NURSING PROCESS

Question 1

deliberative, systematic phase of the
nursing process that involves decision
making and problem solving.

Answer 1

planning

Question 2

Refers to the client’s assessment data and
diagnostic statements for direction in
formulating client goals and designing the
nursing interventions required to present,
reduce or eliminate the client’s health
problems ; nurse’s responsibility

Question 3

begins with the first client contact
and continuous until Nurse-Client
relationship ends, usually, when the client is
discharged from the health agency

Answer 3

planning

Question 4

The nurse performs the admission
assessment usually develops the initial
comprehensive plan of care.

Answer 4

initial planning

Question 5

The nurse has the benefit of seeing the client’s
body language and can gather intuitive kinds
of information that are not available solely
from the

Answer 5

written database

Question 6

• Occurs at the beginning of a shift as the
nurse plans the care to be given that day
• All nurses who work with the client do
ongoing planning.

Answer 6

ongoing planning

Question 7

→ To determine whether the client’s health
status has changed
→ To set priorities for the client’s care during
the shift
→ To decide which problems to focus on
during the shift
→ To coordinate the nurse’s activities so that
more than one problem can be addressed
at each client contact

Answer 7

purposes of ongoing planning

Question 8

process of anticipating and planning
for needs after discharge, is crucial part of
a comprehensive health care plan and
should be addressed in each client’s care
plan ; begins at first client contact

Answer 8

discharge planning

Question 9

process of establishing
a preferential sequencing for addressing
nursing diagnosis and intervention

Answer 9

setting priorities

Question 10

In Maslow’s Hierarchy of Needs,
the physiologic needs of a person such
as air, food, and water, are basic needs
to life and receive _ priority

Answer 10

highest

Question 11

what are the factors to consider when assigning priorities

Answer 11

client’s health values and beliefs
client’s priorities
resources available to the nurse and client
urgency of the health problem
medical treatment plan

Question 12

Is a desired outcome or change in client
behavior

Answer 12

goal

Question 13

More specific, measurable criteria used to
evaluate whether goal has been met

Answer 13

expected outcome

Question 14

a comprehensive taxonomy of patient
outcomes influenced by nursing care.

Answer 14

nursing outcomes classification (NOC)

Question 15

is required in all phases of the Nursing
Process.

Answer 15

standardized or common nursing language

Question 16

Goals that can happen quickly

Answer 16

short term goals

Question 17

Goals that take a long time to achieve

Answer 17

long term goals

Question 18

Goals and outcomes are derived from the
client’s nursing diagnoses – primarily formt
he ; contains the unhealthy response, what should change

Answer 18

diagnostic label

Question 19

is the client, any
part of the client, or some attribute of
the client, such as the client’s pulse or
urinary output

Answer 19

subject

Question 20

specifies an action the client is
to perform

Answer 20

verb

Question 21

may be added to
the verb to explain the circumstances under
which the behavior is to be performed ; what, where, when, or how

Answer 21

condition or modifier

Question 22

indicates the standard by
which a performance is evaluated or the
level at which the client will perform the
specified behavior ; speed, accuracy, distance, quality

Answer 22

criterion of desired performance

Question 23

The establish a time-achievement criterion,
the nurse needs to ask

Answer 23

how long

Question 24

To establish accuracy criterion, the nurse
asks

Answer 24

how well

Question 25

Write goals and outcomes in terms of __ not nurse activitie

Answer 25

client responses

Question 26

Make sure that each goal is derived from only __ nursing diagnosis.

Answer 26

one

Question 27

Nursing process is action oriented, client centered and outcome directed ; action phase in which the nurse performs the nursing intervention ; doing and documenting

Answer 27

implementation

Question 28

Treatments performed through interaction with patients ; medication, IV insertion, counseling

Answer 28

direct care

Question 29

performed away from the patient but on behalf of the patient or group of patients ; managing environment, documentation, interdisciplinary collaboration

Answer 29

indirect care

Question 30

Nurse initiated intervention ; without supervision or directions from the others ; licensed to initiate on the basis of their knowledge and skills

Answer 30

independent nursing intervention

Question 31

Health care provider-initiated intervention ; orders or supervision of a licensed pysicians

Answer 31

dependent intervention

Question 32

• Interdependent intervention • Are therapies that require the combined knowledge, skill & expertise of multiple health care providers • Actions the nurse carries out in collaboration with other health team members

Answer 32

collaborative intervention

Question 33

safe and appropriate for age, health condition ; achievable w resources available ; congruent w client's beliefs and other therepies ; based on nursing knowledge and experience; established standards

Answer 33

criteria for choosing nursing intervention

Question 34

• Problem Solving • Decision Making • Critical thinking

Answer 34

cognitive skills

Question 35

• Verbal non verbal communication • Therapeutic communication

Answer 35

interpersonal skills

Question 36

• Manipulating equipment • Giving injections • Bandaging • Moving, lifting and repositioning the client

Answer 36

technical skills

Question 37

what is the implementation process

Answer 37

reassing a patient determining the nurse's need for assistance implementing nursing intervnetion supervising the delegated care documenting nursing activities

