Module 03: Fundamental Nursing Process (Part 02)

Question 1

Under the nursing process, this transpires after identifying a patient’s nursing diagnoses & collaborative problems.

Answer 1

Planning

Question 2

What does planning under the nursing process include?

Answer 2

(1) Prioritizes the diagnoses.
(2) Sets patient-centered goals & expected outcomes.

Question 3

According to Ackley and Ludwig, 2014, what is planning?

Answer 3

The nurse collaborates with a patient & family (as appropriate) & the rest of the health care team to determine the urgency of the identified problems & prioritizes patient needs.

Question 4

What should nurses consider when planning?

Answer 4

(1) Planning requires critical thinking.
(2) Individualize a plan of care for a patient’s unique needs.
(3) Communicating closely with patients, families & health care team.

Question 5

This is the act of ordering of nursing diagnoses or patient problems using notions of urgency and importance to establish a preferential order for nursing interventions.

Answer 5

Priority Setting

Question 6

Why are priorities important?

Answer 6

Priorities helps to anticipate & sequence nursing interventions.

Question 7

How do you set priorities?

Answer 7

Set priorities by selecting mutually agreed- on priorities with a patient on the basis of urgency of patient’s problems, safety, nature of treatment & the
relationship among the diagnoses.

Question 8

How does a nurse classify priorities?

Answer 8

(1) High
(2) Intermediate
(3) Low importance

Question 9

This considers nursing diagnosis of high priority.

Answer 9

Maslow’s Hierarchy of Needs

Question 10

When can you say that the situation is high priority?

Answer 10

It is high priority nursing diagnosis when it drives priorities by selecting mutually agreed- on priorities with a patient on the basis of urgency of patient’s problems, safety, nature of treatment & the
relationship among the diagnoses. (Acute Pain)

Question 11

When can you say that the situation is intermediate priority?

Answer 11

When it involves non-emergent, none life-threatening needs of patients. (Risk for Infection)

Question 12

When can you say that the situation is low priority?

Answer 12

When it is not always directly related to specific illness or prognosis (Anxiety)

Question 13

How do you set priorities in the clinical nursing practice?

Answer 13

(1) Assess the patient
(2) Identify the problem
(3) Prioritize problems
(4) Identify desired outcomes
(5) Identify interventions for achieving outcomes
(6) Prioritize interventions
(7) Deliver patient care
(8) Evaluate interventions

Question 14

What are the factors that affect priority setting in the clinical nursing practice?

Answer 14

(1) Experience and expertise of nurse
(2) Patient acuity
(3) Availability of resources
(4) Interruptions from care providers
(5) Nurse-patient relationship
(6) Ward organization
(7) Priority setting strategies and frameworks
(8) Philosophies and models of care

Question 15

What are the questions that you need to ask when setting goals and expected outcomes?

Answer 15

(1) What do I plan to achieve?
(2) How will I know when I have achieved what I want?

Question 16

This describes a desired change in a patient’s condition, perceptions, or behavior.

Answer 16

Goal

Question 17

This is the measurable change (patient behavior, physical state, or perception) that must be achieved to reach a goal.

Answer 17

Expected Outcome

Question 18

This is the patient’s highest possible level of wellness & independence in function.

Answer 18

Patient-centered goal

Question 19

What constitutes patient-centered goal?

Answer 19

(1) Mission and values aligned with patient goals
(2) Care is collaborative, coordinated, and accessible.
(3) Physical comfort and emotional well-being are top priorities
(4) Patient and family viewpoints respected and values
(5) Patient and family always included in decisions
(6) Family welcome in care setting
(7) Full transparency and fast delivery of information

Question 20

Is this a goal statement or an outcome statement, “Patient will ambulate independently in 3 days”.

Answer 20

Goal statement

Question 21

Is this a goal statement or an outcome statement, “Patient ambulates in the hall 3 times a day by 4/22.”

Answer 21

Outcome Statement

Question 22

What does SMART mean?

Answer 22

(1) Specific
(2) Measurable
(3) Attainable
(4) Realistic
(5) Timed

Question 23

Under SMART, in this each goal & outcome addresses only one behavior, perception, or physiological response.

Answer 23

Specific

Question 24

Why is the statement “Patient will administer a self-injection
and demonstrate infection control measures.” wrong?

Answer 24

The statement uses two approaches namely administer and demonstrate. Hence, the statement should be - Patient will administer a self-injection and demonstrate infection control measures.

The nurse should word each goal separately.
(a) “Patient will administer a self-injection by discharge”.
(b) “Patient will demonstrate infection control measures at home”.

Question 25

Under SMART, in this the goals and the expected outcomes are the standards against which to measure or observe a patient’s response.

Answer 25

Measurable

Question 26

What is another condition for a measurable outcome?

Answer 26

Goals & expected outcomes are the standards against which to measure or observe a patient’s response.

Example: “Apical pulse will remain between 60 and 100 beats/min”.

Question 27

Under SMART, in this, a goal & an outcome likely are attainable when mutually set with the patient.

Example: Distance to walk; topics to learn about medications.

Answer 27

Attainable

Question 28

In this, the goals and expected outcomes that a patient is able to realistically reach.

Example: Patient who experienced stroke. “Assuming self-care with bathing”.

Initial goal: “Patient will wash hands & face in 72 hours.

Answer 28

Realistic

Question 29

Under SMART, the goal and outcome is time limited so health care team has a common time frame for problem resolution.

Example: Patient will achieve pain relief by day of discharge.

