Nursing Process

Question 1

What is NANDA (North American Nursing Diagnosis Association)

Answer 1

Defines what nurses can do.
Give nurses more EB outcomes and interventions.

Question 2

Clinical judgement model (CJM) compared to the nursing process:
Getting the information
Making meaning of the information
Determine actions to take
Take action
Evaluate outcomes and your thinking

Answer 2

Assessment
Diagnosis
Planning
Implementing
Evaluating

Question 3

First step to nursing process

Answer 3

Assessment

Question 4

Second step to nursing process and the 2 parts of it

Answer 4

Diagnosis
3 part - ACTUAL (currently affecting patient)
2 Part - RISK (potential problem in the future)

Question 5

Third step to the nursing process and the 2 parts of it

Answer 5

Planning
Patient outcomes
Nursing interventions

Question 6

Fourth step to the nursing process

Answer 6

Implementing

Question 7

Fifth step to the nursing process

Answer 7

Evaluation OF PATIENT OUTCOMES

Question 8

A nursing care plan allows the nurse to:

Answer 8

Individualize care
Set priorities
Facilitate Communication
Evaluate patient response
Create a record

Question 9

Types of assessment

Answer 9

Initial assessment, which includes admission and start of shift.
Focused assessment which is focused on just one organ system.

Question 10

Nursing Diagnosis is a clinical judgement about an individuals:

Answer 10

Responses to actual or potential health problems.

Question 11

Nursing diagnosis is:

Answer 11

Problem-focused diagnosis and risk diagnosis

Question 12

ACTUAL Problem (3 part nursing diagnosis)

Answer 12

Problem..R/T (related to)..Etiology (cause)..AEB..Defining characteristics (signs and symptoms)

Question 13

AT RISK (2 part nursing diagnosis)

Answer 13

Problem statement..AEB…Risk factors

Question 14

Maslows Pyramid - 1st step

Answer 14

Physiologic needs:
oxygen, food, elimination, temperature control, sex, movement, rest, comfort

Question 15

Maslows Pyramid - 2nd step

Answer 15

Safety and Security:
Safety from physiologic and psychological threat; protection, continuity, stability, and lack of danger

Question 16

Maslows Pyramid - 3rd step

Answer 16

Love and belonging:
Affiliation, affection, intimacy, support, and reassurance

Question 17

Maslows Pyramid - 4th step

Answer 17

Self-esteem:
sense of self-worth, self respect, independence, dignity, privacy, and self reliance

Question 18

Maslows Pyramid - 5th step

Answer 18

Recognition and realization of ones potential, growth, health, and autonomy

Question 19

Four types of outcomes (smart goals)

Answer 19

Cognitive
Psychomotor
Affective (hardest outcome to achieve)
Physiologic

Question 20

Cognitive outcomes

Answer 20

Increase in patient KNOWLEDGE

Question 21

Psychomotor outcomes

Answer 21

Patients’ achievement of new SKILLS

Question 22

Affective outcomes

Answer 22

Changes in patient VALUES, BELIEFS, AND ATTITUDES

Question 23

Physiologic outcomes

Answer 23

PHYSICAL CHANGES in patient

Question 24

Smart goals

Answer 24

S = specific
M = measurable
A = attainable
R = realistic
T = time

Question 25

Which of these are smart goals?
A.) Offer patient 60mL of fluid every 2 hours while awake
B.) Pt. X will know how to bath her new baby
C.) The patient will walk 50 ft every 2 hours over the next 12 hrs
D.) The patient will cope better
E.) Pt. X will list the dangers of smoking and stop smoking in 2 days

Answer 25

C.) The patient will walk 50 ft every 2 hours over the next 12 hrs