NURSING PROCESS

Question 1

a systematic rationalized method
of planning & providing individualized nursing care.

Answer 1

NURSING PROCESS

Question 2

CLIENT MAY BE;

Answer 2

1. An individual
2. Family
3. Community
4. Group

Question 3

Data from each phase provide input to next phase

Answer 3

CYCLIC & DYNAMIC

Question 4

Plan of care is according to client’s problems/ needs.

Answer 4

CLIENT CENTERED

Question 5

Communicating with clients, significant others, and support groups.

• Collaborating with healthcare team

Answer 5

Interpersonal and Collaborative

Question 6

• Identifying possible solutions and choosing the best one to implement.
• Approaches include trial and error,intuition, and research.
• Directed towards client’s responses to real
  or potential disease/ illness.

Answer 6

Focus on Problem Solving and Decision Making

Question 7

Nursing process is used as a framework for nursing care for all types of settings with clients from all age groups.

Answer 7

Universal Applicability

Question 7

• Making clinical judgements based on knowledge base in nursing and clinical experience.

Answer 7

Use of Critical Thinking and Clinical Reasoning

Question 8

Assessing all viewpoints and
avoiding biases or prejudice.

Answer 8

FAIR MINDEDNESS

Question 8

Thinking for yourself and making
your own judgements.

Answer 8

INDEPENCE

Question 9

Awareness of the limits of
one’s own knowledge

Answer 9

INTELLECTUAL HUMILITY

Question 9

Examining one’s own
biases or customs; Self-awareness.

Answer 9

INSIGHT & EGOCENTRICITY

Question 10

Being able to readily admit and
evaluate inconsistencies with and between one’s
belief and those of another

Answer 10

INTEGRITY

Question 10

Courage to recognize that beliefs
are sometime false or misleading. Courage to be
open to new thinking.

Answer 10

Intellectual Courage to Challenge Status Quo and Rituals

Question 11

in the reasoning
process and examining emotion ladenarguments. Anchored on the belief that wellreasoned thinking will lead to trustworthy
conclusions.

Answer 11

CONFIDENCE

Question 11

Lifelong determination in finding
effective solutions to client and nursing problems

Answer 11

PERSEVERANCE

Question 12

Examining traditions and exploring new options

Answer 12

CURIOSITY

Question 13

Determining which is most
relevant and most important.

Answer 13

SETTING PRIORITIES

Question 13

Explanations of priority
setting and nursing interventions.

Acts as a check for potential errors, justifies nursing actions and contributes to client safety.

Answer 13

DEVELOPING RATIONALE

Question 14

• Understanding relevant
  medical and nursing information and translate knowledge into plan of care.

Answer 14

Learning How to Act

Question 15

Ability to recognize changes in client’s condition over time

Answer 15

Clinical Reasoning in Transition

Question 16

Ability to detect changes, identify change in priorities, adjust nursing care and alert primary
care provider when appropriate.

Answer 16

Responding to Changesin the Client’s Condition

Question 17

Identifying factors that improved
client care and those thaT required changing or
elimination.

• Thinking back / Reviewing interventions implemented and whether they were effective.

Answer 17

REFLECTION

Question 18

Gather information about the
patient’s condition.

Answer 18

ASSESSMENT

Question 18

Identify the patient’s problems.

Answer 18

DIAGNOSIS

Question 18

Set goals of care and desired
outcomes and identify appropriate nursing
actions

Answer 18

PLANNING

Question 19

Perform the nursing actions
identified in planning

Answer 19

IMPLEMENTATION

Question 20

Determine if goals and expected
outcomes are achieved.

Answer 20

EVALUATION

Question 21

TYPES OF ASSESSMENTS:

Answer 21

1. Initial Assessment
2. Problem-Focused Assessment
3. Emergency Assessment
4. Time-Lapsed Assessment

Question 22

Performed within a specified time after admission to a health care
agency

Purpose: to establish a complete
database problem identification, reference and future comparison

Answer 22

INITIAL ASSESSMENT

Question 23

Ongoing process integrated with nursing care.

