Ch.2 Nursing Process

Question 1

The _____________ is an organized sequence of problem-solving steps used by nurses to identify and manage the health problems of clients.

Answer 1

Nursing Process

Question 2

The first step in the nursing process, known as _____________, is the systematic collection of facts or data.

Answer 2

Assessment

Question 3

The assessment of pitting edema in a client’s leg is an example of _____________ data.

Answer 3

Objective

Question 4

The assessment of pitting edema in a client’s leg is an example of _____________ data.

Answer 4

Client

Question 5

A nurse who administers medications according to the plan of care is carrying out the _____________ step of the nursing process.

Answer 5

Implementation

Question 6

A(n) _____________ assessment contains information that provides more details about specific problems and expands the original database.

Answer 6

Focus

Question 7

A(n) _____________ results from analyzing the collected data and determining whether they suggest normal or abnormal findings.

Answer 7

Diagnosis

Question 8

A client complaint of stomach pain is considered _____________ data.

Answer 8

Subjective

Question 9

Problems interfering with the _____________ needs of a client have priority over those affecting other levels of needs.

Answer 9

Physiologic

Question 10

_____________ problems are physiologic complications that require both nurse- and physician-prescribed interventions.

Answer 10

Collaborative

Question 11

List the steps of the nursing process.

Answer 11

Assessment 
Diagnosis 
Planning 
Implementation 
Evaluation

Question 12

What are collaborative problems?

Answer 12

Collaborative problems are those potential complications from a disorder, test, or treatment that the nurse cannot treat independently, for example, hemorrhage. They represent an interdependent domain of nursing practice.

Question 13

What is the role of nurses in managing collaborative problems?

Answer 13

The role of the nurse is to monitor to detect the complication(s) and, if detected, manage the complication cooperatively with nurse- and physician-prescribed interventions.
The nurse is specifically responsible and accountable for the following: Correlating medical diagnoses or medical treatment measures with the risk for unique complications Documenting complications for which clients are at risk Making pertinent assessments to detect complications Reporting trends that suggest development of complications
Managing the emerging problem with nurse- and physician-prescribed measures Evaluating the outcomes

Question 14

Systematic collection of facts or data

Answer 14

Assessment

Question 15

Identification of health-related problems

Answer 15

Diagnosis

Question 16

Process of prioritizing nursing diagnoses and collaborative problems

Answer 16

Planning

Question 17

Process of carrying out the plan of care

Answer 17

Implementation

Question 18

Presented here, in random order, are the steps of the nursing process. Write the correct sequence in the boxes provided below.

1. Implementation
2. Planning
3. Evaluation
4. Assessment
5. Diagnosis

Answer 18

4. Assessment
5. Diagnosis
6. Planning
7. Implementation
8. Evaluation

Question 19

What is meant by the nursing process?

Answer 19

The nursing process is an organized sequence of problem-solving steps used to identify and manage the health problems of clients. The nursing process is the very infrastructure of nursing practice in all health care settings. When nursing practice follows the nursing process, clients receive quality care in minimal time with maximal efficiency. In addition, the nursing process serves as a framework for nursing documentation in medical records, and when medical records are subpoenaed for court cases, the steps in the nursing process are the basis for determining whether standards of care have been met.

Question 20

What are the characteristics of the nursing process?

Answer 20

The nursing process has seven distinct characteristics:

Within the legal scope of nursing 
Based on knowledge 
Planned 
Client centered 
Goal directed 
Prioritized 
Dynamic

Question 21

What are the three types of assessments?

Answer 21

There are three types of assessments:

Database assessment: initial information about the client’s physical, emotional, social, and spiritual health obtained during the admission interview and physical examination.

Focus assessment: the information that provides more details about specific problems and expands the original database.

Functional assessment: a comprehensive evaluation of a client’s physical strengths and weaknesses in areas such as (1) the performance of activities of daily living, (2) cognitive abilities, and (3) social functioning.

Question 22

What is concept mapping?

Answer 22

Concept mapping is a method of organizing information in graphic or pictorial form. It is created by identifying a main subject with interconnected links to related components.
This strategy promotes critical thinking while gathering data from the client and medical record or a written case study, selecting significant information, and organizing related concepts on a one- or two-page working document.

Question 23

What are the characteristics of short-term goals?

Answer 23

Short-term goals have the following characteristics: Developed from the problem portion of the diagnostic statement

Client centered, reflecting what the client will accomplish, not the nurse Measurable, identifying specific criteria that provide evidence of goal achievement
Realistic, to avoid setting unattainable goals, which can be self-defeating and frustrating
Accompanied by a target date for accomplishment, the predicted time when the goal will be met

Question 24

A client reports to the emergency room with chest pain. The medical file shows that the client has a history of hospitalization for chest pain. The family members inform the nurse that the client is a chain smoker. The nurse performs an initial assessment to plan the care.

1. What are the sources of data in this case?

Answer 24

The sources of data in this case would be the client themselves, their family members, their previous case files, and any other medical documents.

Question 25

*A client reports to the emergency room with chest pain. The medical file shows that the client has a history of hospitalization for chest pain. The family members inform the nurse that the client is a chain smoker. The nurse performs an initial assessment to plan the care.

What types of assessment data should be obtained in this case?
Group them into subjective and objective data.

Answer 25

In the given case, the types of data obtained would be both subjective and objective.
The subjective data would include pain, restlessness, anxiety, and palpitation.