Answer 29

Timed

Question 30

This type of intervention can be executed solely by the nurse and require no doctor’s order.

Answer 30

Independent intervention

Question 31

What are some examples of independent intervention?

Answer 31

(1) Positioning patients
(2) Instructing patients in side effects of medications
(3) Providing skin care

Question 32

This type of intervention cannot be executed solely by the nurse and require doctor’s order.

Answer 32

Dependent interventions

Question 33

What are some examples of dependent intervention?

Answer 33

(1) Medication administration
(2) Inserting FC and IV
(3) Preparing patient for diagnostic test

Question 34

This type of intervention cannot be done solely by the nurse and entails work from different healthcare professionals like respiratory therapist and nutritionists.

Answer 34

Collaborative interdependent

Question 35

What are some examples of collaborative interdependent intervention?

Answer 35

(1) Consultation with respiratory therapist
(2) Consultation with Dietician
(3) Physical Therapy

Question 36

What should nurses do under planning?

Answer 36

(1) Establish a plan of care that
prioritizes the diagnoses & establishes nursing interventions, patient-centered
goals, & expected outcomes.
(2) Plan individualize plan of care for a patient’s unique needs.

Question 37

What do outcomes provide?

Answer 37

Outcomes provide the desired physiological, psychological, social, developmental, or spiritual responses.

Question 38

This approach in the nursing process begins after you develop a plan of care.

Answer 38

Implementation

Question 39

What does implementation include?

Answer 39

Direct and indirect care measures

Question 40

What should implementation be?

Answer 40

Patient-centered

Question 41

These are preprinted document containing orders for routine therapies, monitoring guidelines, and/or diagnostic procedures.

Answer 41

Standing Orders

(Example: Order specifying certain medication. (Cardizem,
Cordarone)

Question 42

What are the purpose of nursing interventions classifications?

Answer 42

(1) Standardizing the nomenclature
(2) Expanding nursing knowledge about connections among nursing diagnoses, treatments, & outcomes.
(3) Developing NIC language into software of health care information systems.
(4) Teaching decision making to students; defining & classifying N.I.
(5) Expanding nursing knowledge about connections among nursing diagnoses, treatments, & outcomes.
(6) Determining the cost of services provided by nurses.
(7) Standardizing a clear & consistent language to communicate the unique functions of nursing.
(8) Linking with the classification systems of other health care providers.

Question 43

Explain the implementation process?

Answer 43

(1) Reassessing a patient
(2) Reviewing and revising the existent care plan
(3) Preparing for implementation
(4) Anticipating and preventing complications
(5) Implementation skills (cognitive, interpersonal, and psychomotor)

Question 44

This type of care includes activities of daily living like ambulation, dressing and eating.

Answer 44

Direct Care

Question 45

This includes, shopping, preparing meals, and taking medications.

Answer 45

Instrumental ADL’s

Question 46

What are examples of direct care?

Answer 46

(1) Physical care techniques e.g turning & positioning, administering medications
(2) Lifesaving measure e.g CPR, administering “E” drugs
(3) Counseling
(4) Teaching
(5) Controlling for adverse reactions

Question 47

What are examples of indirect care?

Answer 47

(1) Communicating N.I
(2) Delegating, supervising & evaluating the work of other staff members

Question 48

What should nurses consider under implementation?

Answer 48

(1) The implementation of
nursing skills requires additional K, nursing skills & personnel resources.
(2) Know the purpose of each intervention.

Question 49

This is the final step of the nursing process.

Answer 49

Evaluation

Question 50

Under the nursing process, this pertains to the expected outcomes established during
planning are the standards whether goals have been met.

Answer 50

Evaluation

Question 51

According to She-Yuan et al. 2013, what are the indicators of evaluation?

Answer 51

(1) Examine the results according to clinical data
(2) Compare achieved effect with goals and expected outcomes
(3) Recognize errors
(4) Understand patient situation, participate self-reflection and correct errors

Question 52

What are the steps in evaluating outcomes of care?

Answer 52

(1) Examine the outcome criteria to identify the exact desired patient behavior or response.
(2) Evaluate patient’s actual behavior or response
(3) Compare established outcome criteria with the actual behavior or response
(4) Judge the degree of agreement between outcome and actual behavior

Question 53

What are the components of a care plan revision?

Answer 53

(1) Discontinuing a care plan
(2) Modifying a care plan
(3) reassessment
(4) Redefining diagnoses
(5) Goals and expected outcomes (time frame)
(6) Interventions

Question 54

This is the minimum level of care accepted to ensure high quality of patient care.

Answer 54

Standard of care

Question 55

In this, the nurse collaborates and evaluates effectiveness of interventions as well as documents results.

Answer 55

Standards of Evaluation

Question 56

What are the two components of evaluation?

Answer 56

(1) Examination of condition
(2) Judgement

Question 57

This occurs when the desired goals and expected outcomes are met.

Answer 57

Positive evaluation

Question 58

These are assessment skills use to collect data for determining
if outcomes are met.

Answer 58

Evaluative measures

Question 59

This allows all members of the health care team to know whether or not a patient is
progressing.

Answer 59

Documentation of evaluative
findings

Question 59

What happens do the nursing diagnosis after evaluation?

Answer 59

A patient’s nursing diagnoses, priorities, and interventions sometimes change as a result of
evaluation.

Question 60

What are the two factors examined by evaluation?

Answer 60

Evaluation examines two factors:
appropriateness of the interventions & the correct
application of the intervention.