Exam 1

Question 1

Second phase of the nursing process

Answer 1

Diagnosis

Question 2

The action phase

Answer 2

Implementation

Question 3

1st phase of the nursing process

Answer 3

Assessment

Question 4

Based on the pt’s response to health problems

Answer 4

Diagnosis

Question 5

Includes the history and physical exam

Answer 5

Assessment

Question 6

Divided into two phases

Answer 6

Planning

Question 7

Determine whether the outcomes were met

Answer 7

Evaluation

Question 8

The problem

Answer 8

Diagnosis

Question 9

Includes test results and lab values

Answer 9

Assessment

Question 10

Based on evidence-based care standards

Answer 10

Implementation or Planning

Question 11

Data gathering phase

Answer 11

Assessment

Question 12

Document actions and patient response

Answer 12

Implementation

Question 13

Includes outcomes and interventions

Answer 13

Planning

Question 14

Based on a review of the assessment data

Answer 14

Diagnosis

Question 15

Care plan is modified

Answer 15

Evaluation

Question 16

Hypothesis is made

Answer 16

Diagnosis

Question 17

Delegation occurs

Answer 17

Implementation

Question 18

Finished product is a care plan

Answer 18

Planning

Question 19

4 purposes of Nursing

Answer 19

Promote Health
Prevent Illness
Restore Health
Advocacy

Question 20

Promote Health

Answer 20

Education, encouragement, diet plans, exercise

Question 21

Prevent Illness

Answer 21

Hygiene, Dr’s 1st set of eyes, vaccinations, screenings

Question 22

Restore Health

Answer 22

Position changes, bandage changing

Question 23

Advocacy

Answer 23

When pt is in pain, notice cues and verbal changes, providing resources

Question 24

What is the ANA?

Answer 24

American Nurses Association
Code of ethics, scope standards, advocacy, ethics, quality of practice

Question 25

What is PT, OT, and RT?

Answer 25

Physical Therapy- focuses on improving pt body movement Occupational Therapist- focuses on pts ability to perform daily activities Respiratory Therapist- give pts oxygen, lung performance

Question 26

Roles and Functions of the Nurse

Answer 26

Direct care provider . Leader Communicator Change agent Teacher/educator. Manager Client advocate. Case Manager Counselor. Research consumer

Question 27

Definition of the Nursing Process

Answer 27

A systematic problem-solving process for the delivery of care

Question 28

Purpose of the Nursing Process

Answer 28

To help the nurse provider goal-directed, client-centered care

Question 29

What are the phases of the Nursing process?

Answer 29

1. Assessment 2. Diagnosis 3a. Planning Outcomes 3b. Planning Interventions 4. Implementation 5. Evaluation

Question 30

1st Phase of Nursing

Answer 30

Assessment- Gather data Asses the patient Subjective/objective Primary/secondary Health Hx

Question 31

2nd Phase of Nursing Process

Answer 31

Diagnosis- Identify pts health needs Dx from NANDA Prioritize (Maslows ABCs) . Pick one . Nursing Dx

Question 32

3rd Phase of Nursing Process

Answer 32

A. Planning outcomes- . Decide goals to achieve (measurable) B. Planning interventions- Chose intervention to achieve goals

Question 33

4th Phase of Nursing Process

Answer 33

Implementation- Document Action phase. Do it! Delegations

Question 34

5th Phase of the Nursing Process

Answer 34

Evaluation- Final phase Judge if actions successfully treated pts problems Yes/No- Assessment

Question 35

Clinical Judgement Model

Answer 35

NCJMM Built on & expands nursing process Evidence based Identifies 6 cognitive skilled needed to make clinical judgements

Question 36

NCJMM 6 cognitive skills

Answer 36

Recognize cues Analyze cues Prioritize hypotheses Generate solutions Take action Evaluate Outcomes

Question 37

NCJMM Step 1

Answer 37

Recognize Cues (Assessment)- Data gathering Subjective- what pts says (sx) Objective- what professionals say (observations & labs, CT, MRI) Primary (pt) Secondary (spouse, health record)

Question 38

Different types of assessments

Answer 38

Initial- 1st appointment, ED Ongoing- CA, vitals q 4hrs, pain management Comprehensive- whole body, spiritual Focused- ABD Pain (start with GI) Special needs- nutritional, cultural, psychosocial, family, wellness

Question 39

When do you validate data?

Answer 39

Subjective & objective do not agree Data falls out of nl range Pts statement changes *Once you get your data, document it*

Question 40

NCJMM step 2

Answer 40

Analyze cues/hypotheses (Diagnose)- Identify patterns Draw conclusion to identify pts health status

Question 41

Medical Diagnosis

Answer 41

Describes illness, injury, or disease Remains constant unless cured Made by Drs, NP, and PAs

Question 42

Nursing Diagnosis

Answer 42

Focuses on responses or health problems (N/V now under control… can change) NANDA nursing Dx (Self care deficit, impaired urinary elimination)

Question 43

Components of NANDA Nursing Diagnosis

Answer 43

Type of Nursing Dx- Problem focused, health promotion, at risk Problem- NANDA Dx Etiology- (r/t related to) Related or risk factor or cause Signs & Symptoms- (AEB as evidence by) Cluster of symptoms that support Dx