Question 38

→ Continuous process with each patient interaction modification of a care plan to meet a client whose status has changed significantly → The nurse must reassess the client to make sure if intervention is still needed → New data may indicate a need to change the priorities of care of the

Answer 38

reassessing the client

Question 39

→ The nurse unable to implement the nsg activity safely or deficiently alone (e.g. ambulating an unsteady obese client) → assistance would reduce stress on the client (e.g. turning a person who experience acute pain when moved) → The nurse lack of knowledge or skills in implementing a particular nursing activities (e.g. nurse

Answer 39

determining the nurses need for assistance

Question 40

→ Base nursing interventions on scientific knowledge, nursing research & professional standards of care → Clearly understand the intervention to be implemented & question any that are not understood → Adapt activities to the individual client

Answer 40

implementing nursing interventions

Question 41

→ The nurse responsible for the overall care must ensure that the activities have been implemented according to the care plan → The nurse validate & responds to any adverse findings or client response, this may involve modifying nursing care

Answer 41

supervising delegated care

Question 42

→ the nurse completes the implementing phase by recording the interventions & client responses in the nursing progress notes → Nursing care must not be recorded in advance → The nurse may record routine or recurring activities ( eg mouth care) in the client record at the end of the shift

Answer 42

documenting nursing activities

Question 43

planned, ongoing, purposeful activity in which the clients & health care professionals determine: → the clients progress towards achievement of goals/outcomes → The effectiveness of the nursing care plan

Answer 43

evaluation

Question 44

The desired outcomes must be stated concretely in _- terms

Answer 44

behavioral

Question 45

→ During assessment the nurse collects data for the purposes of __

Answer 45

making diagnosis

Question 46

→ During evaluation the nurse collects data for purposes of __

Answer 46

comparing it to preselected goals/outcomes & judging the effectiveness of the nursing care

Question 47

what are the components of the evaluation phase

Answer 47

collecting data comparing data w desired outcomes relating nursing acts drawing conclusions ab problem stat continuing, modifying, or terminating the nursing care plan

Question 48

The nurse collects data so that conclusions can be drawn about whether

Answer 48

goals have been met

Question 49

• Data must be recorded _ and _ to facilitate the next part of evaluating process

Answer 49

concisely & accurately

Question 50

the client response is the same as the desired outcome

Answer 50

goal was met

Question 51

either a short term outcome was achieved but the long term goal was not, or desired goal was incompletely attained

Answer 51

goal was partially met

Question 52

TRUE OR FALSE It should never be assumed that a nursing activity was the cause of or the only factor in meeting, partially meeting, or not meeting a goal

Answer 52

TRUE

Question 53

The actual problem stated in the nursing diagnosis has been resolved or the potential problem is being prevented & risk factors no longer exist

Answer 53

drawing conclusions

Question 54

• The potential problem stated in the nursing diagnosis is being prevented but the risk factors are still present

Answer 54

drawing conclusions

Question 55

• The actual problem still exist even though some goals are being met

Answer 55

drawing conclusions

Question 56

incomplete or incorrect database ; the nurse needs to

Answer 56

reassess the client and record new data (new data may indicate the need for new nursing diagnosis, new goals, nursing intervention)

Question 57

If the database is incomplete new diagnostic statements may be required • If the database is complete the nurse needs to analyze whether the problems were identified correctly & whether the nursing diagnoses were relevant to the database

Answer 57

planning

Question 58

• If the nursing diagnosis was inaccurate, obviously the goal/outcome statement will need revision • If the nursing diagnosis was appropriate the nurse then checks if the goals were realistic & attainable

Answer 58

desired outcomes

Question 59

Even all the sections of care plan appear to be satisfactory, the manner in which the plan was implemented may have __

Answer 59

interfered with goal achievement

Question 60

an ongoing systematic process designed to evaluate & promote excellence in the health care provided to clients ; evaluation of level of care provided in health care agency ; limited to the evaluation of the performance

Answer 60

quality assurance program

Question 61

what are the components of quality assurance

Answer 61

structure evaluation process evaluation outcome evaluation

Question 62

Focuses on the setting in which care is given

Answer 62

structure evaluation

Question 63

Focuses on how the care was given

Answer 63

process evaluation

Question 64

→ Focuses on demonstrable changes in the client’s health status as a result of nursing care

Answer 64

outcome evaluation

Question 65

Follows client’s care rather than organizational structure ; process rather than individuals ; systematic approach with an intention of improving quality of care rather than ensuring quality of care.

Answer 65

quality improvement

Question 66

rather than individuals, uses a systematic approach with an intention of improving quality of care rather than ensuring quality of care ; national voluntary standards for nursing sensitive care

Answer 66

national quality forum

Question 67

Refers to the examination or review of records

Answer 67

audit

Question 68

→ Is the evaluation of a client’s record after discharge from an agency → Relating to the past events

Answer 68

retrospective audit

Question 69

→ Is the evaluation of a client¡¦s health care while the client is still receiving care from the agency

Answer 69

concurrent audit