Ch. 5

Question 1

What is the purpose of the nursing process?

Answer 1

Organizing the ways nurses think about patient care

Question 2

A patient comes to the ER complaining about nausea and vomiting. What should the nurse ask the patient about first?

Answer 2

Severity and duration of the nausea and vomiting

Question 3

An alert, oriented patient is admitted to the hospital with chest pain. Who is the best source of primary data on this patient?

Answer 3

The patient

Question 4

What is the primary reason of the nursing diagnosis?

Answer 4

Communicating patient needs

Question 5

On what premise is a nursing diagnosis identified for a patient?

Answer 5

Clustered data

Question 6

Which statement is an appropriately written short-term goal?

Answer 6

Patient will walk to the bathroom independently without falling within 2 days after surgery

Question 7

What should be the primary focus for nursing interventions?

Answer 7

Patient needs

Question 8

Which nursing action is critical before delegating interventions to another member of the health care team?

Answer 8

Know the scope of practice for the other team member

Question 9

A patient reports feeling tired and complains of not sleeping at night. What action should the nurse perform first?

Answer 9

Identify reasons the patient is unable to sleep

Question 10

What action should the nurse take regarding a patients plan of care if the patient appears to have met the short-term goal of urinating within 1 hour after surgery?

Answer 10

Monitor patient urine output to evaluate the need for the current plan of care

Question 11

Define the nursing process

Answer 11

The nursing process is the scientific method through which professional nurses systematically identify and address actual or potential patient problems.

Question 12

Critical thinking and the nursing process

Answer 12

allows nurses to collect essential patient data, articulate the specific needs of individual patients, and effectively communicate those needs of individual patients, and effectively communicate those needs, establish realistic goals and customize interventions with members of the health care team

Question 13

Describe the historical development of the nursing process

Answer 13

The nursing process was clearly identified in the 1960s, and have remained unchanged since then - only added outcome identification in the 1990s

Question 14

significance of the nursing process

Answer 14

Professional nursing practice in all types of settings is based on nursing process
Used to assess individuals, families and communities; diagnose needs; plan attainable goals; implement specific interventions; evaluate degrees of goal attainment

Question 15

Articulate the characteristics of the nursing process

Answer 15

Requires nurses to think critically.

It is dynamic, organized and collaborative, and universally adaptable to various types of health care settings.

Question 16

Assessment

Answer 16

Patient care data are gathered

Question 17

Diagnosis

Answer 17

Patient data are analyzed to identify patient problems and then stated as specific nursing diagnoses

Question 18

Planning

Answer 18

The nurse prioritizes the nursing diagnoses and identifies goals with specific outcome identification

Question 19

Implementation

Answer 19

Initiating specific nursing interventions designed to help achieve established goals

Question 20

Evaluation

Answer 20

The nurse determines goal attainment, the effectiveness of interventions and whether the plan of care should be discontinued, continued, or revised

Question 21

Explain the significance of the cyclic and dynamic nature of the nursing process

Answer 21

Requires professional nurse to continuously reassess patients, revise care as needed, and evaluate whether goals are being met.
As goals are met, portions of the nursing plan can be eliminated or discontinued.
Nursing care sometimes needs to be modified to meet previously unidentifiable needs.
The ongoing process of evaluating and adjusting intervention strategies requires nursing care that is based on current EBP

Question 22

Thinking like a nurse

Answer 22

Facilitated by nurses using the nursing process in the development of individualized patient plans of care.

Question 23

Analytical

Answer 23

Is the data collection thorough and accurate?
Are outcomes specific and realistic for the individual patient?
Have all of the underlying factors contributing to the patients response to illness been adequately addressed in the plan of care?
Could any of the nursing interventions have a negative impact on the patient?
Does each intervention provide for patient-centered care and the safety of the patient?
Are there new data that necessitate modification of the existing plan of care?

Question 24

The nursing process is cyclic

Answer 24

As an individual patients condition changes, so does the way a professional nurse thinks about the patients needs, forcing modification of earlier plans of care

Question 25

Data collection

Answer 25

- primary data
   \+ patient interview
- secondary data
- subjective data
   \+ symptoms
   \+ health history
- objective data
   \+ signs
   \+ physical examination
   \+ lab results
   \+ diagnostic test results

Question 26

Types of nursing diagnoses

Answer 26

• actual
• risk
• health-promotion

Question 27

Prioritize nursing diagnoses

Answer 27

• personalize care plans
  + short-term goals
  + long-term goals
  + outcome identification

Question 28

Interventions

Answer 28

• independent
• dependent
• collaborative care
• direct
• indirect

Question 29

Documentation (NIC)

Answer 29

• care plans
  + clinical pathways
  + protocols
  + standing orders

Question 30

Care plan evaluation

Answer 30

• patient goal/outcome attainment?
• continue?
• revise/adapt?
• discontinue?

Question 31

Collaborative

Answer 31

Collaboration among several members of the health care team is often required to adequately address patient needs

Question 32

Adaptable

Answer 32

Developing plans of care for individuals who are hospitalized or are receiving care in an outpatient, long-term care, or home setting
Useful for addressing needs of a specific population (childhood obesity)

Question 33

NANDA-I

Answer 33

Professional nursing org that provides standardized language to identify patient problems and plan customized care

Question 34

Medical diagnoses

Answer 34

Labels for diseases

Question 35

Nursing diagnoses

Answer 35

Describe a response to an actual or potential problem or life process

Question 36

Actual nursing diagnoses

Answer 36

1) patients identified need or problem
2) etiology or underlying cause
3) signs and symptoms or manifestations

Question 37

Risk nursing diagnoses

Answer 37

1) patients identified need or problem

2) factors indicating vulnerability (risk factors)

Question 38

Health-promotion nursing diagnoses

Answer 38

1) nursing diagnostic label

2) defining characteristics

Question 39

Clinical pathways, protocols, standing orders

Answer 39

Impact interventions carried out in the implementation phase of the nursing process

Question 40

Clinical pathways

Answer 40

Care pathways, care maps, critical pathways

Multidisciplinary resources designed to guide patient care

Question 41

Protocols

Answer 41

Written plans that can be generalized to groups of patients with the same or similar clinical needs that do not require a physicians order

Question 42

Standing orders

Answer 42

Written by physicians and list specific actions to be taken by a nurse or other health care provider when access to a physician is not possible
(Chest pain, or after a colonoscopy.)

Question 43

Ethical, legal, and professional practice

Answer 43

• all health care pros are required to document patient interventions they implement in a traditional or EMR
• nurses must document the physical treatment and patient education that is provided
• follow-up evals of interventions must be documented to help health care team determine the effectiveness fo treatments, activities and prescribed meds
• only document interventions that the nurse themselves implemented