Nursing Process

Question 1

What does ADPIE stand for?

Answer 1

• Assessment
• Diagnosis
• Planning
• Implementation
• Evaluation

Question 2

Assessment involves the gathering of information of what kind of sources?

Answer 2

• Pt’s S/S
• Pt Hx
• Subjective findings from the pt (Interviewing)
• Objective findings (Physical Assessment/Vital Signs/Diagnostics/Labs)

Question 3

Nursing diagnoses are related to the ____ or _____ a patient is experiencing.

Answer 3

needs, problems

Question 4

The process of determining priorities and what nursing actions should be performed to help resolve or manage a pt’s problem is done in which step of the nursing process?

Answer 4

Planning

Question 5

The actions that are taken to resolve a pt’s problem/nursing diagnoses are called _____. When the nurse performs these interventions, it is called _____.

Answer 5

interventions; implementation

Question 6

What occurs during evaluation step of the nursing process?

Answer 6

The nurse reflects on the interventions performed and decides whether the pt is closer to achieving the goals and outcomes set in the planning step.

Question 7

What should you do if the pt does not achieve the goals and outcomes set in the planning step?

Answer 7

Always tailor interventions and goals to the pt:
- Revise and change interventions
- Revise and change goals

Question 8

How is objective data limited?

Answer 8

It is limited to what you can detect with your senses – vision, hearing, smell, or touch.

Question 9

Give some examples of objective data that can be collected via vision.

Answer 9

• Directly observing the pt’s physical characteristics, facial expressions, actions, or behavior
• Directly observe characteristics of bodily fluids (blood, emesis, urine, stool, or drainage)
• Read results of diagnostic/lab test results
• Read reports and documentation within the patient’s medical record
• Read results and discern the function of equipment
• Observe the measured volume of urine or drainage in a graduated container, the volume of fluid remaining in the IV bag and/or the amount of liquid drunk from a cup with graduated markings
• Read reputable sources (medical journals, and multimedia devices) to research medical diagnoses, and treatments

Question 10

Give some examples of objective data that can be collected via sight.

Answer 10

• Note sounds made by the patient heard (spoken words, belching, passing flatus, crying, moaning, snoring)
• Note sounds heard during auscultation (respiratory, cardiac, GI)

Question 11

What are some examples of objective data that can be collected via smell?

Answer 11

Detect patient body- or bodily fluid-related odors (foul, sweety, fruity, ammonia-like, sulfurous, fresh, or musty)

Question 12

What are some examples of objective data that can be collected via touch?

Answer 12

• Assess pulse rate
• Palpate for edema, firmness or softness, nodules, skin masses, or tissue
• Detect the pt’s skin temp
• Detect the moisture of the pt’s skin
• Detect the texture of pt’s skin, hair, or nails
• Measure the strength of muscular contractions

Question 13

What are some examples of subjective data?

Answer 13

What the patient feels:
- Pain
- Nausea
- Anxiety
- Fear
- Depression
- Discouragement

Question 14

How can you establish rapport with the pt?

Answer 14

• Introduce yourself and explain your role in the pt’s care.
• Ensure that you have already reviewed the pt’s chart to avoid asking the pt questions that they have already answered and instead validate the information.
• Inform the pt the purpose of the interview and approx. length of time it will take
• Ask some general questions/make small talk to ‘break the ice’ before the interview

Question 15

If a pt is giving more detail than is necessary for you to obtain relevant information or is going on a ‘tangent’, how can you redirect the pt to the subject at hand?

Answer 15

• “Can you tell me more about the pain you have been experiencing?”
• “After that happened, what did you do to relieve the pain?”

Question 16

During a patient interview, if the pt hesitates before answering a question. How would you respond?

Answer 16

Give the pt time because they may be thinking through an answer. If they continue to hesitate, you may need to reword the question.

Question 17

How is Maslow’s hierarchy of human needs, important in prioritizing nursing diagnoses?

Answer 17

Maslow’s hierarchy identifies human needs in an ascending order of importance

Question 18

List the 8 levels of Maslow’s hierarchy of human needs in ascending order

Answer 18

1. Physiological needs
2. Safety and Security
3. Love and belonging
4. Self-esteem
5. Cognitive
6. Self-actualization
7. Transcendence

Question 19

According to Maslow’s hierarchy, what are some examples of physiological needs?

Answer 19

• Food
• Air
• Water
• Temperature regulation
• Rest
• Elimination
• Sex
• Physical activity

Question 20

The need for protection, emotional and physical safety/security, order, law, and shelter is examples of which level in Maslow’s hierarchy?

Answer 20

2. Safety and Security

Question 21

According to Maslow’s hierarchy, what are some examples of love and belonging needs?

Answer 21

• Giving and receiving affection
• Having meaningful relationships
• Belonging to group(s)

Question 22

According to Maslow’s hierarchy, what need should be addressed in the 4th level?

Answer 22

• Need for self-esteem and feeing of self-worth (pride, sense of accomplishment, recognition by others)

Question 23

The need to know, to understand, and to explore are examples of which level in Maslow’s hierarchy?

Answer 23

5. Cognitive

Question 24

What follows the cognitive level in Maslow’s hierarchy and what are some examples of it?

Answer 24

Aesthetic: Symmetry, order, and beauty

Question 25

What need does the 7th level of Maslow’s hierarchy address?

Answer 25

Need for self-actualization (reach one’s growth potential)

Question 26

What level is the highest according to Maslow’s hierarchy and what does it entail?

