Nursing Process: AD

Question 1

Nursing process is a _____, rational method of _______ and providing _______ nursing care.

Answer 1

• Systematic
• planning
• individualized

Question 2

A client may be an?

Answer 2

• individual
• family
• community
• group

Question 3

Purpose of the Nursing Process:

1. To identify a client’s ________
2. To identify _____ or _______ health care problems or needs
3. To establish ______ to meet the identified needs
4. To deliver specific _______ to meet those needs.

Answer 3

• health status
• actual, potential
• plans
• nursing interventions

Question 4

what are the characteristics of nursing process?

Answer 4

• cyclic and dynamic nature
• client centeredness
• focus on problem solving
  -decision making
• interpersonal collaborative style
• universal applicability
• use of critical thinking
• use of clinical reasoning

Question 5

what are the phases in the nursing process?

Answer 5

ADPIE
- assessment
- diagnosis (nursing diagnosis)
- planning
- implementation
- evaluation

Question 6

it is the first step in the nursing process

Answer 6

assessment phase

Question 7

it is the systematic and continuous collection, organization, validation, documentation of data or information

Answer 7

assessment phase

Question 8

this phase is carried out during all phases of the nursing process

Answer 8

assessment phase

Question 9

a characteristic where data from each phase provide input into the next phase. Findings from the evaluation phase feed back into assessment. Hence, the nursing process is a regularly repeated event or sequence of events that is continuously changing

Answer 9

cyclic and dynamic nature

Question 10

a characteristic where the nurse organizes the plan of care according to client problems rather than nursing goals. In the assessment phase, the nurse collects data to determine the client’s habits, routines, and
needs.

Answer 10

client centeredness

Question 11

a characteristic where mental activity in which a problem is identified (unsteady state)
and requires clarifying the nature of the problem and suggesting
possible solutions.

Answer 11

focus on problem solving

Question 12

a characteristic where nurses can be highly creative in determining when and how to
use data to make decisions.

Answer 12

decision making

Question 13

characteristic that requires the nurse to communicate directly and consistently with
clients and families to meet their needs.

Answer 13

interpersonal and collaborative style

Question 14

characteristic that is used as a framework for nursing care in all types of health care settings, with clients of all age groups.

Answer 14

universal applicability

Question 15

characteristic in which requires the nurse to think creatively, use reflection, and engage
in analytical thinking

Answer 15

use of critical thinking

Question 16

characteristic by reflecting the nurse determines whether the outcome of care
was appropriate.

Answer 16

use of clinical reasoning

Question 17

what are the 4 types of assessment?

Answer 17

• initial assessment
• problem-focused
• emergency
• time-lapsed reassessment

Question 18

-performed within a specified time after admission to healthcare facility

Answer 18

initial assessment

Question 19

-done to establish a complete database for problem identification, reference & future comparison.

Answer 19

initial assessment

Question 20

approaches to assessment :
a) ________
b) ________
c) ________

Answer 20

• Head-to-toe approach
• Body systems approach
• Combination approach

Question 21

-performed to determine status of a specific problem identified in an earlier assessment
- example of a problem-focused assessment
- ______
- _____

Answer 21

• problem-focused assessment
• MIO
• Self-care ability

Question 22

-performed during physiologic or psychologic crisis of the
client

Answer 22

• emergency assessment

Question 23

-done several months after initial assessment to compare the client’s status to baseline data previously obtained.

Answer 23

• time-lapsed reassessment

Question 24

assessment involves the following:
* _______
* _______
* ________
* ________

Answer 24

• Collecting data
• Organizing data
• Validating data
• Documenting data

Question 25

- contains all the information about a client - referred to as the baseline information of the client - fundamental data in which the nurse builds client care.

Answer 25

Database

Question 26

Database includes the following: 1. ________ 2. ________ 3. _______ 4. ________

Answer 26

1. nursing health history 2. physical examination (ippa) 3. laboratory & diagnostic test results 4. material contributed by other health personnel

Question 27

who is the primary source in collecting data?

Answer 27

- client

Question 28

who are the secondary source in collecting data?

Answer 28

● Support people (family members) ● Health care providers ● Client records ● Relevant literature ● All sources other than the client

Question 29

what are the 2 types of data?

Answer 29

- subjective - objective

Question 30

______ it is referred to as _______ or covert data ● Data from client’s (and sometimes family’s) point of view. ● Includes feelings, perceptions, and concerns. ● Collected through _______.

Answer 30

- subjective - Symptoms - interview

Question 31

_______ also called ______ or overt data. ● observable and measurable data obtained through _________ and laboratory and diagnostic testing.

Answer 31

- Objective - signs - physical examination

Question 32

what are the 3 methods of collecting data?

Answer 32

- interview - observation - physical examination

Question 33

type of interview that focuses on the profile of the client/health history

Answer 33

- initial formal interview

Question 34

type of interview that informally taken during N-P interaction

Answer 34

- on-going interview

Question 35

Collected information must be organized to be useful.

