Exam 3- Nursing process

Question 1

What is important for a vegan-vegetarian diet?

Answer 1

ESSENTIAL and NONESSENTIAL amino acids!

Question 2

What is a pt performance criteria?

Answer 2

turn and deep cough..to prevent pneumonia

Question 3

What is important for the pt and planning their care plan?

Answer 3

Ambulate frequently.

Question 4

Jewish Kosher diet suggestion?

Answer 4

Swiss cheese + ww bread

Question 5

What sign/symptom would a person who is hyponatremic experience?

Answer 5

Confusion

Question 6

If a pt is hypokalemic what food would you give?

Answer 6

Baked potato

Question 7

If a pt’s bowel elimination is oozing out, the pt has what kind of BM?

Answer 7

FECAL IMPACTION

Question 8

The fight or flight response releases two hormones: epinephrine (adrenaline) and norepinephrine (noradrenaline) are associated with what group?

Answer 8

CATECHOLAMINE

Question 9

If a pt is hypercalcemic and is found to be flacid, what would you test them for?

Answer 9

MUSCLE STRENGTH.

Question 10

If a pt’s BMI is 18, what is their nutritional status?

Answer 10

UNDERWEIGHT because normal is considered 18.5-24.9

Question 11

What is the second phase of the nursing process?

Answer 11

Diagnosing, and is an exclusive responsibility for the R.N by the ANA to analyze data

Question 12

What does a nursing dx do and what must you do to develop a nursing dx?

Answer 12

A nursing dx identifies a client’s response to a health problem. It is not a medical dx.

Question 13

What is a NANDA nursing dx?

Answer 13

world uses same nursing Dx, language to uniform what nurses are doing.

Question 14

What are the 5 components of a NANDA nursing dx?

Answer 14

1. Diagnostic label
2. Definition
3. Defining characteristics- s, sx, cues
4. Related factors- r/t damaged lungs
5. Risk factors- infection r/t poor tissue perfusion.

Question 15

What are the 4 components for status of a nursing dx?

Answer 15

1. Actual Dx- pt’s prob that is present at time of assessment
2. Health promotion dx- to implement behaviors to improve their health cond.
3. Risk Nursing dx- risk factors to indicate a prob is likely to develop unless a nurse intervenes
4. Wellness dx- human respnse to level of wellness in an individual or community.

Question 16

Nursing dx versus a medical dx?

Answer 16

Nursing dx- nursing judgement and a nurse is likely to treat.
Medical dx- made by a physician & refers to a cond. that only a physician can treat.

Question 17

What is the 3 part nursing dx statement?

Answer 17

PES- problem, etiology, signs and symptoms

Question 18

What is the 3rd part to the nursing process?

Answer 18

PLAN!

Question 19

What are the 3 types of planning?

Answer 19

1. Initial- first pt contact, dev. of care plan
2. Ongoing- change made in the plan as you evaluate the pt’s response to care.
3. Discharge- planning for self-care and continuity of care after pt leaves health care setting.

Question 20

What are the 5 R’s of delegation?

Answer 20

1. Right task
2. Right circumstance
3. Right person
4. Right direction/communication
5. Right supervision

Question 21

What is ADPIE?

Answer 21

Assessment
Diagnosing
Planning
Implementation
Evaluation