lecture 3

Question 1

steps of nursing process

Answer 1

assessment
diagnose
plan
implement
evaluate

Question 2

assessment

Answer 2

subjective data
objetive data

Question 3

subjective data

Answer 3

info reported by patient and family and documented in patient’s own words

Question 4

objective data

Answer 4

can be seen or measured

Question 5

physical examination

Answer 5

inspection and observation
palpation to assess parts of body

Question 6

percussion

Answer 6

tapping on the skin to assess underlying tissues

Question 7

auscultation

Answer 7

listening to sounds produced by the body using a stethoscope

Question 8

medical diagnosis

Answer 8

process of determining which disease or condition explains a person’s symptoms and signs

Question 9

PES format

Answer 9

p = problem
e = etiology or cause of the problem
s = signs and symptoms of the problem

Question 10

intervention

Answer 10

actual performance of the nursing interventions in the plan of care

includes : direct patient care, health teaching, carrying out ordered medical treatment

Question 11

evaluation

Answer 11

change, modify, or discontinue

used to determine of nurses have carried out the nursing process as documented in patient records

Question 12

concept map

Answer 12

visual plan of care that illustrates the relationships between pathophysiology, signs, and symptoms

Question 13

what should nursing documentation include

Answer 13

-all treatments and care, including medications
-procedures performed at bedside
- reactions to procedures
observations
-subjective and objective
-evidence of changes
-any unusual incidents

Question 14

nurse notes

Answer 14

pages of narrative recordings containing data carried out by the nurse

Question 15

flow sheets

Answer 15

graphs of vital signs or tables which nurses may check or initial boxes indicating activities or care provided

Question 16

what format is charting done in

Answer 16

SOAPIER
s- subjective
o- objective
a- assessment
p- plan
i- intervention
e- evaluation
r- revision

Question 17

what is the first step in the nursing process

Answer 17

assessment

Question 18

inference

Answer 18

drawing conclusions

Question 19

nursing process is…

Answer 19

assess
diagnose
plan
implement
evaluate

Question 20

the interview consists of 3 basic stages

Answer 20

1. opening
2. body
3. closing

Question 21

what should medical charts include

Answer 21

-face sheet
-nurse’s notes
-physicians progress notes and history
- medication administration record
-surgery operative report
-diagnosis test
-nursing care plan

Question 22

head to toe assessment

Answer 22

initial observation
-breathing
-how the patient is feeling
-general appearance
-skin color
-affect

head
-level of consciousness
-ability to communicate
-appearance of eyes

vital signs
-temperature
-pulse rate
-respiration
-blood pressure

heart and lungs
abdomen
extremities
tubes and equipment

Question 23

As part of an assessment, the nurse asks for
information from the patient. This information is
a subjective indication of illness perceived by
the patient and is called a/an:

1) assessment
2) symptom.
3) sign
4) observation

Answer 23

2. symptom

Question 24

All of the following components can be found on
the chart except the:

1) face sheet
2) physician’s order
3) patient’s history and physical
4) patient’s nurse assignment.

Answer 24

4) patient’s nurse assignment

Question 25

Linda knows as part of her nursing assignment
that she is to review and update the nursing
care plan on her patients:

1) hourly
2) every shift
3) every 24 hours.
4) weekly

Answer 25

3) every 24 hours

Question 26

defining characteristics

Answer 26

problem statements and nursing diagnoses differ from medical diagnoses whereas medical diagnosis labels the illness

Question 27

long term care

Answer 27

long term care facility begins the care planning process when patient is admitted

Question 28

home health care

Answer 28

problem statements must include problems identified in family’s ability to cope with illness or situation

Question 29

Which one of the following sets of assessment data is most
likely to be present with the nursing diagnosis Risk for
infection?

1) Fever, dysuria, change in urine concentration, and
urinary urgency
2) Abdominal pain, sore mouth, hyperactive bowel sounds,
and leukopenia
3) Fatigue, electrocardiographic changes, dependent
edema, and activity intolerance
4) Abdominal incision, decreased hemoglobin, and
indwelling catheter present.

Answer 29

4) Abdominal incision, decreased hemoglobin, and
indwelling catheter present.

Question 30

short term goals

Answer 30

achievable within 7-10 days

Question 31

long term goals

Answer 31

may take many weeks or months to achieve

Question 32

A nurse has established expected outcomes for an assigned patient. The nurse carries out this
important activity for the purpose of:

1) evaluating the occurrence of complications.
2) measuring quality of care.
3) measuring the effectiveness of nursing interventions..
4) stopping care when outcomes are met.

Answer 32

3) measuring the effectiveness of nursing interventions..

Question 33

interventions in clinical setting

Answer 33

constantly being reprioritized based on patient’s fluctuating situation and unit environment

Question 33

implementing care

Answer 33

-expected to perform at standard of care listed in the procedure manual
-consider which interventions for a patient can be combined
-range of motion exercises may also be incorporated into the bath routine

Question 33

During the implementation of the nursing process:

1) The planned nursing interventions are carried
out.
2) Reassessment of data is used to determine
whether the expected outcomes have been
achieved
3) Revision of the nursing care plan is performed
4) Goals are established for the patient

Answer 33

1) The planned nursing interventions are carried
out.

Question 33

Before Ms. Bricker, LPN, carries out any interventions such as the administration of a
medication, she must know:

1) the reason for the intervention
2) the usual standard of care
3) the expected outcome
4) any potential danger
5) All of the above.

Answer 33

5) All of the above.

Question 34

After Ms. Bricker, LPN, has given her patient medication, she returns later to the patient’s room to evaluate the effectiveness of the medication. She knows that in the
evaluation phase of the nursing process:

1) the nursing process has been completed.
2) she doesn’t need to revise the care plan if needs aren’t
met.
3) if the expected outcomes are considered met, the nurse’s notes must contain data to support this
4) there will be no further need for reassessment.

Answer 34

3) if the expected outcomes are considered met, the nurse’s notes must contain data to support this

Question 35

Debbie, a student nurse, is learning about care plans. She knows all of the following are true regarding care plans
except:

1) the family and patient are invited to the care planning
2) the care plan for the home health patient encompasses
the needs and concerns of the family as well as the patient
3) an LPN is responsible for constructing the care plan.
4) students are required by most instructors to come to the
clinical experience with a nursing care plan in hand for
assigned patients

Answer 35

3) an LPN is responsible for constructing the care plan

Question 36

Flora, an LPN, is helping her patient understand the side effects of a medication. This is what
type of action?

1) Independent.
2) Dependent
3) Interdependent
4) Evaluation

Answer 36

1) Independent