Answer 35

- organizing data

Question 36

through organizing data, data ________ & data _______ is a useful way to identify significant and related information. > Actual/ Abnormal findings > Risk/ Related Factors > Strengths/ weaknesses

Answer 36

- screening - clustering

Question 37

what are the 3 models or frameworks used in organizing data?

Answer 37

1. Gordon’s 11 Functional Health Pattern Framework 2. Orem’s Self-care Model 3. Roy’s Adaptation Model

Question 38

The model describes the client’s need for adequate nutrition, normal elimination, and adequate rest to promote normal human functioning and development.

Answer 38

- orem's self-care model

Question 39

Outlines the data to be collected and classifies observable behavior into four categories: physiological, self-concept, role function, and interdependence

Answer 39

- roy's adaptation model

Question 40

“Double-checking” or verifying data to confirm that it is accurate and factual

Answer 40

- validating data

Question 41

Usually done when discrepancies occur in the data gathered in the interview and PE

Answer 41

validating data

Question 42

validating data ensures... > ensures that assessment data is ______ > ensures that ______ & related _______ data agree > ______ important data may be gathered > _______ jumping to conclusions > differentiates between ______ & ______

Answer 42

- complete - objective, subjective - additional - avoid - cues, inferences

Question 43

- Assessment data must be recorded and reported. - Accurate and complete recording of assessment data is essential for communicating information to health care team.

Answer 43

documenting data

Question 44

refers to the reasoning process

Answer 44

diagnosing

Question 45

statement or conclusion regarding the nature of a phenomenon

Answer 45

diagnosis

Question 46

standardized NANDA names for the diagnoses

Answer 46

diagnostic labels

Question 47

causal relationship between the problem & its related or risk factors

Answer 47

etiology

Question 48

recognizing the participation and contributions of nurses in the United States and Canada.

Answer 48

NANDA (North American Nursing Diagnosis Association)

Question 49

The purpose of NANDA International is to _____, _______, and promote a ________ of nursing diagnostic terminology of general use to professional nurses

Answer 49

- define - refine - taxonomy

Question 50

_______ is a clinical judgment by the physician that determines a specific disease, condition or pathological state.

Answer 50

- medical diagnosis

Question 51

_________ is a clinical judgment about individual, family, or community responses to actual or potential health problems/life processes.

Answer 51

nursing diagnosis

Question 52

it is a statement of the client’s problem which consists of the diagnostic label plus etiology.

Answer 52

nursing diagnosis

Question 53

what is the nursing diagnosis for these medical diagnosis 1. pneumonia 2. amputation 3. type 2 diabetes mellitus 4. post-op prostatectomy 5. cerebrovascular accident

Answer 53

1. ineffective airway clearance 2. disturbed body image 3. risk for unstable blood glucose 4. impaired urinary elimination 5. self-care deficit: dressing

Question 54

Type of nursing dx that focuses on a client problem at the time of assessment Ex. Ineffective Breathing Pattern and Anxiety

Answer 54

actual dx

Question 55

Type of nursing dx, problem does not exist but the presence of risk factors indicates that a problem is likely to develop if unattended. Ex. Risk for Infection

Answer 55

risk dx

Question 56

Type of nursing dx which human responses to levels of wellness in an individual, family or community that have a readiness for enhancement . Ex. Readiness for Enhanced Nutrition

Answer 56

wellness dx

Question 57

Making a nursing diagnosis is the scientific identification of the client’s needs. It requires: (1) use of _____ (2) identification of ______ in the external & internal environment (3) awareness of client’s ________ to stress

Answer 57

- judgment - stresses - reaction

Question 58

what part statement consists of a NANDA label only.

Answer 58

one-part statement

Question 59

What are the 3 types of nursing diagnosis

Answer 59

- actual dx - risk dx - wellness dx

Question 60

what format is used in the two-part statement

Answer 60

PE format (problem statement and etiology)

Question 61

describes the client’s response to an actual or potential health problem or wellness condition.

Answer 61

problem statement or diagnostic label

Question 62

the related cause or primary factors contributing to the problem. The two parts are joined by the words ________

Answer 62

- etiology - related to

Question 63

what format used for three-part statement

Answer 63

PES format

Question 64

subjective and objective data and clinical manifestations. * Connects the two parts using as manifested by or evidenced by

Answer 64

signs and symptoms or defining characteristics

Question 65

This format can not be used in risk nsg. Dx

Answer 65

basic three-part statement

Question 66

process of designing an action plan through which lifestyle behaviors can be prevented, reduced or eliminated.

Answer 66

planning

Question 67

phase which involves decision making and problem solving.

Answer 67

planning

Question 68

End product of the planning phase is the _______

Answer 68

NURSING CARE PLAN.

Question 69

3 types of planning

Answer 69

- initial - ongoing - discharge

Question 70

developing a preliminary plan of care by the nurse who performs the admission assessment.

Answer 70

initial planning

Question 71

continuous updating of client’s plan of care. Nurse can individualize the initial plan further.

Answer 71

ongoing planning

Question 72

Involves critical anticipation and planning for client’s needs after discharge.

Answer 72

discharge planning