Chapter 5

Question 1

What is nursing ?

Answer 1

is the protection , promotion , and optimization of health and abilities , prevention of illness and injury , facilitation of healing , alleviation of suffering through the diagnosis and treatment of human response , and advocacy in the care of individuals , families , groups , communities , and populations

Question 2

The nursing process ?

Answer 2

is a systematic method by which nurses plan and provide care for patients.

Question 3

The defined assessment ?

Answer 3

as a systematic , dynamite way to collect and analyze data about a client, the first step in delivering nursing care.

Question 4

Nursing process?

Answer 4

-Organizational framework for the practice of nursing
-Problem solving
-Six phases
-ANA Nursing Scope and Standards of Practice

Question 5

Six phases of the nursing process ?

Answer 5

1.Assessment (Gather information about the patient’s condition )
2.Diagnosis (Identify the patient’s problems)
3.Outcomes identification (goal)
4.Planning (identify appropriate nursing action) 5.Implementation (Implement Perform the nursing actions identified in planning)
6.Evaluation (Determine if goals met and outcomes achieved)

Question 6

Types of A cue date ?

Answer 6

is a piece or pieces of data that often indicate that an actual or potential problem has occurred or will occur

Question 7

Subjective date ?

Answer 7

Subjective data is information that is provided by the patient .

Statements about nausea and descriptions of pain, fatigue , and anxiety are examples of subjective data .

Other terms for subjective data are symptoms and subjective cues .

Subjective data are hidden until shared by the patient.

Question 8

Objective date ?

Answer 8

-Objective data are observable and measurable signs . For example , the LPN / LVN is able to observe capillary refill , measure a patient’s blood pressure , and observe and measure edema . Other terms for objective data are signs and objective cues

Question 9

Types of data ?

Answer 9

Cue
Subjective
Objective

Question 10

Sources of data ?

Answer 10

Primary source (the patient)
Secondary sources (Secondary sources include family members, significant others, medical records , diagnostic procedures, and previous nursing progress notes)

Question 11

Methods of Data Collection?

Answer 11

Interviews ( Biographic data provide information about the facts or events in a person’s life - the health history , and the family history)

Physical exams allow the nurse to establish a database (a large store or bank of information ) for the patient.

Question 12

A nursing diagnosis/patient problem statement is a type of health problem that can be identified by the nurse ?

Answer 12

-NANDA International
-Components
-Patient problems may be actual or potential

Question 13

Patient problems NANDA-I ?

Answer 13

nursing diagnosis/patient problem statement

-is a type of health problem that can be identified by the nurse -“a clinical judgment concerning a human response to health conditions/life processes, or a vulnerability for that response , by an individual , family, group or community .

Question 14

Components of a patient problem statement ?

Answer 14

-Patient’s presenting signs and symptoms Contributing ,etiologic ( causative), and related factors will write

• Defining characteristics are the clinical cues, signs, and symptoms that furnish evidence that the problem exists.

The cues, signs, and symptoms identified in the patient’s assessment are prefaced with “ as evidenced by” in the patient problem statement.

Question 15

Patient problem statement may be actual or potentially ?-.

Answer 15

Acute problems are typically rapid in onset and are limited in the duration of time.

Acute problems can become chronic if the condition is not resolved. And
-If the patient’s condition is expected to change, add the phrase “ potential for” before the patient problem statement.
For example, it is reasonable to expect that a patient being prepared for surgery will experience pain, alteration in mobility , or the need for education . Therefore , a patient problem statement would be Potential for Discomfort . This problem or data

Question 16

Actual patient problem statement ?

Answer 16

An actual patient problem statement identifies health-related problems that exist and are discovered during the nursing assessment.
-These health problems can be treated by the nurse

Question 17

Potential patient problems are written as two part statements ?

Answer 17

(1 ) the patient problem statement with the adjective “potential “ in front of it, and (2 ) the risk factor

Question 18

A medical diagnosis ?

Answer 18

is the identification of a disease or condition with evaluation of physical signs , symptoms , patient interview , laboratory tests , diagnostic procedures , review of medical records , and patient history .

Question 19

Collaborative problems ?

Answer 19

are health-related problems that the nurse anticipates based on the condition or diagnosis of a patient .

