TEST 2 - UNIT B - CH 7 - NURSING PROCESS (Fundamentals Book)

Question 1

The nursing process is a

Answer 1

cyclical, critical thinking process

Question 2

The nursing process of

Answer 2

five steps to follow in a purposeful, goal‑directed, systematic way to achieve

Question 3

The nursing process - way to achieve

Answer 3

optimal client outcomes

Question 4

The nursing process is a variation of

Answer 4

scientific reasoning that helps nurses organize nursing care and apply the optimal available evidence to care delivery.

Question 5

The nursing process is a variation of

Answer 5

dynamic, continuous,
client‑centered, problem‑solving, and decision‑making framework that is foundational to nursing practice

Question 6

The nursing process provides a framework throughout which

Answer 6

nurses can apply knowledge, experience, judgment, and skills, as well as established standards of nursing practice to the formulation of a plan of nursing care.

Question 7

This nursing plan is applicable to any

Answer 7

client system, including individuals, families, groups, and communities.

Question 8

The nursing process helps nurses integrate

Answer 8

critical thinking creatively to base nursing judgments on reason.

Question 9

The nursing process promotes

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the professionalism of nursing while differentiating the practice of nursing from the practice of medicine and that of other health care professionals.

Question 10

● Assessment/data collection involves

Answer 10

the systematic collection of information about clients’ present health statuses to identify needs and additional data to collect based on findings. Nurses can collect data during an initial assessment (baseline data), focused assessment, and ongoing assessments.

Question 11

● Methods of data collection include

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observation, interviews with clients and families, medical history, comprehensive or focused physical examination, diagnostic and laboratory reports, and collaboration with other members of the health care team.

Question 12

● To collect data effectively, nurses must

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ask clients appropriate questions, listen carefully to responses, and have excellent head‑to‑toe physical assessment skills. Nurses also must employ clinical judgment and critical thinking in accurately recognizing when to collect assessment data. They also must recognize the need to collect assessment data prior to interventions.

Question 13

● Nurses collect subjective data (manifestations) during a

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nursing history. They include clients’ feelings, perceptions, and descriptions of health status. Clients are the only ones who can describe and verify their own manifestations.

Question 14

● Nurses observe and measure

Answer 14

objective data (findings) during a physical examination. They feel, see, hear, and smell objective data through observation or physical assessment of the client. (7.2)

Question 15

● During this assessment/data collection, the nurse

Answer 15

validates, interprets, and clusters data.

Question 16

● Documentation of the assessment data must be

Answer 16

thorough, concise, and accurate.

Question 17

Sources of data for collection and assessment

Answer 17

primary and secondary

Question 18

primary sources can be

Answer 18

subjective / objective

Question 19

secondary sources can be

Answer 19

subjective / objective

Question 20

Primary sources
SUBJECTIVE:

Answer 20

SUBJECTIVE: What the client tells the nurse
“My shoulder is really, really sore.”

Question 21

Primary sources
objective

Answer 21

OBJECTIVE: Data the nurse obtains through observation and examination:
Client grimaces when attempting to brush their hair with their left arm.

Question 22

Secondary sources
SUBJECTIVE

Answer 22

● What others tell the nurse
● What the client has told them:
“They told me that their shoulder is sore every morning.”

Question 23

Secondary sources
OBJECTIVE

Answer 23

Data the nurse collects from other sources (family, friends, caregivers, health care professionals, literature review, medical records):
Physical therapy note in chart indicates client has decreased range of motion of left shoulder.

Question 24

The nursing process includes sequential but overlapping steps:

Answer 24

● Assessment/data collection*
● Analysis/data collection*
● Planning
● Implementation
● Evaluation

Question 25

*PNs combine the assessment and analysis steps into

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a single data collection step.

Question 26

The accuracy and thoroughness of assessment/analysis/data collection and planning have a direct effect on

Answer 26

implementation and evaluation.

Question 27

Use of the nursing process results in a

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comprehensive, individualized, client‑centered plan of nursing care that nurses can deliver in a timely and reasonable manner.