Purpose: to determine the status of a specific problem identified in an earlier assessment

Answer 23

PROBLEM - FOCUSED ASSESSMENT

Question 24

Done during any physiological or psychological crisis of the client.

Purpose: to identify life-threatening problems / To identify new or overlooked problems

Answer 24

EMERGENCY ASSESSMENT

Question 26

– Done several months
after initial assessment.

Purpose: to compare the client’s current status to baseline data previously obtained

Answer 26

TIME LAPSED ASSESSMENT

Question 27

is the process of gathering
information about a client’s health status

Answer 27

DATA COLLECTION

Question 28

contains all the information of the
client. Includes nursing health history, physical assessment, primary care provider’s history and physical examination, results of laboratory and diagnostic tests and materials contributed by
other health personnel.

• Client data should include past
  history and current problems.

Answer 28

DATABASE

Question 29

2 TYPES OF DATA

Answer 29

SUBJECTIVE & OBJECTIVE

Question 30

o Symptoms or covert data (unseen)

o Can be described or verified only by that person.

o Sensations, feelings, values, beliefs, attitudes, perceptions of personal health status and life situation

Answer 30

SUBJECTIVE DATA

Question 31

o Signs or overt data (seen)

o Detectable by an observer or can be measured or tested against an accepted standard.

o Obtained by observation or physical examination.

Answer 31

OBJECTIVE DATA

Question 32

Occurs whenever the nurse is in
contact with the client or support persons.

Answer 32

OBSERVING

Question 33

Used mainly when taking the
nursing health history.

Answer 33

INTERVIEWING

Question 34

– a planned communication; a
conversation with a purpose

Answer 34

INTERVIEW

Question 35

• the nurse asks the
  client

Answer 35

FOCUSED INTERVIEW

Question 36

• Highly structured and elicits specific information
• The nurse establishes the purpose of the interview and controls the interview
• Client may have limited opportunity to ask questions or discuss concerns
• Usually used when time is limited (e.g. emergency situation)

Answer 36

DIRECTIVE INTERVIEW

Question 37

• Also known as rapport-building
  interview
• Allows the client to control the purpose, subject matter and pacing

Answer 37

NON - DIRECTIVE INTERVIEW

Question 38

-Used in directive interview

-Yes or No Questions
-What, When, Where, Who, Do, Did, Does, Is, Are, Was, Were
questions

-Often used when information is needed quickly

Answer 38

CLOSED QUESTION

Question 39

-Used in non-directive interview\

-Invite clients to discover, explore, elaborate, clarify, or
illustrate their thoughts

-What and How

-Gives clients freedom to divulge only the information they are
ready to disclose

Answer 39

OPEN ENDED QUESTION

Question 40

– Closed. Directs client’s answer and gives less opportunity to decide whether the answer is true or not. May create problems if client gives inaccurate answers to please the nurse.

Answer 40

LEADING

Question 40

questions that client can answer
without pressure. Open-ended and nondirective.

Answer 40

NEUTRAL QUESTION

Question 41

– Client communicates what they
think, feel, know, and perceive in response to questions from the nurse.

Answer 41

BODY

Question 41

– Establish rapport and orient the
purpose and flow of interview.

Answer 41

OPENING

Question 42

Offer to answer questions.
Conclude and provide the summary to verify accuracy and agreement. Thank the client and
express concern for their welfare. Plan the next
meeting ahead.

Answer 42

CLOSING

Question 43

Major method used in physical
examination or physical assessment.

Answer 43

EXAMINING

Question 44

data collection that uses
observation to detect health problems

Answer 44

SYSTEMATIC

Question 45

Techniques used in examination:
▪ I
▪ A
▪ P
▪ P

Answer 45

▪ INSPECTION
▪ AUSCULATION
▪ PALPATION
▪ PERCUSSION