Question 20

Differentiating medical and nursing diagnoses ?

Answer 20

Although the patient is often able to recover from a medically diagnosed condition , the diagnosis does not change

-A patient problem statement may change or resolve as care is provided or the condition changes.

Question 21

PATIENT-CENTERED GOALS?

Answer 21

• A patient- centered goal indicates the degree of wellness desired, expected, or possible for the patient to achieve
• Provides a description of the specific, measurable behavior the patient will exhibit in a given time frame

Question 22

Planning ?

Answer 22

• The nurse establishes priorities of care and nursing interventions are chosen that will best address the nursing diagnosis

-Information is communicated through care plan so that all healthcare personnel will be directly involved in the care of the patient

-The nurse decides what interventions will be effective after working with the patient and significant others

Question 23

PRIORITY SETTING?

Answer 23

-Nursing diagnoses are ranked in order of importance for the patient’s life and health

-Physiologic needs come before safety and security Safety and security needs come before love and belonging needs

—Life- and health
- threatening problems are ranked before other types of problems

Actual problems may be ranked before risk problems Priorities change as the patient progresses in the hospitalization ; as some problems are resolved, new ones can be addressed

Question 24

Nursing interventions ?

Answer 24

Activities that promote the achievement of the desired patient outcome -Classified as physician-prescribed or nurse-prescribed

Question 25

WRITING NURSING INTERVENTIONS ?

Answer 25

Because nursing interventions in manuals and textbooks are often broad, general statements , it is often necessary to convert these into more specific instructional statements Nursing interventions must be written to reduce the likelihood of misinterpretation Should include the subject, action verb, and qualifying details

Question 26

EVALUATION ?

Answer 26

-Establishing desired patient outcomes The nurse predicts the condition of the patient following nursing interventions

-This prediction is expressed in a statement that indicates the degree of wellness desired, expected, or possible for the patient to achieve Outcome: A statement provides a description of the specific measurable behavior that the patient will be able to exhibit in a given time frame following the intervention
Goal: A statement about the purpose to which an effort is directed

Question 27

COMMUNICATING THE NURSING CARE PLAN ?

Answer 27

Written nursing care plan is the product of the nursing process It is important to have written guidelines to promote the continuity of patient care Formats for the written nursing care plan vary among institutions Nursing care plans may be prepared for each patient, be standardized for a group of patients, or be computerized

Question 28

Common components in the educational setting ?

Answer 28

NANDAdiagnostic labels Patient-centered goals and desired patient outcomes Nursing interventions Orders

Question 29

One of two types of care plans are noted in the educational setting ?

Answer 29

-care plan in 4 to 5 column format -concept map

Question 30

The NANDA -has formed a relationship with two other groups?

Answer 30

• Nursing Intervention Classification (NIC) is a research group working at the University of iowa to standardize the language used to organize and describe interventions

-Nursing Sensitive Outcome Classification ( ) is a research group working at the University of iowa that has developed a standardized system to name and measure the results of patient outcomes

Question 31

ROLE OF THE LICENSED PRACTICAL/VOCATIONAL NURSE?

Answer 31

• The nursing process may vary from state to state; review the state’s nurse practice act -Provide direct bedside nursing care -

This direct care position allows the LPN / L * VN to closely observe , prioritize , intervene , and evaluate the care provided to and for the patient

Question 32

Managed care ?

Answer 32

A health care system whose aim is to enhance specific clinical and financial outcomes within a specific time frame

Question 33

A certified nursing specialty refers to the assignment of a health care provider to a patient so the care of that patient is overseen by one individual?

Answer 33

Case management

Question 34

CRITICAL THINKING ?

Answer 34

Critical thinkers think with a purpose They question information, conclusions, and points of view
They are logical and fair in their thinking Critical thinking is a complex process, and no single simple definition explains all of the aspects of critical thinking
The nurse must be able not only to perform skills, but also think about what he or she is doing
Nurses use a knowledge base to make decisions, generate new ideas, and solve problems

Question 35

IMPLEMENTATION?

Answer 35

Fifth phase of the nursing process The nurse and other members of the team put the established plan into action to promote outcome achievement

-Using evidence - based interventions , the plan is implemented in a timely and safe manner