Nursing Process Notes

Question 1

In the cognitive domain of learning, their are 4 types

Answer 1

Problem solving
Decision making
Creativity
Critical thinking (using multidepartment in hospital / knowledge from other subject fields)

Question 2

What is dynamic about the nursing process?

Answer 2

It allows nurses to change their nursing dx

Question 3

In the assessment phase what occurs?

Answer 3

Collect data (objective and subjective)
Organize data
Validate data
Document data

Question 4

In the diagnosing phase, what occurs?

Answer 4

Analyzing data
Identify health problems, risks, and strengths
Formulate diagnostic statements

Question 5

In the planning phase, what occurs?

Answer 5

Prioritizing problems and dx
Formulate goals
Select nursing interventions
Write nursing interventions

Question 6

In the implementing phase, what occurs?

Answer 6

Reassess the pt
Implement nursing interventions
Supervise delegated care

Question 7

What occurs in the evaluating phase?

Answer 7

Collect the data related to the outcomes
Compare the data
Modify or terminate the care plan
Draw conclusions

Question 8

This occurs in the assessment phase:

Answer 8

Collecting objective, subjective and observation data

(observation = palpation, percussion, auscultation)

Question 9

In the diagnosing phase, the nurse will

Answer 9

Identify the pts strengths, pt weaknesses, problem solve

Question 10

In the planning phase the nurse will formulate

Answer 10

PTs goals and outcomes (desired outcomes are positive)

Question 11

The purpose of assessing is to

Answer 11

Gather a baseline or data base about the pts response to health concerns

Question 12

The two types of initial assessments are

Answer 12

Physical exam (completed within 24 hours of pt arrival) and gather pt history

Question 13

The primary source of data is who?

Answer 13

The pt

Question 14

Secondary sources of data are/ or can be

Answer 14

parents
caregivers

Question 15

What are the two types of interview methods in data collection and the question words associated with them

Answer 15

Directive - quick and closed-ended questions
Nondirective - open-ended questions (how)

Question 16

List the types of data collection

Answer 16

Observe
Interview (consider pt privacy, comfort, and distance from pt)
Listen
Inspect

Question 17

List the types of planning

Answer 17

Initial
Ongoing (done by all nurses who work with pt)
Discharging

Question 18

Which parts of the nursing process address the pt?

Answer 18

Assess
Diagnosis
Planning
Evaluation

Question 19

Which part of the nursing process address the nurse?

Answer 19

Implementing

Question 20

A NANDA two-part diagnosis only includes the __________ and ________.

Answer 20

Problem and Etiology (This is a Risk diagnosis)

Question 21

A NANDA three-part diagnosis includes

Answer 21

Problem
Etiology
Signs and symptoms

Question 22

What is the advantage of a NANDA three-part diagnosis?

Answer 22

Including the s/s means that we know what is causing the problem and shows proof (this is an Actual diagnosis)

Question 23

What are the types of nursing diagnosis?

Answer 23

Actual (3 part)
Risk (2 part)
Health promotion (wellness)
Syndrome

Question 24

All NANDA diagnosis do this

Answer 24

Promote taxonomy of nursing

Question 25

Acute pain addresses which domain in the NANDA diagnosis

Answer 25

Safety

Question 26

Which domain in the NANDA diagnosis does respiratory address?

Answer 26

Safety

Question 27

What is initial planning?

Answer 27

Client contact and continues until patient leaves
Hands on exam

Question 28

How are pts goals written?

Answer 28

The patient will …

Question 29

When planning, goals should be SMART

Answer 29

Specific
Measurable
Attainable
Realistic
Time-framed

Question 30

What are the two reasons to reassess a pt?

Answer 30

To identify if the intervention is still needed
To see if their health status changed

Question 31

Describe what etiology is

Answer 31

The cause of the problem

Question 32

Signs and symptoms are considered _____ in the NANDA nursing dx

Answer 32

Proof

Question 33

List the levels of physiological priority

Answer 33

High (life threatening)
Medium (health threatening)
Low (developmental needs)

Question 34

List and describe the three domains of learning

Answer 34

Cognitive -what you know
Affective (Interpersonal) - how you learn/ know
Psychomotor (Technical) - hands on

Question 35

Describe an informal nursing care plan

Answer 35

a strategy of action that exist in the nurses mind

Question 36

Describe formal nursing care plan

Answer 36

computerized guide that organizes information about the pts care

Question 37

Describe a standardized care plan

Answer 37

Care plan for a group of pts with common needs

Question 38

Describe individualized care plan

Answer 38

Tailored to meet the unique needs of a specific pt