Answer 26

Transcendence of self and helping others self-actualize

Question 27

What does NANDA-I stand for? And what is it responsible for?

Answer 27

North American Nursing Diagnosis Association International is responsible for creating and maintaining an approved list of nursing diagnoses throughout most countries including the U.S and Canada

Question 28

How often is the NANDA-I diagnosis list updated/published?

Answer 28

Every 2 years

Question 29

What are the components in a 3-part nursing diagnosis statement?

Answer 29

PES Statement:
- Problem (diagnostic label based on the pt’s needs)
- Etiology (“related to”; causative factor(s))
- Signs and Symptoms (“as evidenced by”; supportive data)

Question 30

In what type of scenario, would a 2-part nursing diagnosis (PE or problem and etiology only) statement be sufficient?

Answer 30

When the nursing diagnosis expresses for the risk for a problem or possible problem

Question 31

When the NANDA-I diagnosis falls into the category of “wellness,” “syndrome,” or “specified”, what type of nursing diagnosis statement would be best? 1, 2 or 3-part?

Answer 31

1 part: Clearly states pt’s need w/o requiring further elaboration

Question 32

1-part nursing diagnosis statement includes wellness, syndrome, and specified. Give examples of each.

Answer 32

• Wellness: “readiness for enhanced…” which means that the pt is willing to improve their lack of hope, knowledge, coping or other needs
• Syndrome: Group of signs and symptoms which already refers to the defining characteristics. Ex. “Post-trauma syndrome”, “frail elderly syndrome”
• Specified: Clearly applies to one defined pt need and adding more information would be redundant. Ex. “Latex allergy response” does not need to be followed by “related to allergy to latex”

Question 33

In the planning step, why is it important to have a nursing goal?

Answer 33

It provides the overall direction in which one must progress to improve a problem

Question 34

How do short-term goals and long-term goals differ in when they are expected to be met?

Answer 34

Short-term goals are expected to be met by the time of discharge or transfer to another level of care whereas long-term are not

Question 35

Identify what is the PES in following nursing diagnosis statement: “Ineffective airway clearance related to secretions in the airways as evidenced by abnormal lung sounds, orthopnea, and dyspnea.”

Answer 35

Problem: Ineffective airway clearance
Etiology: Secretions in the airways
S/S: Abnormal lung sounds, orthopnea, and dyspnea

Question 36

Expected outcomes are statements of _____ action for a patient within _____ time frame and in response to nursing interventions

Answer 36

measurable; specific

Question 37

What is the standardized classification for nursing expected outcomes?

Answer 37

Nursing Outcomes Classification (NOC) contains a list of 500+ expected outcomes designed to coordinate with established NANDA-I diagnoses

Question 38

Outcome statements should include 4 components, which are?

Answer 38

1. A realistic, specific action to be taken by the pt
2. An action that the pt is willing and able to perform
3. An action that is measurable
4. A definite time frame for the action to have been accomplished

One way to remember is the goal setting mnemonic SMART (Specific, Measurable, Attainable, Realistic, Timely)

Question 39

What is the standardized language for nursing interventions?

Answer 39

Nursing Intervention Classification (NIC)

Question 40

What should be included in the initial implementation steps (prior to performing a nursing intervention)?

Answer 40

1. Checking the HCP’s order. Safety: Always review the order before executing it rather than simply going by what someone tells you is ordered. Be sure the order is appropriate for the pt and nothing has changed to contraindicate it.
2. Referring to facility procedures unless you already know them
3. Gathering needed equipment and supplies. Check to ensure that a consent form has been signed if needed.
4. Obtaining assistance if needed
5. Identifying your pt using 2 methods of identification according to facility policy. Safety: Always ensure that you are providing ordered care to the correct patient.
6. Introducing yourself to the pt if you have not previously done so. Include your name and title, such as I’m Jane Johnson, a student nurse.”
7. Explaining the procedure to the patient, using words the pt understands. Include info about what the pt will do, what the pt will feel, and what the pt is expected to do.
8. Provided privacy by closing doors and windows blinds, and if needed asking visitors to step out briefly
9. Washing your hands or using hand sanitizer according to facility policy
10. Using standard precautions unless otherwise noted
11. Using good body mechanics. Safety: Raise the bed to a comfortable working height to prevent injury to your back. Lower the near siderail.
12. Making any assessments needed to ensure that the pt still requires the procedure and is able to tolerate it
13. Continuing to observe the pt during the procedure to be aware of pain, discomfort, or any other problems

Question 41

What should the ending implementation steps entail?

Answer 41

1. Evaluating the pt’s response to the procedure
2. Ensuring the pt is safe and comfortable, in proper body alignment, w/ clean linens and call light within reach
3. Safety: Lower the bed to its lowest height to reduce the risk of falls. Raise the bed rails as appropriate and according to facility policy.
4. Performing hand hygiene
5. Asking the pt if they need anything and informing them when you plan to return
6. Leaving the room door open or closed according to the pt’s preference
7. Documenting your interventions and their effectiveness according to facility policy
8. Properly disposing of used supplies, PPE, and trash, in addition to returning equipment to the proper location

Question 42

In the evaluation step of the nursing process, you should evaluate whether your nursing interventions brought about the desired outcomes. What types of questions would you ask yourself?

Answer 42

• Are the nursing diagnoses correct?
• Have you established realistic, reachable goals?
• Have you determined the correct priorities for your nursing diagnoses?
• Have you selected and implemented the correct interventions?
• Has the pt’s condition changed?