Unit V (Nursing Process)

Question 1

Name the five steps of the nursing process.

Answer 1

1) Assessment
2) Diagnosis
3) Planning
4) Implementation
5) Evaluation.

Question 2

The nurse is collecting data regarding the patients response patterns. What stage of the nursing process is the nurse in?

Answer 2

1) Assessment

Question 3

The nurse is prioritizing problems related to the patients response patterns to form a plan of care. What stage of the nursing process is the nurse in?

Answer 3

3) Planning

Question 4

The nurse has administered pain medication and later asks the patient if the medication was effective in relieving the pain. What step of the nursing process is the nurse in?

Answer 4

5) Evaluation

Question 5

The nurse is analyizing the patients response patterns. What step of the nursing process is the nurse in?

Answer 5

2) Diagnosis

Question 6

The nurse administers medication. What stage of the nursing process is the nurse in?

Answer 6

4) Implmentation

Question 7

The nurse assists the patient to high fowlers position to relieve shortness of breath. What stage of the nursing process is the nurse in?

Answer 7

4) Implementation

Question 8

The nurse asks that patient to point to the location of their pain and to rate it on a pain scale. What stage of the nursing proccess is the nurse in?

Answer 8

1) Assessment

Question 9

The nurse concludes the blood pressure medication has not alleviated the patients hypertension. What stage of the nursing process is the nurse in?

Answer 9

5) Evaluation

Question 10

The nurse writes: The pt will have improved gas exchange with expected responses of: absence of adventitious breath sounds. What stage of the nursing process is the nurse in?

Answer 10

3) Planning

Question 11

The nurse identifies the pt to have fluid volume overload. What stage of the nursing process is the nurse iin?

Answer 11

2) Diagnosing

Question 12

The nurse identifies the patient to have risk of falls. What stage of the nursing process is the nurse in?

Answer 12

2) Diagnosing

Question 13

The nurse is listening to breath sounds to obtain a basline upon admission. What stage of the nursing process is the nurse in?

Answer 13

1) Assessing

Question 14

The nurse writes: The nurse will assess for skin break down using the Braden Scale. What stage of the nursing process is the nurse in?

Answer 14

3) Planning

Question 15

The nursing student lists the ‘RAT:’ for the nursing intervention. What stage of the nursing process is the nursing student in?

Answer 15

3) Planning

Question 16

The nurse finds the patients dyspnea has improved after recieving the prescribed breathing treatment. What stage of the nursing process is the nurse in?

Answer 16

5) Evaluating

Question 17

During the nursing process, what type of diagnoses are made? What type of diagnoses are to be avoided?

Answer 17

Nursing Diagnoses are made, Medical diagnoses are avoided.

Question 18

When does the nursing process involve nursing outcomes and interventions for families?

Answer 18

• When family will be caregivers

- Newborn/Children (Pediatrics)

Question 19

When does the nursing process involve nursing outcomes and interventsion for community?

Answer 19

-Preventative measures (Vaccinations/Screening)

Question 20

A purpose of the nursing process is to identify patients _______ ______.

Answer 20

health status.

Question 21

A purpose of the nursing processis to identify ______ or _______ health problems.

Answer 21

actual -or- potential

Question 22

A purpose of the nursing process is to establish a _____ to meet ______ ______.

Answer 22

plan -to meet- identified needs

Question 23

How is the nursing process organized?

Answer 23

according to the patients problems.

Question 24

How is the nursing process interpersonal?

Answer 24

The nurse must communicate with the patient to meet their needs.

Question 25

How is the nursing process collaborative?

Answer 25

Requires interaction with other members of the healthcare team to provide quality care.

Question 26

When setting outcomes for the patient, who should the collaborate with? What idea does this encompass?

Answer 26

The patient. Idea: Patient Centered Care

Question 27

What does NANDA stand for?

Answer 27

North American Nursing Diagnosis Association

Question 28

How does NANDA focus their diagnoses?

Answer 28

Focus on the scope of nursing pracitce

Question 29

What does NANDA serve to distinguish?

Answer 29

Distinguish the nurses role from the physicians.

Question 30

The nurse is performing a procedure that has been proven effective through research. This type of practice is called:

Answer 30

Evidence based practice.

Question 31

What does Evidence Based Practice intergrate?

Answer 31

Research with Clinical Practice

Question 32

Items such as medication errors, near misses, and duplication of services are the focus of what group?

Answer 32

QI: Quality Improvement

Question 33

True of False:

Quality Improvement and Evidence Based Practice go hand in hand.

Answer 33

True

Question 34

Things done to prevent disease fall under what type of prevention?

Answer 34

Primary

Question 35

Early detection measures that allow for prompt interventions fall under what type of prevention?

Answer 35

Secondary

Question 36

Techniques used to manage the disease fall under what level of prevention?

Answer 36

Tertiary

Question 37

List the examples of cues:

Answer 37

• What the pt says

- What the nurse can see, hear, feel, measure.

Question 38

Define inferences.

Answer 38

Interpretation or conclusion made based on cues or observed data.

Question 39

What must the nurse be careful of when making inferences?

Answer 39

Avoid jumping to conclusion.

Do subjective and objective data agree?

Question 40

Where does the nursing student organize assessment data?

Answer 40

Summary Assessment Map

Question 41

What should the nurse avoid when creating the nursing diagnosis?

Answer 41

Avoid MEDICAL diagnosis.