Intro Chapter 4

Question 1

What is the purpose of the nursing process

Answer 1

Problem-solving to care for patients based on priority

Question 2

Steps of nursing process

Answer 2

ADPIE

1. Assessment
2. Diagnosis
3. Planning/goals
4. Interventions
5. Evaluation

Question 3

Assessment

Answer 3

Collection of objective and subjective data from the patient or family and labs

Question 4

Diagnosis

Answer 4

Nurses determination of the patient’s problem, assigning a nurses diagnosis from the official NANDA list

Question 5

Planning/goals

Answer 5

Setting a goal the patient will meet to solve the problem, congruent with patient goals

Question 6

Interventions

Answer 6

Actions the nurse will take to help the patient reach the goal

Question 7

Evaluation

Answer 7

Looking at how everything turned out (did the patient meet the goal? Did the intervention work?

Establish new goal and start again

Question 8

T/F The nursing process is the foundation of a nursing care plan

Answer 8

T

Question 9

Subjective data

Answer 9

Things that the patient tells you, personal stories, can come from family

Question 10

Objective data

Answer 10

Measurable data, labs, vitals call mom diagnostic test

Question 11

What Does observation mean in reference to objective data

Answer 11

Seeing

Question 12

What does palpitation mean in reference to objective data

Answer 12

Touching

Question 13

What does percussion mean in reference to objective data

Answer 13

Thumping (finger tapping method)

Assesses organ size or inflammation

Question 14

What does auscultation mean in reference to objective data

Answer 14

Listening

Question 15

What is a nursing diagnosis

Answer 15

Patient’s response to an illness or medical diagnosis

Question 16

How is a nursing diagnosis written

Answer 16

In three parts

Problem patient is dealing with) related to (the original cause of the problem) evident by (sign or symptom of problem

Question 17

How is Maslow‘s hierarchy of needs used with nursing diagnosis

Answer 17

It guides prioritization of nursing diagnosis

Question 18

What is the most important priority as a nurse Taking care of a patient

Answer 18

Physiological needs

we must be able to breathe before we can do anything else!!!

Question 19

How are goals for nursing plans written

Answer 19

SMART

S- pecific (dictates days activities 
M- easurable (objective)
A- ttainable
R- ealistic 
T- time framed

Question 20

Read the Example of a goal below

Answer 20

The patient will demonstrate an effective breathing pattern by 2:30 PM May 25, 2020 AEB a respiratory rate between 12 to 20 breaths per minute

Question 21

What is the most important thing to remember about to goal

Answer 21

They are typically the opposite of the problem

Example
Problem: pain:: goal: no pain

Question 22

What do patient goals describe

Answer 22

Goals the patient is going to accomplish

Question 23

Three types of interventions

Answer 23

1. Independent
2. Dependent
3. Collaborative

Question 24

Independent interventions

Answer 24

Without orders, what the nurse does within her scope of practice

Repositioning, teaching patient

Question 25

Dependent intervention

Answer 25

Orders from physician

Administering medication, starting a tube feed

Question 26

Collaborative Intervention

Answer 26

The nurse works with other disciplines

Question 27

What does evaluation assess and reflect

Answer 27

assess the effectiveness of interventions and reflect goals

Question 28

How do you know if you are interventions were effective or not

Answer 28

If the goals were met not met or partially met will have to be modified

Question 29

Communication is vital between nurses

Answer 29

Done during shift exchange by report

Question 30

What is the golden rule with documentation

Answer 30

If you didn’t document it did not happen