Question 28

● Nurses use *

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critical thinking skills (a diagnostic reasoning process) to identify clients’ health statuses or problem(s), interpret or monitor the collected database, reach an appropriate nursing judgment about health status and coping mechanisms, and provide direction for nursing care.

Question 29

● Analysis/data collection requires nurses to look at the data and

Answer 29

Recognize patterns or trends.
◯ Compare the data with expected standards or reference ranges.
◯ Arrive at conclusions to guide nursing care.

Question 30

● RNs make multiple analyses based on their

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interpretations of collected data.

Question 31

● As with the assessment/data collection step,

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complete and accurate documentation is essential.

Question 32

Nurses decide, using

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reasoning and judgment, which data account for clients’ health status or problems.

Question 33

At times, this requires further data collection and analysis. As nurses again cluster the collected data, a specific finding might serve as

Answer 33

an alert to a specific problem that requires planning and intervention.

Question 34

Documentation should focus on

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facts and should be highly descriptive.

Question 35

● When planning client care (RN) or contributing to a client’s plan of care (PN), nurses must establish

Answer 35

priorities and optimal outcomes of care they can readily measure and evaluate.

Question 36

These established priorities and outcomes of client care then direct nurses in

Answer 36

selecting interventions to include in a plan of care to promote, maintain, or restore health.

Question 37

● Nurses do three types of planning.

Answer 37

Initially, they develop a comprehensive plan of care for clients based on comprehensive assessments they complete, for example, on admission to a health care facility or to a home health organization.

Question 38

● Nurses do

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ongoing planning throughout the provision of care.

Question 39

While obtaining new information and evaluating responses to care, they

Answer 39

modify and individualize the initial plan of care.

Question 40

● Discharge planning is a

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process of anticipating and planning for clients’ needs after discharge.

Question 41

To be effective, discharge planning must begin

Answer 41

during admission.

Question 42

● Throughout the planning process, nurses set

Answer 42

priorities, determine client outcomes, and select specific nursing interventions.

Question 43

● Nurses participate in priority setting when they

Answer 43

identify a preferential order of problems.

Question 44

priority setting ( preferential order of problems) guides the

Answer 44

delivery of nursing care. They can use guidelines to set priorities (Maslow’s hierarchy of basic needs).

Question 45

● Nurses work with clients to identify

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goals and outcomes.

Question 46

◯ Goals identify

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optimal status, whereas outcomes identify the observable criterion that will determine success or failure of the goal.

Question 47

goals and outcomes

Answer 47

terms are interchangeable.

Question 48

With any format, the goal/outcome must be

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client‑centered, singular, observable, measurable, time‑limited, mutually agreeable, and reasonable.

Question 49

Concise, measurable goals help nurses and clients

Answer 49

evaluate progress:

Question 50

◯ Nurses use

Answer 50

short‑ and long‑term goals to guide the client toward the planned outcome and determine the effectiveness of nursing care.

Question 51

● Nurses identify

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actions and interventions that help achieve optimal outcomes.

Question 52

Scientific principles provide the

Answer 52

rationale for nursing interventions.

Question 53

Nurses use

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evidence and scientific rationale to take autonomous actions to benefit clients.

Question 54

They base these actions on

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identified problems and health care needs, and make sure they are within their scope of practice.

Question 55

Nurses perform or delegate the interventions and are

Answer 55

accountable for them.

Question 56

An example of delegation

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is repositioning a client at least every 2 hr to prevent skin breakdown.

Question 57

Provider‑initiated/dependent interventions:

Answer 57

Interventions nurses initiate as a result of a provider’s prescription (written, standing, or verbal) or the facility’s protocol (blood administration procedures).

Question 58

◯ Collaborative interventions: *

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Interventions nurses carry out in collaboration with other health care team professionals

Question 59

EX of collaboration

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(ensuring that a client receives and eats their evening snack).

Question 60

● The nursing care plan (NCP) is the

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end product of the planning step.

Question 61

Nurses organize the NCP for*

Answer 61

quick identification of problems, outcomes, and interventions to implement.

