nursing process

Question 1

o Systematic, rational method of planning and
providing individualized nursing care

Answer 1

Nursing process

Question 2

Phases of the Nursing Process

Answer 2

o Assessing
o Diagnosing
o Planning
o Implementing
o Evaluating

Question 3

Planning the interview and setting

Answer 3

Time
Place
Seating arrangement
Distance
Language

Question 4

Cephalocaudal approach

Answer 4

• Head-to-toe progression

Question 5

Conceptual Models and Frameworks

Answer 5

Gordon’s functional health pattern framework
o Orem’s self-care model
o Roy’s adaptation model

Question 6

Assist clients to identify and explore lifestyle
habits and health behaviors, beliefs, values, and
attitudes

Answer 6

Wellness Models

Question 7

4 types of assessment

Answer 7

o Initial nursing assessment
o Problem-focused assessment
o Emergency assessment
o Time-lapsed reassessment

Question 8

DATA COLLECTION METHODS

Answer 8

Observing
Interviewing
Examining

Question 9

Cephalocaudal approach

Answer 9

Head-to-toe progression

Question 10

Assist clients to identify and explore lifestyle
habits and health behaviors, beliefs, values, and
attitudes

Answer 10

Wellness Models

Question 11

Nonnursing Models

Answer 11

Body systems model

Maslow’s Hierarchy of Needs

Developmental theories

Question 12

Developmental theories

Answer 12

▪ Havighurst’s age periods and
developmental tasks
▪ Freud’s five stages of development
▪ Erikson’s eight stages of development
Piaget’s phases of cognitive
development
▪ Kohlberg’s stages of moral development

Question 13

The act of “double-checking,” verifying data to
confirm it is accurate and factual

Answer 13

Validation

Question 14

Nurses use critical thinking skills to interpret assessment
data and identify client strengths and problems.

Answer 14

DIAGNOSING

Question 15

A statement or conclusion regarding the nature of
a phenomenon

Answer 15

• Diagnosis

Question 16

STATUS OF THE NURSING DIAGNOSES
o Problem presents at the time of assessment.
o Presence of associated signs and symptoms

Answer 16

• Actual nursing diagnosis

Question 17

STATUS OF THE NURSING DIAGNOSES
o Cluster of nursing diagnoses that have similar
interventions

Answer 17

Syndrome diagnosis

Question 17

STATUS OF THE NURSING DIAGNOSES
o Preparedness to implement behaviors to improve
their health condition
o Example: Readiness for Enhanced Nutrition

Answer 17

Health promotion diagnosis

Question 18

STATUS OF THE NURSING DIAGNOSES
o Problem does not exist.
o Presence of risk factors

Answer 18

Risk nursing diagnosis

Question 19

o Cluster of nursing diagnoses that have similar
interventions

Answer 19

Syndrome diagnosis

Question 20

o Separation into components (deductive
reasoning)

Answer 20

• Analysis

Question 21

o Putting together of parts into whole (inductive
reasoning)

Answer 21

• Synthesis

Question 22

THE DIAGNOSTIC PROCESS

Answer 22

• Critical thinking
• Analysis
• Synthesis

Question 23

o Problem (P)
o Etiology (E)
o Joined by the words “related to”

Answer 23

Basic Two-Part Statements

Question 24

▪ Problem (P)
▪ Etiology (E)
▪ Signs and symptoms (S)

Answer 24

Basic Three-Part Statements
o PES format

Question 25

o Health promotion diagnoses beginning with
Readiness for Enhanced
o Seven syndrome diagnoses

Answer 25

One-Part Statements

Question 26

DEVELOPING NURSING CARE PLANS
A strategy for action that exists in nurse’s mind

Answer 26

Informal nursing care plan

Question 27

DEVELOPING NURSING CARE PLANS
A formal plan that specifies actions for a group of
clients with common needs

Answer 27

Standardized care plan

Question 27

DEVELOPING NURSING CARE PLANS
Written or computerized guide

Answer 27

Formal nursing care plan

Question 28

DEVELOPING NURSING CARE PLANS
Tailored to meet the unique needs of a specific
client

Answer 28

Individualized care plan

Question 29

Types of Nursing Interventions
o Activities nurses are licensed to initiate (i.e.,
physical care, ongoing assessment)

Answer 29

Independent interventions

Question 30

Types of Nursing Interventions
Activities carried out under primary care
provider’s orders or supervision, or according to
specified routines

Answer 30

Dependent interventions

Question 31

Types of Nursing Interventions
o Actions nurse carries out in collaboration with
other health team members
o Reflect overlapping responsibilities of healthcare
team

Answer 31

Collaborative interventions**

Question 32

Groups information into three categories

Answer 32

o Problems
o Interventions
o Evaluation

Question 33

NURSING CARE PLAN
o Written for each client

Answer 33

Traditional care plans

Question 34

NURSING CARE PLAN
o Based on institutions standards of practice

Answer 34

Standardized care plans

Question 35

Concise method of organizing and recording data
* Series of cards kept in a portable index file or on
computer-generated form
* Information quickly accessible

Answer 35

KARDEXES

Question 36

Skin Assessment Record
Such as

Answer 36

the Braden Assessment

Question 37

Body temperature, pulse, respiratory rate, blood
pressure, weight, other significant clinical data

Answer 37

Graphic Record

Question 38

o Initial nursing assessment for each client

Answer 38

The Joint Commission

▪ History
▪ Physical examination
▪ Performed and documented within 24
hours of admission

Question 39

aka covert data

Answer 39

subjective data

Question 40

aka overt data

Answer 40

objective data

Question 41

Cues

Answer 41

▪ Subjective, objective data that can be
directly observed by the nurse

Question 42

▪ Nurse’s interpretation based on cues

Answer 42

Inferences

Question 42

The first taxonomy was

Answer 42

alphabetical.

Question 43

The first taxonomy was alphabetical.
* Later version based on

Answer 43

“human response patterns”

Question 44

• Taxonomy II has three levels.

Answer 44

o Domains
0 Classes
o Nursing diagnoses

Question 44

o Deliberate, systematic, problem-solving phase of
nursing process

Answer 44

planning