Unit 1: Ch. 5 Intro to the Nursing Process Flashcards
What is the purpose of the nursing process?
a. Providing patient-centered care
b. Identifying members of the health care team
c. Organizing the way nurses think about patient care
d. Facilitating communication among members of the health care team
Answer: c
The nursing process is the methodology used to “think like a nurse.” Providing patient-centered care and enhancing communication among health team members is facilitated through the use of care plans. Collaborating with rather than identifying members of the health care team is part of many plans of care.
A patient comes to the emergency department complaining of nausea and vomiting. What should the nurse ask the patient about first?
a. Family history of diabetes
b. Medications the patient is taking
c. Operations the patient has had in the past
d. Severity and duration of the nausea and vomiting
Answer: d
In an emergent situation, the nurse initially focuses on the patient’s chief complaint to determine its cause. Before initiating care, the nurse gathers information on the other topics.
An alert, oriented patient is admitted to the hospital with chest pain. From whom should the nurse collect primary data on this patient?
a. Family member
b. Physician
c. Another nurse
d. Patient
Answer: d
The nurse collects primary data directly from patients who are alert and oriented. Family members and other members of the health care team may provide secondary data on patients.
What is the primary purpose of the nursing diagnosis?
a. Resolving patient confusion
b. Communicating patient needs
c. Meeting accreditation requirements
d. Articulating the nursing scope of practice
Answer: b
Each nursing diagnosis identifies either a patient problem or need, which is its purpose. Resolving patient confusion, meeting accreditation requirements, and articulating the nurse’s scope of practice are not related to the primary purpose of the nursing diagnostic process.
On what premise is a nursing diagnosis identified for a patient? (Select all that apply.)
a. Recognized cues
b. Nursing intuition
c. Clustered data
d. Medical diagnoses
Answer: a, c
Nursing diagnoses emerge from groupings of clustered data collected and cues recognized during the assessment phase of the nursing process. The nurse documents the patient’s medical diagnosis as one piece of data, which may be clustered with others to support a nursing diagnosis. Data collected from a nurse’s intuition may also be listed in the patient’s assessment findings if they are objectively recorded without prejudice and are not judgmental
Which statement is an appropriately written short-term goal?
a. Patient will walk to the bathroom independently without falling within 2 days after surgery.
b. Nurse will watch patient demonstrate proper insulin injection technique each morning.
c. Patient’s spouse will express satisfaction with patient’s progress before discharge.
d. Patient’s incision will be well approximated each time it is assessed by the nurse.
Answer: a
Goals are to be patient-focused, realistic, and measurable. Only the first goal meets these three criteria.
What should be the primary focus for nursing interventions?
a. Patient needs
b. Nurse concerns
c. Physician priorities
d. Patient’s family requests
Answer: a
Patient needs are always the primary focus of nursing interventions. Nursing concerns, physician priorities, and family requests can provide additional guidance in the development of a patient-centered plan of care.
Which nursing action is critical before delegating interventions to another member of the health care team?
a. Locate all members of the health care team.
b. Notify the physician of potential complications.
c. Know the scope of practice and competency of the other team member.
d. Call a meeting of the health care team to determine the needs of the patient.
Answer: c
Knowing the scope of practice and competency of the other team member is critical to understanding what is appropriate and safe to delegate to that person. It is unnecessary to locate or meet with all members of the health care team prior to delegation. Physicians are already aware of potential complications related to patient care.
A patient reports feeling tired and complains of not sleeping at night. What action should the nurse perform first?
a. Consider possible reasons for the patient’s inability to sleep.
b. Request medication to help the patient sleep.
c. Tell the patient that sleep will come with relaxation.
d. Notify the physician that the patient is restless and anxious.
Answer: a
When a patient shares a concern, the first action by the nurse is to assess potential reasons for the patient’s problem. Depending on the underlying reason for the patient’s inability to sleep, the nurse may then want to administer prescribed sleep medication, teach the patient some relaxation techniques, or discuss patient behaviors with the primary care provider.
