mod 5 ch 16

Question 1

nursing process

Answer 1

• Critical thinking
• Patient-centered care
• Goal-oriented tasks
• Evidence-based practice
• Nursing intuition

The nursing process utilizes five sequential steps: assessment, analysis, planning, implementation, and evaluation.

Question 2

nursing process

Answer 2

• Assessment- gather data, obj and subj
• analysis- cluster data and id problem
• planning- dev plan of care to achieve goals
• implementation- carry out plan
• evaluation- collect to evaluate, revise plan as needed or end if obj reached

Question 3

effective use nursing process

Answer 3

• It is organized.
• It is outcome-oriented.
• It is collaborative, incorporating an interprofessional team.
• It is dynamic, changing over time in response to patient needs.
• It requires knowledge application, analysis, and critical thinking.
• It is universally adaptable to all types of patients in all kinds of health care settings.

Question 4

Which nursing skill is essential to utilize throughout the nursing process?

Answer 4

Critical thinking

Critical thinking requires that the nurse think logically about the patient’s health problems and how best to address them, and it is used throughout the nursing process.

Question 5

Place the steps of the nursing process in the order in which each should occur.

Answer 5

Assessment	
Analysis	
Planning	
Implementation	
Evaluation

Question 6

Match the nursing process characteristic to its description.

Answer 6

The nursing process incorporates the interprofessional team.
—Collaborative
Nurses evaluate patient results to determine effectiveness.
—-Outcome-oriented
Nurses use critical thinking for each step of the nursing process.
—–Analytical
The nursing process helps ensure that patient care is well planned.
—–Organized

Question 7

analysis

Answer 7

recognize cues then form diagnostic conclusions based on identified patters

clinical judgement based on collected data
collaborative problem- actual problem treated by interdisciplinary team

Question 8

critical thinking

Answer 8

promotes thorough, comprehensive, and accurate analysis to identify nursing diagnoses unique to the individual patient

Question 9

diagnostic decision-making process

Answer 9

includes clustering data, identifying patient problems, and formulating diagnoses.

Question 10

International Classification for Nursing Practice (ICNP)

Answer 10

standardized nursing language system used for point-of-care documentation for patient data and clinical activity. ICNP language can be used to identify diagnoses, interventions, and outcomes.

Question 11

Which nursing concept is defined as an actual or potential problem or response to a problem?

Answer 11

diagnosis

Question 12

Which aspects do nurses make judgments about when determining initial nursing diagnoses?

Answer 12

• vulnerabilities
• pt problems
• health promotion
• risk for problems

Question 13

Which action reflects a primary task in the analysis step of the nursing process?

Answer 13

Forming diagnostic conclusions

Nurses form diagnostic conclusions according to identified problems that reflect patient conditions requiring nursing care in the analysis step of the nursing process.

Question 14

3 types nursing interventions

Answer 14

• nurse-initiated- do not require HCP prescription
• HCP initiated
• collaborative

Question 15

Which term describes how the nursing process changes over time in response to patients’ individual needs?

Answer 15

dynamic

Question 16

Which statement defines collaborative interventions?

Answer 16

Involve the expertise of health care team members

Question 17

Match the type of nursing intervention to the example.

Answer 17

Patient positioning
---Independent
Foley catheter insertion
----Dependent
Respiratory therapy consult
----Interdependent

Question 18

giving care

Answer 18

direct care- care on pts

indirect care- performed on behalf of pts

Question 19

implementing care

Answer 19

• –Reassess the patient.
• —Review and revise the existing plan of care.
• –Organize resources and care delivery.
• —Anticipate and prevent complications.
• –Implement nursing interventions.

Question 20

Which function describes the primary purpose for documenting nursing interventions?

Answer 20

Facilitate communication.

Communication is the most important reason proper documentation is performed. It facilitates communication among all health care team members and decreases the potential for error

Question 21

During the implementation step of the nursing process, a nurse reviews and revises a patient’s plan of care. Place the steps of review and revision in the order in which each should occur.

Answer 21

• Reassess the patient.
• Review and revise the existing plan of care.
• Organize resources and care delivery.
• Anticipate and prevent complications.
• Implement nursing interventions.

Question 22

critical thinking process

Answer 22

• examine results
• compare achieved effect w goals and outcomes
• recognize errors

Question 23

evaluation

Answer 23

• question interventions

- revise plan

Question 24

Which aspect would the nurse consider as a component of the evaluation step of the nursing process?

Answer 24

The patient’s achievement of short- and long-term goals

The evaluation phase is specifically when the nurse determines whether the patient’s short- and long-term goals were met.

Question 25

Which critical-thinking functions must the nurse perform to effectively evaluate patient goals during the final step of the nursing process?

Answer 25

- recognizing errors - compare achieved effect w goals - examine results acc to clinical findings

Question 26

Which questions are critical for the nurse to ask during each step in the nursing process?

Answer 26

- collected data thorough and accurate? - could interventions affect pt negatively? - are all underlying factors addressed in plan care?

Question 27

Which phrase describes the primary purpose of nursing analysis and diagnosis?

Answer 27

communicate pt problems

Question 28

Which questions would the nurse ask to evaluate the effectiveness of nursing interventions?

Answer 28

- should plan be discontinued - have new assessment data been id'd should be considered? - does plan care need be modified in response to pt changes?

Question 29

Which characteristics of the nursing process allow the nurse to effectively apply critical thinking to patient care?

Answer 29

- organized - outcome oriented - allows rn apply knowledge - rn think analytically - incorporates interprofessional tm

Question 30

Which organization defines standards of nursing practice and states that the nursing process forms the foundation for clinical decision making?

Answer 30

american nurses association

Question 31

Which step of the nursing process does the nurse use when obtaining the following patient information: blood pressure of 180/75, pulse of 90, and a complaint of chest pain?

Answer 31

assessment

Question 32

Which type of data do the patient’s family members, friends, or other nurses provide?

Answer 32

secondary

Question 33

Which type of patient assessment takes into account all factors, such as the patient’s physical, psychological, emotional, environmental, cultural, and spiritual health?

Answer 33

holistic

Question 34

Which nursing action occurs during the analysis step of the nursing process?

Answer 34

cluster pt data to id pt problems

Question 35

Which phrases describe the role of the International Classification for Nursing Practice (ICNP) in the nursing process?

Answer 35

- prov stand rn language - id common labels rn diagnoses' - prov point care doc for clinical activity

Question 36

During which step of the nursing process would the nurse prioritize nursing diagnoses?

Answer 36

planning

Question 37

During which step of the nursing process would the nurse establish long-term goals with the patient?

Answer 37

planning

Question 38

Which part of the nursing process involves the nurse setting short-term goals for the patient?

Answer 38

planning

Question 39

Which step of the nursing process involves carrying out nursing actions designed to meet a patient’s unique needs?

Answer 39

implementation

Question 40

Which intervention reflects direct nursing care?

Answer 40

giving injection

Question 41

Which statements reflect the nurse’s role during the implementation step of the nursing process?

Answer 41

- accountable safe practice - perform steps intervention accurately - understand why intervention planned

Question 42

Which step of the nursing process considers the effectiveness of nursing care?

Answer 42

evaluation

Question 43

Which step of the nursing process includes a decision point on whether to discontinue, continue, or revise the plan of care?

Answer 43

evaluation