Chapter 3

Question 1

What does the acronym ADPIE stand for?

Answer 1

Assessment, Diagnosis, Planning, Implementation, Evaluation

Question 2

What are the 5 steps in The Nursing Process?

Answer 2

Assessment, Diagnosis, Planning, Implementation, Evaluation

Question 3

Categorizing data and collecting data are all part of which step of the Nursing Process?

Answer 3

Assessment

Question 4

Interviewing the patient, interviewing patients family and reviewing the chart are all examples of?

Answer 4

Assessment

Question 5

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.

Answer 5

True

Question 6

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

Answer 6

Subjective - you were not a witness to this information

Question 7

Subjective or objective? The patient states they had a high BP last week, so you manually check their BP and it is 120/80

Answer 7

Objective - you took the VS and witnessed the reading

Question 8

What are four methods of physical assessment?

Answer 8

Inspection, Palpation, Percussion, Auscultation

Question 9

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?

Answer 9

Initial assessment

Question 10

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?

Answer 10

Ongoing assessments

Question 11

Joint Commission requires we take a _____ assessment which we often refer to as the 6th vital sign.

Answer 11

Pain

Question 12

Asking a patient if they want a spiritual leader involved in their care is an example of which type of assessment?

Answer 12

Spiritual Health

Question 13

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?

Answer 13

Functional ability assessment

Question 14

A professional organization of nurses standardized nursing terminology and investigates, researches and defines nursing diagnosis

Answer 14

NANDA

Question 15

Subjective or objective? Patient says “My throat hurts when I swallow”

Answer 15

Subjective

Question 16

Subjective or objective? White patches observed in the back of the throat and tonsillar area red and swollen

Answer 16

Objective

Question 17

Primary or secondary source?
You read from the chart that the WBC count was 14,000

Answer 17

Secondary

Question 18

Primary or secondary source?
The patient states they are feeling short of breath

Answer 18

Primary

Question 19

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

Answer 19

Secondary / Objective

Question 20

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?

Answer 20

Diagnosis

Question 21

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?

Answer 21

Planning outcomes

Question 22

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?

Answer 22

Planning interventions

Question 23

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?

Answer 23

Implementation

Question 24

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?

Answer 24

Implementation

Question 25

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?

Answer 25

Evaluation

Question 26

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?

Answer 26

Assessment

Question 27

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?

Answer 27

Planning Outcomes

Question 28

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.

Answer 28

Primary / Subjective

Question 29

A _____ is a type of focused assessment that provides in-depth information about a particular area of client functioning

Answer 29

special needs assessment

Question 30

A ____ assessment is completed when a patient first comes to the healthcare facility.

Answer 30

initial

Question 31

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.

Answer 31

Collaborative problem

Question 32

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.

Answer 32

Medical diagnosis

Question 33

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.

Answer 33

Nursing diagnosis

Question 34

Which two nursing organizations have been responsible for making diagnosis a part of the professional nursing role?

Answer 34

ANA and NANDA International

Question 35

What does r/t mean in the following sentence? Anxiety r/t prior negative experiences and lack of trust in health professionals.

Answer 35

related to

Question 36

List the three types of planning.

Answer 36

Initial, ongoing, discharge