Chapter 3 Flashcards
What does the acronym ADPIE stand for?
Assessment, Diagnosis, Planning, Implementation, Evaluation
What are the 5 steps in The Nursing Process?
Assessment, Diagnosis, Planning, Implementation, Evaluation
Categorizing data and collecting data are all part of which step of the Nursing Process?
Assessment
Interviewing the patient, interviewing patients family and reviewing the chart are all examples of?
Assessment
True or False: An RN may delegate data collection tasks such as blood glucose or temperature to an LPN or UAP but is responsible for completing all the steps of the nursing process themselves.
True
Subjective or objective data? The patient tells you they had a BP of 185/110 last week when they checked it in the machine at CVS
Subjective - you were not a witness to this information
Subjective or objective? The patient states they had a high BP last week, so you manually check their BP and it is 120/80
Objective - you took the VS and witnessed the reading
What are four methods of physical assessment?
Inspection, Palpation, Percussion, Auscultation
When you get a patient transferred to you from another floor in the hospital and are now their nurse for the remainder of your shift, what is the first assessment of the pt called?
Initial assessment
You did your initial assessment on your patient at the start of your shift. Now you are making assessments every 3 hours. What are these subsequent assessments called?
Ongoing assessments
Joint Commission requires we take a _____ assessment which we often refer to as the 6th vital sign.
Pain
Asking a patient if they want a spiritual leader involved in their care is an example of which type of assessment?
Spiritual Health
What type of assessment is performed before a patient is discharged and helps determine if they should go home, home with home health or a rehab facility?
Functional ability assessment
A professional organization of nurses standardized nursing terminology and investigates, researches and defines nursing diagnosis
NANDA
Subjective or objective? Patient says “My throat hurts when I swallow”
Subjective
Subjective or objective? White patches observed in the back of the throat and tonsillar area red and swollen
Objective
Primary or secondary source?
You read from the chart that the WBC count was 14,000
Secondary
Primary or secondary source?
The patient states they are feeling short of breath
Primary
State whether the following data are primary or secondary AND subjective or objective:
You see in the client’s health record that her breast examination was normal
Secondary / Objective
Adrian, a nurse, reflects on her client’s admission information, including physical assessment and related family concerns. She considers all information to reach conclusions. Which step of the nursing process is this?
Diagnosis
The nurse, Linda, identifies some concerns about her client’s financial situation and ability to pay the hospital bill. She approaches the healthcare provider to request that a social worker meet with the client prior to discharge. Which step of the nursing process is this?
Planning outcomes
Rosalind, a nurse, considers the most recent evidence-based policy on care of the client with pneumonia while identifying client needs. Which part of the nursing process is this?
Planning interventions
Mrs. Clancy is a nursing home resident at risk for falls. The head nurse asks one of the unlicensed assistive personnel to assist Mrs. Clancy to the dining hall and help prepare her for dinner. Which part of the nursing process is this?
Implementation
Mr. Thompson had surgery yesterday for a hernia repair. His pain is significant. The nurse delivers an injection of pain medicine 30 minutes before Mr. Thompson needs to ambulate in the hall. Which part of the nursing process is this?
Implementation
The nurse is caring for Ms. Lee, a client who does not speak English. The nurse learns from the patient’s family that Ms. Lee has specific religious needs that she cannot address because of the hospital routine. Adjustments are made in the plan of care based on this information. Which part of the nursing process is this?
Evaluation
Mr. Patel was recently started on a new hypertension medication. During a home visit, the nurse asks what Mr. Patel has eaten in the last 24 hours. Which part of the nursing process is this?
Assessment
Mrs. Waters fell in her room at the care center and fortunately was not injured. Documented in her chart was “no further falls will occur while in the care center.”
Which part of the nursing process is this?
Planning Outcomes
State whether the following data are primary or secondary AND subjective or objective:
The client tells the nurse she experiences cramping during her menstrual cycle.
Primary / Subjective
A _____ is a type of focused assessment that provides in-depth information about a particular area of client functioning
special needs assessment
A ____ assessment is completed when a patient first comes to the healthcare facility.
initial
State whether the following represents a nursing diagnosis, medical diagnosis, or collaborative problem: After giving birth, all women are at risk for developing postpartum hemorrhage.
Collaborative problem
State whether the following represents a nursing diagnosis, medical diagnosis, or collaborative problem: A patient has signs and symptoms of appendicitis, which must be treated with surgery and antibiotics.
Medical diagnosis
State whether the following represents a nursing diagnosis, medical diagnosis, or collaborative problem: A client is at risk for constipation because they postpone defecation and also do not consume enough dietary fiber and fluids. The problem can be prevented by patient teaching, which the nurse is licensed to do.
Nursing diagnosis
Which two nursing organizations have been responsible for making diagnosis a part of the professional nursing role?
ANA and NANDA International
What does r/t mean in the following sentence? Anxiety r/t prior negative experiences and lack of trust in health professionals.
related to
List the three types of planning.
Initial, ongoing, discharge
