N200 Midterm Nursing Process

Question 1

The nursing process provides?

Answer 1

a common language and process for nurses to think through clients’ clinical problems while focusing on a particular client’s unique needs.

Question 2

The nursing process is used to….

Answer 2

diagnose, and treat human responses to actual or potential health problems

Question 3

What are the 5 steps in the nursing process?

Answer 3

ADPIE
Assessment: gather information about the client’s condition
Diagnosis: identify the client’s problem
Plan: set goals of care and desired outcomes and identify appropriate nursing actions
Implementation: perform the nursing actions identified in planning
Evaluation: detmerine if goals met and outomes achieved

Question 4

With assessment, what is subjective data?

Answer 4

Interview and health history- what the patient tells you

Question 5

With assessment, what is objective data?

Answer 5

what you see, includes:
Physical Exam
Diagnostic and Lab Data
Observation of client’s behavior- what you see

Question 6

what is a data cluster?

Answer 6

set of signs or symptoms gathered during assessment that you group together in a logical way.

Question 7

A related factor is

Answer 7

a condition, historical factor, or etiology that gives a context for the defining characteristics and shows a type of relationship with the nursing diagnosis

Question 8

Collaborative Problems

Answer 8

Actual or potential physiological complication that nurses monitor to detect the onset of changes in a client’s status
PHYSIOLOGICAL complication that requires the nurse to use nursing and … to maximize pt outcomes

Question 9

What is included in the diagnostic process

Answer 9

Analysis and Interpretation (Data Validation and Clustering; Derived from assessment)
Identification of Client Needs (Based on defining characteristics; Clinical criteria)
Formulation of Nursing Diagnosis

Question 10

risk nursing diagnosis

Answer 10

describes human responses to health conditions or life processes that may develop in a vulnerable individual, family, or community

Question 11

What are the 4 types of nursing diagnosis?

Answer 11

Actual nursing diagnosis
Risk nursing diagnosis
Health Promotion diagnosis
Wellness nursing diagnosis

Question 12

health promotion nursing diagnosis

Answer 12

A health promotion nursing diagnosis is a clinical judgment of a person’s, family’s, or community’s motivation, desire, and readiness to increase well-being and actualize human health potential as expressed in their readiness to enhance specific health behaviors such as nutrition and exercise.

Question 13

actual nursing diagnosis

Answer 13

describes human responses to health conditions or life processes that exist in an individual, family, or community.

Question 14

etiology or related factor of a nursing diagnosis

Answer 14

The etiology or related factor of a nursing diagnosis is always within the domain of nursing practice and a condition that responds to nursing interventions.

Question 15

diagnostic label

Answer 15

is the name of the nursing diagnosis as approved by NANDA International

Question 16

nursing diagnosis format includes (4)

Answer 16

Diagnostic Label
Related Factors
Etiology
Risk Factors

Question 17

The related factor

Answer 17

is identified from the patient’s assessment data and is the reason the patient is displaying the nursing diagnosis. The related factor is associated with a patient’s actual or potential response to the health problem and can change by using specific nursing interventions.

Question 18

Related factors for NANDA-I diagnoses include what four categories?

Answer 18

1. pathophysiological (biological or psychological),
2. treatment-related,
3. situational (environmental or personal)
4. maturational

Question 19

Where can errors occur in the diagnostic process?

Answer 19

Errors can occur in the diagnostic process during data collection data clustering, data interpretation and statement of the nursing diagnosis

Question 20

Name 5 ways error can be avoided in the diagnostic process.

Answer 20

1. Identify the client’s response, not the medical diagnosis.
2. Identify a NANDA diagnostic statement rather than the symptom.
3. Identify a treatable etiology rather than a clinical sign or chronic problem.
4. Identify the problem caused by the treatment or diagnostic study rather than the treatment or study itself.
5. Validate that measurable objective physical findings support subjective data

Question 21

Name 5 ways error can be avoided in the diagnostic process (cont’d….)

Answer 21

6. Identify the client response to the equipment rather than the equipment itself.
7. Identify the client’s problems rather than your problems.
8. Identify the client problem rather than the nursing intervention.
9. Identify the client problem rather than the goal.
10. Make professional rather than prejudicial judgments. say “pt declines X due to X” rather than “pt refuses…”

Question 22

A nurse reviews data gathered regarding a patient's pain symptoms. The nurse compares the defining characteristics for acute pain with those for chronic pain and in the end selects acute pain as the correct diagnosis. This is an example of the nurse avoiding an error in:
A.	Data collection.
B.	Data clustering.
C.	Data interpretation.
D.	Making a diagnostic statement.
Rationale

Answer 22

C. Data interpretation.
In the review of data, the nurse compares defining characteristics for the two nursing diagnoses and selects one based on the interpretation of data. Making a diagnostic statement is incorrect because the nurse has not included a related factor.

Question 23

The nursing diagnosis readiness for enhanced communication is an example of a(n):
A.	Risk nursing diagnosis.
B.	Actual nursing diagnosis.
C.	Health promotion nursing diagnosis
D.	Wellness nursing diagnosis.

