Nx 100 Ch 11 - 16

Question 1

5 steps of the nursing process

Answer 1

assessment
diagnosing
planning
implementing
evaluating

Question 2

assessment

Answer 2

collecting, validating, and communicating pt data

Question 3

diagnosing

Answer 3

analyzing patient date to identify patient strengths and goals

Question 4

planning

Answer 4

specifying patient outcomes (actual & potential) and related nursing interventions

Question 5

implementing

Answer 5

carrying out the care plan

Question 6

evaluating

Answer 6

measuring extent to which patient achieved outcomes

Question 7

5 characteristics of the nursing process

Answer 7

systematic - ordered sequence
dynamic - each step interacts and overlaps
interpersonal - the pt is the heart of Nx
outcome oriented - nurses and patients work together to identify outcomes
universally applicable - a framework for all nursing activities

Question 8

4 types of nursing assessment

Answer 8

initial comprehensive - upon admission; head to toe
focused - specific problems, symptoms
emergency - condition causing emergency
time-lapsed - comparing status to a base line

Question 9

4 phases of a nursing interview

Answer 9

preparatory - gathering records and info
introduction - greeting pt
working phase - collecting subjective data
termination

Question 10

Maslow’s hierarchy of human needs

Answer 10

physiologic
safety
love and belonging
self-esteem
self actualization

Question 11

prioritizing nursing diagnosis

Answer 11

high priority - a.b.c. compromised
medium priority - nonthreatening
low priority - diagnosis not specifically related to current health problems

Question 12

types of nursing diagnoses

Answer 12

actual - real problem
risk - ex. risk for falls
possible - to be ruled out
wellness - no health problems, desire to increase or enhance present state
syndrome - trauma (rape or PTSD)