Unit Two Test

Question 1

when you gather history and physical assessment

Answer 1

assessment phase

Question 2

putting plan into action

Answer 2

implementation phase

Question 3

did the outcome come out as wanted

Answer 3

evaluation phase

Question 4

what is the pneumonic for steps in nursing proccess

Answer 4

ADPIE
assessment
diagnosis
planning
implementation
evaluation

Question 5

assessment is ________

Answer 5

ongoing

Question 6

what do you first assess

Answer 6

chief complaint

Question 7

maslow’s hierarchy

Answer 7

physiological needs
safety needs
love and belonging
esteem needs
self actualization

Question 8

actual problem=

Answer 8

ongoing problem

Question 9

not as important because has not happened yet=

Answer 9

risk for

Question 10

sex is located in what stage and why

Answer 10

physiological need because something has happened and lost participation in physical activity for a while

Question 11

what are the 3 parts of formulating a nursing diagnosis

Answer 11

problem statement
etiology
defining characteristics

Question 12

what is the pneumonic used for nursing diagnosis

Answer 12

PES
problem
etiology
signs and symptoms

Question 13

avoid using ______ diagnosis with nursing diagnosis statement

Answer 13

medical

Question 14

what is the first step in any plan

Answer 14

establish patient outcome

Question 15

an outcome statement should have

Answer 15

objective, observable patient behaviors which are MEASURABLE and REALISTIC

Question 16

planning needs to be

Answer 16

specific

Question 17

outcome will need to start with

Answer 17

“the patient will..”

Question 18

outcomes can be

Answer 18

short or long term

Question 19

when planning outcome what is the pneumonic used

Answer 19

SMART
specific
measurable (quantity, freq, weight)
attainable
realistic
time limited (short term/ long term)

Question 20

planned treatments and actions that are performed to help the patient to reach the outcomes that are set for them

Answer 20

nursing interventions

Question 21

no order needed=

Answer 21

independent nursing interventions

Question 22

in conjunction with an interdisciplinary team member

Answer 22

interdependent nursing interventions

Question 23

require an order

Answer 23

dependent nursing interventions

Question 24

your actions you are going to perform to help patient reach goal will always start with

Answer 24

” the nurse will…”

Question 25

interdependent is when working with

Answer 25

nutrition, physical therapy etc

Question 26

carrying out nursing interventions

Answer 26

implementation

Question 27

while implementing you need to

Answer 27

include your patient

Question 28

who should evaluate

Answer 28

author of the plan of care nurses responsible for pt care healthcare team the patient too

Question 29

fecal impaction

Answer 29

may or may not need an order

Question 30

need what parts of brain for critical thinking

Answer 30

both sides

Question 31

what separates professional nurses form technical and ancillary staff

Answer 31

clinical decision-making skills

Question 32

"its true because I believe it"

Answer 32

innate egocentrism

Question 33

"its true because we believe it"

Answer 33

innate socioecentrism

Question 34

"its true because I want to believe it

Answer 34

innate wish fulfillment

Question 35

"its true because I have always believed it"

Answer 35

innate self-validation

Question 36

"its true because it is in my selfish interest to believe it"

Answer 36

innate selfishness

Question 37

purposefully thinking back on a situation to discover purpose or meanign

Answer 37

reflection

Question 38

nurse who engages in critical thinking is also to express ideas and thinking in clear and precise terms, articulate

Answer 38

language

Question 39

the direct understanding of particulars in a situation without conscious deliberation

Answer 39

intuition

Question 40

attitudes for critical thinking

Answer 40

responsibility, disciplined, integrity

Question 41

what should you never use when documenting

Answer 41

white out erasable ink obliterate NO pencils

Question 42

summary worksheet reference of basic information that traditionally is not part of the record

Answer 42

Kardex

Question 43

vertical or horizontal columns for recording dates and times and related assessment and intervention information

Answer 43

flow sheets/forms

Question 44

in a court of law "care not documented is

Answer 44

care that was not provided"

Question 45

why would it be a reason to document refusal of medication

Answer 45

because it looks like you forgot to give it and will be accused of not doing your job

Question 46

how would you correct errors

Answer 46

single line through entry error and your initials

Question 47

how would you enter a late entery

Answer 47

add the entry to the first available line and label "late entry" (in body of entry add what time it was supposed to be entered and also add what time it is your entering data now