Nursing Process

Question 1

The registered nurse analyzes the assessment
data to determine the diagnoses or issues –
validates the issues with client, family and other
healthcare provider when possible and
appropriate.

Answer 1

Nursing Process

Question 2

First step of the Nursing Process. Nurse collects the
patients’ data. It’s is the interaction with the client –
Physical, cognitive, economic, etc. The nurse analyzes the data from the client.

Answer 2

ASSESSMENT

Question 3

Collecting, validating, and clustering data , sets tone for
the rest of the process and the rest of the process that
follows it. First and most important step that identifies
the client.

Answer 3

ASSESSMENT

Question 4

COGNITIVE SKILLS

Answer 4

Critical Thinking
Clinical Decision-Making

Question 5

Why? Inquiry interpretation,
analysis and synthesis.

Answer 5

Critical Thinking

Question 6

Looking for cues
and identifying patterns

Answer 6

Clinical Decision-Making

Question 7

PROBLEM SOLVING SKILLS

Answer 7

Reflexive Thinking
Hit-or-Miss Thinking
Critical-Thinking Approach
Intuition

Question 8

automatic, without
conscious deliberation, earned with experience.

Answer 8

Reflexive Thinking

Question 9

Trial-and-Error
Approach

Answer 9

Hit-or-Miss Thinking

Question 10

Scientific
Method

Answer 10

Critical-Thinking Approach

Question 11

Developed through experience, how
experienced nurses solve problems.

Answer 11

Intuition

Question 12

Needed to perform the 4 techniques of physical
assessment (Inspection, Palpation, Percussion,
auscultation) – mastered through experience and
practice.

Answer 12

PSYCHOMOTOR SKILLS

Question 13

Needed to practice the art of nursing. Essential in
developing caring, therapeutic nurse-patient
relationship. Both verbal and non0verbal
communication skills. Establishes trust and mutual
respect before beginning assessment.

Answer 13

AFFECTIVE/INTERPERSONAL SKILLS

Question 14

Being responsible and accountable, you are an
advocate of your patients. Respect for patient’s
rights and ensure patient confidentiality.

Answer 14

ETHICAL SKILLS

Question 15

FOUR BASIC TYPES OF HEALTH ASSESSMENT

Answer 15

INITIAL COMPREHENSIVE ASSESSMENT
ONGOING OR PARTIAL ASSESSMENT
FOCUSED OR PROBLEM-ORIENTED ASSESSMENT
EMERGENCY ASSESSEMENT

Question 16

− Collection of both subjective and objective data.
− It is a total health assessment
− Other members of the healthcare team may
participate (e.g. physician, physical Therapist)

Answer 16

INITIAL COMPREHENSIVE ASSESSMENT

Question 17

− Data collection after comprehensive database is
established.
− Reassessment of initial problems detected to
determine any changes
− A follow up on the health status
− Mini-overview of the client’s body system and
holistic health patterns.

Answer 17

ONGOING OR PARTIAL ASSESSMENT

Question 18

− Performed when comprehensive database exists
for a client who comes to healthcare agency with
a specific health concern.
− Thorough assessment of a particular client
problem and does not cover related areas
related to the problem.

Answer 18

FOCUSED OR PROBLEM-ORIENTED ASSESSMENT

Question 19

Very rapid assessment performed in lifethreatening
situations like choking, cardiac
arrest, drowning. An immediate assessment is
needed to provide prompt treatment.

Answer 19

EMERGENCY ASSESSEMENT

Question 20

ABCDE RULE

Answer 20

A– Airway
B – Breathing
C – Circulation
D– Disability
E – Exposure

Question 21

Second step in the nursing process. Analyzes the
assessment data in determining diagnosis. The nurse
analyzes the data from the assessment.

Answer 21

DIAGNOSIS

Question 22

2 TYPES OF DIAGNOSIS

Answer 22

Medical Diagnosis
Nursing Diagnosis

Question 23

Made by the physician or
any advanced healthcare professional.

Answer 23

Medical Diagnosis

Question 24

Distinct step in the nursing
process. Nurses assign meaning to collected data
using the NANDA – approved nursing diagnosis.

Answer 24

Nursing Diagnosis

Question 25

DATA COLLECTION

Answer 25

Subjective Data
Objective Data

Question 26

Data comes from the patient
Covert Data – Not measurable

Answer 26

Subjective Data

Question 27

Data comes from the
observations of the nurse – Overt Data – Measurable.

Answer 27

Objective Data

Question 28

SOURCES OF DATA

Answer 28

Primary Data
Secondary Data

Question 29

the data is obtained from the
patient.

Answer 29

Primary Data

Question 30

data is obtained from
anyone else than the patient.

Answer 30

Secondary Data

Question 31

METHODS OF DATA COLLECTION

Answer 31

Observation Method
Interview Method
physical Assessment

Question 32

Use of the five senses. look at both your patient
and their environment to detect anything out of
the ordinary. – must observe non-verbal cues.

Answer 32

Observation Method

Question 33

− Conversation with a purpose. Structured intended
to obtain subjective data.
− Needs good interpersonal communication skills.
− Needs to maintain neutral, non-judgmental
position and accept patient’s verbal and nonverbal
communication.
− BE EMPATHETIC

Answer 33

Interview Method

Question 34

Provides Objective Data

Answer 34

Physical Assessment

Question 35

S.O.A.P.I.E. Method

Answer 35

S – Subjective Data
O – Objective Data
A – Assessment Plan
P – Planning
I – Interventions
E – Evaluations

Question 36

D.A.R Method

Answer 36

D – Data
A – Action
R – Response

Question 37

P.I.E Method

Answer 37

P – Problem
I – Interventions
E – Evaluations

Question 38

You narrate everything that occurred.

Answer 38

Narrative Method

Question 39

TYPES OF NURSING DIAGNOSIS

Answer 39

Actual
Potential
Possible
Collaborative
Wellness

Question 40

Occurring health problems

Answer 40

ACTUAL

Question 41

High Risk

Answer 41

POTENTIAL

Question 42

Needs further data to support

Answer 42

POSSIBLE

Question 43

Both medical and nurse

Answer 43

COLLBORATIVE

Question 44

Health seeking behavior

Answer 44

WELLNESS

Question 45

The fourth step of the nursing process. Nurses develops
the plan of care that prescribes interventions to attain
expected outcome. Involves both patient and family.
Setting goals and outcomes.

Answer 45

PLANNING

Question 46

The Planning should Be …

Answer 46

Smart
Measurable
Attainable
Relevant
Time bounded
Evaluate
Reevaluate

Question 47

TYPES OF NURSING INTERVENTION

Answer 47

Independent
Dependent
Collaborative

Question 48

Nursing Intervention solely from the nurse

Answer 48

Independent

Question 49

Nursing Intervention prescribed by the Physician

Answer 49

Dependent

Question 50

Nursing Intervention collaboration between the
physician and nurse.

Answer 50

Collaborative

Question 51

MASLOW’S HEIRARCHY OF NEEDS

Answer 51

Self-actualization

Esteem
Love and Belonging
Safety Needs
physiological Needs

Question 52

• Also called “Interventions”
• Implements the intervention identified in the plan of
  care.
• Carrying out the plan to achieve goals or outcomes

Answer 52

IMPLEMENTATION

Question 53

Nurse evaluates the patients progress towards
attainment of outcomes. Evaluation occurs continuously.
✓ The goal was completely met
✓ The goal was partially met
✓ The goal was completely unmet
✓ Care ongoing
- This is followed by the evidences or result to support such
statements.

Answer 53

EVALUATION