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NUR 112 Lectures > Unit B - Chapter 7 - Nursing Process > Flashcards

Unit B - Chapter 7 - Nursing Process Flashcards

1
Q

nursing process

A

cyclical,
critical thinking process
consists of five steps
purposeful, goal‐directed, systematic way - achieve optimal client outcomes

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2
Q

nursing helps nurses organize

A

nursing care and apply the optimal available evidence to care delivery

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3
Q

nursing process is a framework that is

A

foundational to nursing practice

which 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

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4
Q

nursing process is applicable to any

A

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

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5
Q

nursing process helps nurses integrate

A

critical thinking creatively to base nursing judgments on reason.

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6
Q

nursing process promotes

A

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

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7
Q

The nursing process includes sequential but overlapping steps: (5)

A

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

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8
Q

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

A

implementation and evaluation.

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9
Q

Use of the nursing process results in a

A

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

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10
Q

Assessment/data collection involves

A

systematic collection of information about clients’ present health statuses
identify needs and additional data to collect based on findings.

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11
Q

Nurses can collect data during

A

an initial assessment (baseline data), focused assessment, and ongoing assessments.

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12
Q

Methods of data collection include

A

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.

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13
Q

To collect data effectively, nurses must

A

ask clients appropriate questions,
listen carefully to responses,
have excellent head-to-toe physical assessment skills.

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14
Q

Nurses also must employ clinical judgment and critical thinking in accurately recognizing when to

A

collect assessment data.

must recognize need to collect assessment data prior to interventions.

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15
Q

Nurses collect __________ data (manifestations) during
a nursing history.

They include

A

subjective

clients’ feelings, perceptions, and descriptions of health status.

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16
Q

_________ are the only ones who can describe and verify their
own manifestations.

A

Clients

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17
Q

Nurses observe and measure __________ data (findings) during a physical examination. 

A

objective

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18
Q

Nurses feel, see, hear, and smell objective data through _________ or ________ of the client.

A

observation or physical assessment

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19
Q

During this assessment/data collection, the nurse________,_______, and_________ data.

A

Validates, interprets clusters

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20
Q

Documentation of the assessment data must be (3)

A

thorough, concise, and accurate.

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21
Q

Sources of data for collection and assessment

A

Primary sources

Secondary sources

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22
Q

Types of Primary sources


A

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

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

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23
Q

Types of Secondary sources

A

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

● OBJECTIVE:
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.

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24
Q

Nurses use ___________ 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.

A

critical thinking skills (a diagnostic reasoning process)

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25
Q

critical thinking skills

A

a diagnostic reasoning process

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26
Q

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

A

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

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27
Q

As nurses cluster collected data, a specific finding might serve as

A

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

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28
Q

As with the assessment/data collection step, complete and accurate documentation is essential. Documentation should focus on

A

facts and should be highly descriptive

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29
Q

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

A

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

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30
Q

Established priorities and outcomes of client care then direct nurses in 

A

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

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31
Q

Nurses do three types of planning.

A

comprehensive plan of care

ongoing planning throughout the provision of care.

Discharge planning

32
Q

comprehensive plan of care

A

based on comprehensive assessments

example admission to a health care facility or to a home health organization.

33
Q

Maslow’s hierarchy of basic needs

A

Self actualization

Self -esteem

Love and belonging

Safety and security

Physiological

34
Q

ongoing planning throughout the provision of care.

A

While obtaining new information and evaluating responses to care, they modify and individualize the initial plan of care.

35
Q

Discharge planning

A

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

36
Q

To be effective, discharge planning must begin 

A

during admission

37
Q

Throughout the planning process, nurses set.

A

priorities,
determine client outcomes, and
select specific nursing interventions

38
Q

Nurses participate in priority setting when

A

they identify a preferential order of problems.

39
Q

preferential order of problems guides

A

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

40
Q

Nurses work with clients to identify

A

goals and outcomes.

41
Q

Goals

A

◯ Goals identify optimal status,

42
Q

Outco mes

A

outcomes identify the observable criterion that will determine success or failure of the goal.

43
Q

goal/outcome must be 

A

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

44
Q

◯ Concise, measurable goals help nurses and clients

A

evaluate progress:

45
Q

◯ Nurses use short- and long-term goals to

A

guide the client toward the planned outcome and determine the effectiveness of nursing care

46
Q

Nurses identify actions and interventions that help achieve

A

optimal outcomes

47
Q

What principles provide the rationale for nursing interventions

A

Scientific principles

48
Q

Nurse-initiated/independent interventions:

A

Nurses use evidence / scientific rationale to take autonomous actions to benefit clients.

base actions on identified problems / health care needs,

make sure within their scope of practice.

49
Q

Nurses perform or delegate what

Example

A

the interventions and are accountable for them.

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

50
Q

Provider-initiated/dependent interventions:

A

Interventions nurses initiate as a result of a provider’s prescription (written, standing, or verbal) or

facility’s protocol (blood administration procedures).

51
Q

Collaborative interventions:

Ex

A

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

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

52
Q

NCP

A

nursing care plan (NCP)

end product of planning step.

organize NCP for quick identification of
problems,
outcomes, and
interventions to implement.

53
Q

In the implementation step of nursing process, base care provided on

A

assessment data,
analyses,
plan of care developed in previous steps of nursing process.

54
Q

In the implementation step, must use_______,______,_____
to select / implement appropriate therapeutic interventions

A

problem-solving,
clinical judgment, and
critical thinking

55
Q

appropriate therapeutic interventions promote, maintain, or restore
Nurses also use interpersonal skills (therapeutic communication) and technical skills (psychomotor performance) when implementing nursing interventions

A

. health.

56
Q

Nurses use interpersonal skills (therapeutic communication) and technical skills (psychomotor performance) when implementing

A

nursing interventions

57
Q

Therapeutic interventions also include measures to

A

minimize risk (wearing personal protective equipment).

58
Q

Nurses intervene to respond to unplanned events

A

(an observation of unsafe practice, a change in status, or the emergence of a life-threatening situation)

59
Q

Nurses use evidence-based rationale for the selection and implementation of

A

all therapeutic interventions.

60
Q

These types of behaviors should be at the center of all therapeutic interventions

A

caring

professional

61
Q

During implementation, nurses perform 

A

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

62
Q

In the evaluation step of the nursing process, nurses

A

evaluate clients’ responses to nursing interventions

form a clinical judgment about the extent to which clients have met goals / outcomes.

63
Q

Nurses continuously evaluate

A

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

64
Q

Nurses determine the_______ of the nursing care plan.

A

effectiveness

65
Q

Nurses collect data based on the

A

outcome criteria

then compare what actually happened with the planned outcomes.

66
Q

Evaluation helps determine

A

what further actions to take.

67
Q

● Clients’ outcomes in specific, measurable terms are

A

easier to evaluate.

68
Q

QUESTIONS TO CONSIDER in evaluation step of nursing process

A

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

69
Q

FACTORS THAT CAN LEAD TO LACK OF GOAL ACHIEVEMENT

A

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

70
Q

5 steps of nursing process

A

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

71
Q
  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.
A

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.

72
Q
  1. Achargenurseisobservinganewlylicensednursecare 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
A

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.

73
Q
  1. 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 with 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.
A

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).

74
Q
  1. 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
A

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 is a 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.

75
Q
  1. A nurse is discussing the nursing process with 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.”
A

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.

76
Q

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

A

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

77
Q

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

A

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

NUR 112 Lectures (10 decks)

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