Question 62

IMPLEMENTATION

Answer 62

● In this step of the nursing process, nurses base the care they provide on assessment data, analyses, and the plan of care they developed in the previous steps of the nursing process

Question 63

In the implementation step, the nurse must use

Answer 63

problem‑solving, clinical judgment, and critical thinking to

Question 64

problem‑solving, clinical judgment, and critical thinking is used to

Answer 64

select and implement appropriate therapeutic interventions using nursing knowledge, priorities of care, and planned goals or outcomes to promote, maintain, or restore health.

Question 65

Nurses also use

Answer 65

interpersonal skills (therapeutic communication) and technical skills psychomotor performance) when implementing nursing interventions.

Question 66

● Therapeutic interventions also include

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measures nurses take to minimize risk (wearing personal protective equipment).

Question 67

Nurses intervene to respond to

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unplanned events (an observation of unsafe practice, a change in status, or the emergence of a life‑threatening situation).

Question 68

● Nurses use

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evidence‑based rationale for the selection and implementation of all therapeutic interventions.

Question 69

Additionally,_______________should be at the center of all therapeutic nursing interventions.

Answer 69

caring and professional behavior

Question 70

● During implementation, nurses perform

Answer 70

nursing actions, delegate tasks, supervise other health care staff, and document the care and clients’ responses.

Question 71

Maslows heirarchy of needs

Answer 71

self actualization / self esteem / love and belonging / safety and security / physiological

Question 72

EVALUATION

Answer 72

● In this step of the nursing process, nurses evaluate clients’ responses to nursing interventions and form a clinical judgment about the extent to which clients have met the goals and outcomes.

Question 73

● Nurses continuously

Answer 73

evaluate clients’ progress toward outcomes,
use clients’ data to determine whether or not to modify the plan of care.

Question 74

● Nurses determine the

Answer 74

effectiveness of the nursing care plan.

Question 75

They collect data based on the

Answer 75

outcome criteria then compare what actually happened with the planned outcomes. This helps determine what further actions to take.

Question 76

● Clients’ outcomes in________ __________ ___________ are easier to evaluate.

Answer 76

specific, measurable terms

Question 77

QUESTIONS TO CONSIDER when deciding effecting of POC

Answer 77

● “Did the client meet the planned outcomes?”
● “Were the nursing interventions appropriate and effective?”
● “Should I modify the outcomes or interventions?”

Question 78

FACTORS THAT CAN LEAD TO LACK OF GOAL ACHIEVEMENT

Answer 78

● An incomplete database
● Unrealistic client outcomes
● Nonspecific nursing interventions
● Inadequate time for the client to achieve the outcomes

Question 79

1. By the second postoperative day, a client has not achieved satisfactory pain relief. Based on this evaluation, which of the following actions should the nurse take, according to the nursing process?
   A. Reassess the client to determine the reasons for inadequate pain relief.
   B. Wait to see whether the pain lessens during the next 24 hr.
   C. Change the plan of care to provide different pain relief interventions.
   D. Teach the client about the plan of care for managing the pain.

Answer 79

1.
A. CORRECT: Collect further data from the client to determine why they have not achieved satisfactory pain relief, because various factors might be interfering with their comfort. The nursing process repeats in an ongoing manner across the span of client care.
B. Do not wait longer to see how the client would respond, but take action to determine why the client is not achieving satisfactory pain relief.
C. Do not make random changes to the plan of care without gathering evidence to guide the nurse in knowing what new interventions might help.
D. The action does not acknowledge the client’s condition or that the current plan is ineffective.

