d. ) Administering an antibiotic.
a.) Identifying major problems or needs.
Nursing Process: diagnosis
Identifying problems/needs is part of a nursing diagnosis. For example, a client with difficulty breathing would have Impaired Gas Exchange related to constricted airways as manifested by shortness of breath (dyspnea) as a nursing diagnosis. Organizing the family history is part of the assessment phase. Establishing goals is a part of the planning phase. Administering an antibiotic is part of the implementation phase.
Which of the following behaviors would indicate that the nurse was utilizing the assessment phase of the nursing process to provide nursing care?
a. ) Proposes hypotheses.
b. ) Generates desired outcomes.
c. ) Reviews results of laboratory tests.
d. ) Documents care.
c.) Reviews results of laboratory tests.
Nursing Process: Assessment
During assessment, data are collected, organized, validated, and documented. Hypotheses are generated during diagnosing; outcomes are set during planning; and documentation occurs throughout the nursing process.
Which of the following elements is best categorized as secondary subjective data?
a. ) The nurse measures a weight loss of 10 pounds since the last clinic visit.
b. ) Spouse states the client has lost all appetite.
c. ) The nurse palpates edema in lower extremities.
d. ) Client states severe pain when walking up stairs.
b.) Spouse states the client has lost all appetite.
Nursing Process: Assessment
Primary data come from the client (option 4), whereas secondary data come from any other source (chart, family). Subjective data are covert (reported or an opinion), whereas objective data can be measured or validated (weight—option 1, edema—option 3). If the spouse had stated that the client had eaten only toast and tea, this would be secondary objective (measured) data.
The nurse wishes to determine the client’s feelings about a recent diagnosis. Which interview question is most likely to elicit this information?
a. ) “What did the doctor tell you about your diagnosis?”
b. ) “Are you worried about how the diagnosis will affect you in the future?”
c. ) “Tell me about your reactions to the diagnosis.”
d. ) “How is your family responding to the diagnosis?”
c.) “Tell me about your reactions to the diagnosis.”
Nursing Process: assessment
Eliciting feelings requires an open-ended question that does more than seek factual information (option 1) and cannot be answered with a single word (option 2). The family can provide indirect information about the client, but is not most likely to provide the most accurate information (option 4).
The use of a conceptual or theoretical framework for collecting and organizing assessment data ensures which of the following?
a. ) Correlation of the data with other members of the health care team.
b. ) Demonstration of cost-effective care.
c. ) Utilization of creativity and intuition in creating a plan of care.
d. ) Collection of all necessary information for a thorough appraisal.
d.) Collection of all necessary information for a thorough appraisal.
Nursing Process: Assessment
Frameworks help the nurse be systematic in data collection. Other members of the health care team may use very different conceptual organizing frameworks so data may not correlate (option 1). Cost-effective care (option 2) is more likely to occur with systematic application of the Nursing Process, but use of a framework for assessment alone may not accomplish this goal. Because the framework is structured and because of the nature of client needs/problems, creativity and intuition in care planning are not assured (option 3).
Which of the following is the purpose of assessing?
a. ) Establish a database of client responses to their health status.
b. ) Identify client strengths and problems.
c. ) Develop an individualized plan of care.
d. ) Implement care, prevent illness, and promote wellness.
a.) Establish a database of client responses to their health status.
Nursing Process: assessment
Assessing provides a database of the client’s physiological and psychosocial responses to his or her health status. Client strengths and problems (option 2) are identified in the diagnosing phase of the nursing process, a care plan is established (option 3) in the planning phase, and care, prevention, and wellness promotion (option 4) are part of the implementing phase.
In the validating activity of the assessing phase of the nursing process, the nurse performs which of the following?
a. ) Collects subjective data.
b. ) Applies a framework to the collected data.
c. ) Confirms data is complete and accurate.
d. ) Records data in the client record.
c.) Confirms data is complete and accurate.
Nursing Process: assessment
In validating, the nurse confirms that data is complete and accurate. Subjective data is collected in the collecting activity (option 1), a framework is applied to the data in the organizing activity (option 2), and data is recorded in the documenting activity (option 4).
A major characteristic of the nursing process is which of the following?
a. ) A focus on client needs.
b. ) Its static nature.
c. ) An emphasis on physiology and illness.
d. ) Its exclusive use by and with nurses.
a.) A focus on client needs.
Nursing Process: assessment
The nursing process focuses on client needs. It is dynamic rather than static (option 2), emphasizes client responses rather than physiology and illness (option 3), and is collaborative rather than used exclusively by nurses (option 4).
Which of the following would be true regarding use of the observing method of data collection?
a. ) When observing, the nurse uses only the visual sense.
b. ) Observing is done only when no other nursing interventions are being performed at the same time.
c. ) Data should be gathered as it occurs, rather than in any particular order.
d. ) Observed data should be interpreted in relation to other sources of collected data.
d.) Observed data should be interpreted in relation to other sources of collected data.
Nursing process: assessment
Interpreting collected data is necessary to help validate its accuracy. Observing includes the senses of smell, hearing, and touch in addition to vision (option 1). Using priority setting, observing must often be performed simultaneously with other activities (option 2). A systematic approach to observing data helps ensure nothing is missed and the nurse pays attention to the most important data first (option 4).
Which of the following represent effective planning of the interview setting? Select all that apply.
a. ) Keep the lighting dimmed so as not to stress the client’s eyes.
b. ) Ensure that no one can overhear the interview conversation.
c. ) Stand near the client’s head while they are in the bed or chair.
d. ) Keep approximately 3 feet from the client during the interview.
e. ) Use a standard form to be sure all relevant data are covered in the interview.
b.) Ensure that no one can overhear the interview conversation.
Nursing Process: planning
The nurse plans the interview so that privacy is observed. A comfortable distance between nurse and client to respect the client’s personal space is about 3 feet. Using a standard form will help ensure the nurse doesn’t omit gathering any vital information. Lighting should be at a normal level—neither bright nor dim (option 1). The nurse should be at the same height as the client, usually sitting, at approximately a 45-degree angle facing the client. The nurse standing over the client creates an uncomfortable atmosphere for an interview (option 3).
