Nursing Process- Ch1

Question 1

Subjective data

Answer 1

What the patient tells me

• health history
• pain

Question 2

Objective data

Answer 2

What I observe

Ex: BP

Question 3

Pain is always…

Answer 3

Subjective

Question 4

Steps of the nursing process

Answer 4

Assessment: collect data
Diagnosis: interpret data,validate diagnosis
Outcome identification: identify expected outcomes
Planning : establish priorities
Implementation: safe and timely manner, follow through
Evaluation: progress towards outcomes (recheck)

Question 5

Assessment

Answer 5

1st step of nursing process 
Gather data: reliable, organized, systematic, accurate, relevant 
Review clinical record
Interview 
Health history 
Physical exam
Functional assessment 
Consultation 
-full exam upon admission

Question 6

Nursing Process is what?

Answer 6

Problem solving approach to arrive at a solution

Question 7

During the assessment is it important to prioritize data.. These are always the first level priorities?

Answer 7

A-airway
B-breathing
C-circulation

Question 8

Second level priorities?

Answer 8

Acute pain
Change in mental status
Infection

Question 9

Third level priorities?

Answer 9

Needing activity 
Meal is incorrect
Hunger 
Thirst 
Anxiety

Question 10

What is a cue?

Answer 10

A cue is a piece of information, a S/S, or a piece of laboratory data

Question 11

Steps in the nursing process (cont)

Answer 11

Interpret data: diagnosis 
-identify clusters, make inferences 
Validate inferences 
Compare clusters of clues with definitions 
Identify related factors 
Establish a nursing diagnosis

Question 12

What is EBP?

Answer 12

It is a systematic approach to practice that emphasizes the use of the best evidence.
All patients deserve the best care with the most current and best practice techniques to ensure the best outcomes

Question 13

Types of data

Answer 13

Complete (total health) database: full physical
Episodic or problem centered: concern of 1 problem, cue or body system
Follow up: the status of any problem should be evaluated at regular intervals
Emergency: urgent rapid collection of crucial info and is used for lifesaving measures

Question 14

During the assessment is it important to prioritize data.. These are always the first level priorities?

Answer 14

A-airway
B-breathing
C-circulation

Question 15

Second level priorities?

Answer 15

Acute pain
Change in mental status
Infection

Question 16

Third level priorities?

Answer 16

Needing activity 
Meal is incorrect
Hunger 
Thirst 
Anxiety

Question 17

What is a cue?

Answer 17

A cue is a piece of information, a S/S, or a piece of laboratory data

Question 18

Steps in the nursing process (cont)

Answer 18

Interpret data: diagnosis 
-identify clusters, make inferences 
Validate inferences 
Compare clusters of clues with definitions 
Identify related factors 
Establish a nursing diagnosis

Question 19

What is EBP?

Answer 19

It is a systematic approach to practice that emphasizes the use of the best evidence.
All patients deserve the best care with the most current and best practice techniques to ensure the best outcomes

Question 20

Types of data

Answer 20

Complete (total health) database: full physical
Episodic or problem centered: concern of 1 problem, cue or body system
Follow up: the status of any problem should be evaluated at regular intervals
Emergency: urgent rapid collection of crucial info and is used for lifesaving measures