Nursing Process

Question 1

List the five steps of the nursing process

Answer 1

1. Assessment
2. Diagnosis
3. Planning
4. Implementation
5. Evaluation

Question 2

What is involved in the assessment phase of the nursing process?

Answer 2

Assess the client through collecting data, such as symptoms, clinical state, and known medical diagnoses

Question 3

What are the primary and secondary sources of data during the assessment phase of the nursing process?

Answer 3

Primary source - the patient
Secondary source - family, current and past medical records, other health care professionals

Question 4

How do we gather data about the client throughout the assessment stage of the nursing process?

Answer 4

Interview the client, physical examination/head-to-toe, and general survey

Question 5

What is involved in the diagnosis stage of the nursing process?

Answer 5

Analyze data collected to identify health problems, risks, and strengths

Question 6

Define what a nursing diagnosis is

Answer 6

A clinical judgement that identifies the actual or potential health conditions

Question 7

What are the three different types of nursing diagnoses?

Answer 7

1. Problem focused (actual)
2. Risk for
3. Health promotion

Question 8

What are the three sections involved in documenting a nursing diagnosis?

Answer 8

1. Part of diagnosis/nursing problem
2. Etiology/cause/contributor (rt)
3. Signs & symptoms/clinical manifestations

Question 9

Define a problem focused/actual nursing diagnosis

Answer 9

Response to a health problem or life process that currently exists - clinical judgement about a current patient health problem, which is present at the time of the nursing assessment

Question 10

Define a risk for nursing diagnosis

Answer 10

May develop in a vulnerable client, usually indicated by risk factors - clinical judgement concerning the susceptibility of an individual for developing undesirable health condition

Question 11

Define a health promotion nursing diagnosis

Answer 11

A clinical judgement that an individual, family, or community is able to transition to a level of higher wellness - an individual must show a desire for increased wellness

Focuses on enhancing health

Question 12

What is involved in the planning stage of the nursing process?

Answer 12

Determine client outcomes and plan interventions - goal is to assist in meeting desired outcomes/goals

Question 13

Describe short-term and long-term goals, as well as an example of each

Answer 13

Short-term
- outcomes that are achievable in less than one week and are more immediate
- ex. voids within 6hrs after delivery of infant

Long-term
- outcomes that may take weeks or months and are typically used for chronic health concerns
- ex. by 12 weeks post-op, will have full ROM of right shoulder

Question 14

What are SMART goals?

Answer 14

Specific, measurable, attainable, relevant, time-based

Question 15

What are expected outcomes in the nursing process?

Answer 15

Measurable changes in a client’s status that you expect in response to nursing care

Question 16

What is involved in the implementation stage of the nursing process?

Answer 16

Implementing nursing goals/interventions and reassessing how they are working

Question 17

What are examples of direct care nursing interventions?

Answer 17

ADLs, IADLs, physical care techniques, life-saving measures, counselling, teaching

Question 18

What are examples of indirect care nursing interventions?

Answer 18

Communicating nursing interventions/report, delegating, supervising, evaluating the work of others, consulting interdisciplinary team members

Question 19

What are nurse initiated interventions?

Answer 19

Interventions which do not require direction or orders

Question 20

What are physician initiated interventions?

Answer 20

Interventions dependent on nursing interventions (ex. administering medications)

Question 21

What are collaborative interventions?

Answer 21

Interdependent nursing interventions require combined knowledge and expertise from different health care providers

Question 22

What is involved in the evaluation stage of the nursing process?

Answer 22

Determines the effectiveness and outcome of nursing goals - the GOAL is evaluated, not the intervention

The analysis of the client’s responses to the interventions - evaluate the individual’s condition, and compare actual outcomes with expected outcomes

Question 23

What are first-level priority problems?

Answer 23

EMERGENT - life-threatening, immediate ABC (airway, breathing, circulation)

Question 24

What are second-level priority problems?

Answer 24

URGENT - necessitating prompt intervention (i.e., mental status change, acute pain, acute urinary elimination problems, untreated medical problems, abnormal lab values, risk of infection, safety and security

Question 25

What are third-level priority problems?

Answer 25

Important, addressed after more urgent problems (i.e., knowledge deficit, risk or potential for)

Question 26

What are collaborative problems?

Answer 26

Treatment involves multiple disciplines (i.e., data regarding alcohol use)