Question 80

2. A charge nurse is observing a newly licensed nurse care for a client who reports pain. The nurse checked the client’s MAR and noted the last dose of pain medication was 6 hr ago. The prescription reads every 4 hr PRN for pain. The nurse administered the medication and checked with the client 40 min later, when the client reported improvement. The newly licensed nurse left out which of the following steps of the nursing process?
   A. Assessment
   B. Planning
   C. Intervention
   D. Evaluation

Answer 80

2. A. CORRECT: The newly licensed nurse should have used the assessment step of the nursing process by asking the client to evaluate the severity of pain on a 0 to 10 scale. The nurse also should have asked about the characteristics of the pain and assessed for any changes that might have contributed to worsening of the pain.
   B. The newly licensed nurse used the planning step of the nursing process when deciding that it was the right time to administer the medication.
   C. The newly licensed nurse used the implementation step of the nursing process when administering the medication.
   D. The newly licensed nurse used the evaluation step of the nursing process when checking the effectiveness of the pain medication in relieving the client’s pain.

Question 81

3. A charge nurse is reviewing the steps of the nursing process with a group of nurses. Which of the following data should the charge nurse identify as objective data? (Select all that apply.)
   A. Respiratory rate is 22/min w/ even, unlabored respirations.
   B. The client’s partner states, “They said they hurt after walking about 10 minutes.”
   C. The client’s pain rating is 3 on a scale of 0 to 10.
   D. The client’s skin is pink, warm, and dry.
   E. The assistive personnel reports that the client walked with a limp.

Answer 81

3. A. CORRECT: Objective data includes information the nurse measures (vital signs).
   B. Subjective data includes a client’s reported manifestations, even if a secondary source gave the nurse the information.
   C. Subjective data includes a client’s reported manifestations.
   D. CORRECT: Objective data includes information the nurse observes (skin appearance).
   E. CORRECT: Objective data includes information from the observations of others (family and staff).

Question 82

4. A charge nurse is talking with a newly licensed nurse and is reviewing nursing interventions that do not require a provider’s prescription. Which of the following interventions should the charge nurse include? (Select all that apply.)
   A. Writing a prescription for morphine sulfate as needed for pain
   B. Inserting a nasogastric (NG) tube to relieve gastric distention
   C. Showing a client how to use progressive muscle relaxation
   D. Performing a daily bath after the evening meal
   E. Repositioning a client every 2 hr to reduce pressure injury risk

Answer 82

4. A. Have a prescription from the provider to administer a medication. After obtaining the prescription, the nurse has the flexibility to determine when to administer a PRN medication.
   B. Have a prescription from the provider for the insertion of an NG tube. This is a provider‑initiated intervention.
   C. CORRECT: Showing a client how to use progressive muscle relaxation is an appropriate nurse‑initiated intervention for stress relief. Unless there - contraindication for a specific client, use this technique with clients without a provider’s prescription.
   D. CORRECT: Performing a bath is a routine nursing care procedure. Unless there is a contraindication for a specific client, determine when bathing is optimal for a client without a provider’s prescription.
   E. CORRECT: Repositioning a client every 2 hr is an appropriate nurse‑initiated intervention for clients. Unless there is a contraindication for a specific client, use this strategy without a provider’s prescription.

Question 83

5. A nurse is discussing the nursing process w/ a newly licensed nurse. Which of the following statements by the newly licensed nurse should the nurse identify as appropriate for the planning step of the nursing process?
   A. “I will determine the most important client problems that we should address.”
   B. “I will review the past medical history on the
   client’s record to get more information.”
   C. “I will carry out the new prescriptions from the provider.”
   D. “I will ask the client if their nausea has resolved.”

Answer 83

5. A. CORRECT: Prioritize the client’s problems during the planning step of the nursing process.
   B. Review the client’s history during the assessment/data collection step of the nursing process.
   C. Implement nurse‑ and provider‑initiated actions during the intervention step of the nursing process.
   D. Gather information about whether the client’s problems have been resolved during the evaluation step of the nursing process.

Question 84

● List at three actions to take during the analysis or data collection step.

Answer 84

● Recognize patterns or trends.
● Compare the data with expected standards or reference ranges.
● Arrive at conclusions to guide nursing care.

Question 85

● List four factors to consider during the evaluation step when clients have not achieved their goals.

Answer 85

● An incomplete database
● Unrealistic client outcomes
● Nonspecific nursing interventions
● Inadequate time for the client to achieve the outcomes