Midterm (Lesson 1)

Question 1

It is a systematic method that directs the nurse and patient in planning patient care, and enables you to organize and deliver nursing care.

Answer 1

Nursing Process

Question 2

It is patient centered and outcome oriented.

Answer 2

Nursing Process

Question 3

It is used to identify, diagnose, and treat human responses to health and illness.

Answer 3

Nursing Process

Question 4

FIVE STEPS OF THE NURSING PROCESS;

Answer 4

1ST STEP: ASSESSING
2ND STEP: DIAGNOSING
3RD STEP: PLANNING
4TH STEP: IMPLEMENTING
5TH STEP: EVALUATING

Question 5

ASSESSING;

Answer 5

COLLECT DATA
ORGANIZE DATA
VALIDATE DATA
DOCUMENT DATA

Question 6

DIAGNOSING;

Answer 6

• ANALYZE DATA
• IDENTIFY HEALTH PROBLEMS, RISKS, AND STRENGTHS
• FORMULATE DIAGNOSTIC STATEMENTS

Question 7

PLANNING;

Answer 7

• PRIORITIZE PROBLEMS/DIAGNOSES
• FORMULATE GOALS/DESIRED OUTCOMES
• SELECT NURSING INTERVENTIONS
• WRITE NURSING INTERVENTIONS

Question 8

SMART;

Answer 8

S- pecific
M- easurable
A- ttainable
R- ealistic
T- ime framed/bounded

Question 9

IMPLEMENTING;

Answer 9

• REASSESS THE CLIENT
• DETERMINE THE NURSES’ NEED FOR ASSISTANCE
• IMPLEMENT THE NURSING INTERVENTIONS
• SUPERVISE DELEGATED CARE
• DOCUMENT NURSING ACTIVITIES

Question 10

EVALUATING;

Answer 10

• COLLECT DATA RELATED TO OUTCOMES
• COMPARE DATA WITH OUTCOMES
• RELATE NURSING ACTIONS TO CLIENT GOALS/OUTCOMES
• DRAW CONCLUSIONS ABOUT PROBLEM STATUS
• CONTINUE, MODIFY, OR TERMINATE THE CLIENT’S CARE PLAN

Question 11

ADPIE;

Answer 11

Assess
Diagnose
Plan
Implement
Evaluate

Question 12

Gather info Review History

Answer 12

Assess

Question 13

Identify problem list

Answer 13

Diagnose

Question 14

Develop goals, desired outcomes, action plan

Answer 14

Plan

Question 15

Perform nursing actions

Answer 15

Implement

Question 16

Were desired outcomes and goals achieved?

Answer 16

Evaluate

Question 17

Is the systematic and continuous collection, organization, validation, and documentation of data (information).

Answer 17

ASSESSING/ASSESSMENT

Question 18

A continuous process carried out during all phases of the nursing process.

Answer 18

ASSESSING/ASSESSMENT

Question 19

UNIQUE FOCUS OF NURSING ASSESSMENT;

Answer 19

■ Nursing assessments
■ Medical assessments

Question 20

do not duplicate medical assessments

Answer 20

Nursing assessments

Question 21

target data pointing to pathologic conditions

Answer 21

Medical Assessments

Question 22

COMPONENTS OF A NURSING HEALTH HISTORY;

Answer 22

■ BIOGRAPHIC DATA
■ CHIEF COMPLAINT OR REASON FOR VISIT
■ HISTORY OF PRESENT ILLNESS
■ PAST HISTORY
■ FAMILY HISTORY OF ILLNESS
■ LIFESTYLE
■ SOCIAL DATA
■ PSYCHOLOGICAL DATA
■ PATTERNS OF HEALTH CARE

Question 23

GORDONS HEALTH PATTERNS;

Answer 23

■ Health perception-management
■ Nutritional-metabolic
■ Elimination
■ Activity-exercise
■ Sleep-rest
■ Cognitive -perceptual
■ Self-perception-self-concept
■ Role-relationship
■ Sexuality-reproductive
■ Coping-stress-tolerance
■ Value-belief

Question 24

TYPES OF NURSING ASSESSMENTS;

Answer 24

■ Initial Assessment
■ Focused assessment/Problem-focused assessment
■ Emergency assessment
■ Time-lapsed assessment

Question 25

Performed within specified time after admission to a health care agency

Answer 25

Initial Assessment

Question 26

Done to establish a complete database for problem identification, reference, and future comparison

Answer 26

Initial Assessment

Question 27

Ongoing process integrated with nursing care

Answer 27

Focused assessment/Problem-focused assessment

Question 28

Done to determine the status of specific problem identified in an earlier assessment

Answer 28

Focused assessment/Problem-focused assessment

Question 29

During any physiological or psychological crisis of the client

Answer 29

Emergency assessment

Question 30

Done to identify life-threatening problems; and determine new or overlooked problems

Answer 30

Emergency assessment

Question 31

Several months after initial assessment

Answer 31

Time-lapsed assessment

Question 32

Done to compare the client's current status to baseline data previously obtained

Answer 32

Time-lapsed assessment

Question 33

Is the process of gathering information about a client's health status

Answer 33

Data Collection

Question 34

TYPES OF DATA;

Answer 34

■ Subjective Data (Symptoms) ■ Objective Data (Signs)

Question 35

Information perceived only the affected person

Answer 35

Subjective data (Symptoms)

Question 37

Cannot be perceived or verified by another person

Answer 37

Subjective data (Symptoms)

Question 38

Observable and measurable data

Answer 38

Objective Data (Signs)

Question 39

Data that can be seen, heard or felt by someone other than the person experiencing it

Answer 39

Objective Data (Signs)

Question 40

Examples of Subjective Data (Symptoms)

Answer 40

feeling nervous, nauseated, chilly, itching, pain, feeling of worry

Question 41

Examples of Objective Data (Signs)

Answer 41

elevated temperature, moist skin, refusal to eat, vital signs

Question 42

CHARACTERISTICS OF DATA;

Answer 42

■ Complete ■ Factual and accurate ■ Relevant

Question 43

SOURCES OF DATA;

Answer 43

■ Primary ■ Secondary

Question 44

Primary;

Answer 44

Patient

Question 45

Secondary;

Answer 45

➤ Family members ➤ Significant other ➤ Other healthcare professionals ➤ Health records ➤ Literature

Question 46

DATA COLLECTION METHODS;

Answer 46

■ OBSERVING ■ INTERVIEWING ■ EXAMINING

Question 47

using the senses to observe client data

Answer 47

OBSERVING

Question 48

OBSERVING;

Answer 48

➤ Vision ➤ Smell ➤ Hearing ➤ Touch

Question 49

is a planned communication or a conversation with a purpose

Answer 49

INTERVIEWING

Question 50

INTERVIEWING;

Answer 50

➤ Focused interview ➤ Directive interview ➤ Nondirective interview

Question 51

the physical examination or physical assessment is a systematic data collection method that uses observation to detect health problems.

Answer 51

EXAMINING

Question 52

To conduct the examination, the nurse uses techniques of

Answer 52

inspection, auscultation, palpation, and percussion.

Question 53

The nurse uses written or electronic format that organizes the assessment data systematically

Answer 53

Organizing Data

Question 54

Organizing Data;

Answer 54

Conceptual Models/Frameworks Wellness Models Non- Nursing models

Question 56

The act of "double-checking" or verifying data to confirm that is accurate and factual

Answer 56

Validating Data