Unit 3 Exam 2 Nursing Process

Question 0

1973

Answer 0

Classification of the nursing process

ANA published Standards of Nursing Practice

Question 1

Lydia Hall

Answer 1

1955-introduce the term “nursing process”

Question 3

1989

Answer 3

Lynda Carpenito/ nursing dx

NANDA approval by ANA

Question 4

1982

Answer 4

North American Nursing Dx Association

Question 5

Components of the Nursing Process

Answer 5

Assessing
Diagnosing
Planning
Implementing
Evaluating

Question 6

Professional Benefits

Answer 6

defines scope of practice

Question 7

Nurse Benefits

Answer 7

allows professional growth
more effective in care/ more productive
–> collaboration

Question 8

Patient Benefits

Answer 8

Continuous, individualized, pt. centered care

Allows pt and family to participate

Question 9

Assessing

Answer 9

1st step of nursing practice
deliberate/ systematic/ holistic
identify current/ potential problems
utilizes therapeutic communication technology

Question 10

Purpose of Data Collection

Answer 10

Identify the Patient’s…..

• present and past health status, coping patterns, and functioning status
• response to both medical & nursing treatments
• risk for potential problems
• desire for a higher level of wellness (always room for improvement)

Question 11

Subjective Data

Answer 11

pt’s perception – “what pt. tells you”

Symptoms/ covert

Question 12

Objective Data

Answer 12

Signs

Measurable

Question 13

Primary Source(s) of Data

Answer 13

Patient (pt)

Question 14

Secondary Sources of Data

Answer 14

Family/ Significant Other
Healthcare team
Health Records
Literature Review

Question 15

Data Validation

Answer 15

ensure accuracy of information

BEST WAY is to Validate data directly with PATIENT

Question 16

Cues

Answer 16

acquired via 5 senses

subjective & objective

Question 17

Inferences

Answer 17

nurses judgement/ interpretation of cues
very subjective
assign meanings to cluster of cues

**more cues/ more data–> increase potential judgements/ dx the more accurate your inferences

Question 18

Actual Nursing Diagnosis

Answer 18

CLINICALLY VALIDATED by defining characteristics (signs & symptoms)
Comes from NANDA list

Question 19

3 Parts of the Nursing Dx

Answer 19

1. Problem (NANDA label) & Definition
2. Etiology ( R/T or Risk Factors)
3. Defining Characteristics ( Signs and symptoms)

Question 20

Risk Dx Definition (not that important)

Answer 20

Human Responses to health conditions life process that may develop in a VULNERABLE individual, family, or community. Supported by RISK FACTORS that contribute to increased vulnerability

Question 21

Risk Dx

Answer 21

Risk Factors GUIDE NURSING INTERVENTIONS to reduce or prevent the occurrence of the problem

2 Part Statement:No defining characteristics (s/s) b/c they represent POTENTIAL problems

Question 22

Health Promotion Dx

Answer 22

Readiness for ENHANCED

1 Part statement

Question 23

Nursing Dx

Answer 23

Describe Human Response NOT a Disease
Change from day to day
Tx by nurse (w/in scope)
May apply to alterations in individuals or GROUPS

Question 24

Collaborative Problems

Answer 24

physiological problem that nurse monitors and collaborates with medical team –> tx

Question 25

Planning

Answer 25

Third Step in Nursing Process

Question 26

3 Components of Planning Phase

Answer 26

1. Prioritize Nursing Dx
2. Develop Pt Goals
3. Plan Interventions