Ch 10-13 Nursing Process ADPIE

Question 1

assessing

Answer 1

• collect data
• organize data
• validate data
• document data

Question 2

diagnosing

Answer 2

• analyze data
• identify health problems, risks, and strengths
• formulate diagnostic statements

Question 3

planning

Answer 3

• prioritize problems/diagnoses
• formulate goals/desired outcomes
• select nursing interventions
• write nursing interventions

“SMART”

Question 4

implementing

Answer 4

• reassess the client
• determine the nurse’s need for assistance
• implement the nursing interventions
• supervise delegated care
• document nursing activities

Question 5

evaluating

Answer 5

• collect data related to outcomes
• compare data with outcomes
• relate nursing actions to client goals/outcomes
• draw conclusions about problem status
• continue, modify, or terminate the client’s care plan

Question 6

actual nursing diagnosis

Answer 6

describe response to condition

(Problem-Etiology-S/S)

anxiety r/t “etiology” AEB “s/s”

• label
• related to
• as evidence by (s/s)

Question 7

risk nursing diagnosis

Answer 7

describes response to health condition/life process that may develop

“risk for infection r/t ____(etiology)”

• label
• related to
• no Evidence by

Question 8

health promotion nursing diagnosis

Answer 8

desire to increase well-being, usually outside of the hospital

ex: person training for a marathon wants to know how to carb load

starts with “readiness or willingness”
- only has the label

Question 9

syndrome diagnosis

Answer 9

cluster of nursing diagnosis with similar interventions

ex: trauma

• only has the label

Question 10

how do the interventions relate to the actual/risk nursing diagnosis?

Answer 10

it is usually the opposite of the etiology “related to”

ex: risk for constipation r/t immobility & opioid intake

intervention will be to increase patients mobility & decrease opioid use
- get them in a chair
- use other pain medication to minimize opioids

Question 11

4 types of assessment

Answer 11

1. initial
2. problem-focused
3. emergency
4. time-lapsed

Question 12

prioritize needs from most important to least

Answer 12

1. critical needs
2. urgent needs
3. routine needs
4. extra
5. safety
6. physiological (if it compromise ABC, then it’s first)
7. psychological
8. health promotion

Question 13

What are the three parts of the NANDA nursing diagnosis?

Answer 13

1. problem statement/diagnostic label
2. etiology/probable cause
3. defining characteristics/signs and symptoms

Question 14

4 types of nursing diagnosis

Answer 14

1. actual
2. risk
3. health promotion
4. syndrome