Answer 23

C. Health promotion nursing diagnosis
A patient’s readiness for enhanced communication is an example of a health-promotion diagnosis because it implies the patient’s motivation and desire to strengthen his health.

Question 24

Which of the following are examples of collaborative problems? (Select all that apply.)
A.	Nausea
B.	Hemorrhage
C.	Wound infection
D.	Fear

Answer 24

Which of the following are examples of collaborative problems? (Select all that apply.)

B. Hemorrhage
C. Wound infection
collaborative problems, actual or potential physiological complications. Nurses typically monitor for these to detect changes in a patient’s status. Nausea and fear are both NANDA-I approved nursing diagnoses.

Question 25

The following nursing diagnoses all apply to one patient. As the nurse adds these diagnoses to the care plan, which diagnoses will not include defining characteristics?
A.	Risk for aspiration
B.	Acute confusion
C.	Readiness for enhanced coping
D.	Sedentary lifestyle

Answer 25

A. Risk for aspiration
A risk diagnosis does not have defining characteristics, but instead risk factors. Risk factors are the environmental, physiological, psychological, genetic, or chemical elements that place a person at risk for a health problem.

Question 26

Define Planning with regard to nursing diagnosis.

Answer 26

Client-centered goals are established and interventions are designed to achieve the goals.

Question 27

What are the 4 steps to Designing nursing care for a client?

Answer 27

set priorities
determine goals
develop expected outcomes
formulate a plan of care

Question 28

Expected Outcomes

Answer 28

• the specific, step-by-step objective that leads to attainment of the goal and the resolution of the etiology for the nursing diagnosis.
• Measurable change of the clients status in response to nursing care

Question 29

What are the 3 types of Nursing INterventions?

Answer 29

Nurse-initiated interventions
Physician-initiated interventions
Collaborative interventions by ancillary personal, protocols and standing orders.

Question 30

Implementation

Answer 30

describes the initiation of nursing behavior in which the actions necessary for achieving the goals and expected outcomes of nursing care are initiated and completed. Write how pt tolerated action

Question 31

Implementation Process includes (4)

Answer 31

Reassessing the client
Organizing resources and care delivery
Anticipating and preventing complications
Communicating nursing interventions

Question 32

What are the 3 implementation skills associated with the nursing process?

Answer 32

Cognitive skills
Interpersonal skills: family dynamics
Psychomotor skills

Question 33

The evaluation step of the nursing process

Answer 33

measures the client’s response to nursing actions and the client’s progress toward achieving goals.

Question 34

Describes?
A written guideline for client care used by all members of the nursing team
Coordinates nursing care, promotes continuity of care, and lists outcome criteria to be used in the evaluation of nursing care.
Communicates nursing priorities to other health care professionals
Decreases the risk of incomplete, incorrect, or inaccurate care

Answer 34

Nursing Care Plan

Question 35

Describes?
Visual representation of client problems that show relationships to one another
Groups and categorizes nursing concepts for a holistic view of health care needs
Gather assessment data
Review references (textbooks, pathways,education materials)
Skeleton Diagram
Identify Diagnosis
Analyze relationships
Interventions and Evaluations

Answer 35

Concept Map

Question 36

allow staff from all disciplines to develop integrated care plans for a projected length of stay or number of visits for clients.

Answer 36

Critical pathways

Question 37

Consultation

Answer 37

is a process in which a specialist’s help is sought to identify ways to handle problems in client management or problems related to the planning and implementation of programs.

Question 38

Discharge teaching and planning occurs the _____ the patient is admitted to the hospital.

Answer 38

MOMENT

Question 39

Collaborative interventions,

Answer 39

or interdependent interventions, are therapies that require the combined knowledge, skill, and expertise of multiple health care professionals.

Question 40

______are patient care management plans that provide the multidisciplinary health care team with the activities and tasks to be put into practice sequentially (over time); their main purpose is to deliver timely care at each phase of the care process for a specific type of patient

Answer 40

Critical pathways

Question 41

A nurse assesses a 78-year-old patient who weighs 240 pounds (108.9 kg) and is partially immobilized because of a stroke. The nurse turns the patient and finds that the skin over the sacrum is very red and the patient does not feel sensation in the area. The patient has had fecal incontinence on and off for the last 2 days. The nurse identifies the nursing diagnosis of risk for impaired skin integrity. Which of the following goals are appropriate for the patient? (Select all that apply.)
A. Patient will be turned every 2 hours within 24 hours.
B. Patient will have normal bowel function within 72 hours.
C. Patient’s skin will remain intact through discharge.
D. Patient’s skin condition will improve by discharge.

Answer 41

B. Patient will have normal bowel function within 72 hours.
C. Patient’s skin will remain intact through discharge.
The skin remaining intact is an appropriate goal for the patient’s at-risk diagnosis. A return of normal bowel functioning is also appropriate since it indicates removal of a risk factor. Turning the patient is an intervention; skin condition improving by discharge is a poorly written goal that is not measurable.

Question 42

DAR

Answer 42

Data
Action
Response