LESSON 1 - BEGINNING THE ASSESSMENT

Question 1

A systematic, rational method of planning and providing individualized nursing care

Answer 1

NURSING PROCESS

Question 2

3 Purpose of Nursing Process:

Answer 2

1. Identify a client health status and actual or potential health care problems and needs.
2. Establish plans to meet the identifying needs.
3. Deliver specific nursing intervention to meet needs.

Question 3

5 Characteristic of nursing process:

Answer 3

•planned.
•universally applicable.
•goal directed.
•cyclic and dynamic.
•client centered.

Question 4

Benefits of Nursing Process:

Answer 4

•Provides an orderly & systematic method for planning & providing care

•Enhances nursing efficiency by standardizing nursing practice

•Facilitates documentation of care

•Provides a unity of language for the nursing profession

•Stresses the independent function of nurses

•Increases care quality through the use of deliberate actions

Question 5

The Nursing Process consist of a series of five component or phases which are:

Answer 5

1- Assessing.
2- Diagnosis.
3- Planning.
4- Implementing.
5- Evaluating.

Question 6

Is a systematic and continuous collection, organization, validation and documentation of data.

Answer 6

ASSESSMENT

Question 7

Nursing ______ focus upon client’s responses to a health problem.

Answer 7

ASSESSMENT

Question 8

The assessment process involve four closely activities which are:

Answer 8

I- Collecting data.
II- Organizing data.
III- Validating data.
IV- Documenting data.

Question 9

Is the process of gathering information about clients, and health status.

Answer 9

COLLECTING DATA

Question 10

these data that can be described or verified only by that person.
e.g itching, pain, feelings, stress.

Answer 10

Subjective data (symptoms)

Question 11

obtained through OBSERVATION and are verifiable and that can be seen heard, felt, or smelled, by observation and physical examination.
e.g discoloration, lungs sounds, vomited 100ml.

Answer 11

Objective data (signs)

Question 12

4 Sources of data:

Answer 12

a- client.
b- Health care professionals.
c- Support people
d- Client records.

Question 13

a Data collection method where it gathers data by using the five senses.

Answer 13

Observing

Question 14

in doing this, before you begin, you’ll need to create an environment in which the patient feels comfortable, establish rapport and explain what you’ll cover in the ________.

Answer 14

Interviewing

Question 15

to make the most of your patient interview, before you begin, you’ll need to ________

Answer 15

1. create an environment in which the patient feels comfortable
2. establish rapport
3. explain what you’ll cover in the interview.

Question 16

The things to consider to create the proper environment are:

Answer 16

1. Settling in
2. Watch what you say
3. Communicate Effectively

Question 17

Settling in covers:

Answer 17

1. choose a quite, private, well-lit interview setting
2. make sure that the patient is comfortable
3. introduce yourself and explain the purpose of the health history and assessment
4. reassure the patient that everything he says will be kept confidential
5. tell the patient how long the interview

Question 18

Watch what you say means to:

Answer 18

1. assess the patient to see if language barriers exist
2. speak slowly and clearly
3. address the patient by a formal name

Question 19

Realize that you and the patient communicate nonverbally as well as verbally. Being aware of these two forms of communication will aid you in the interview process.

Answer 19

Communicate Effectively

Question 20

2 communication strategies

Answer 20

a. Nonverbal communication strategies
b. Verbal communication strategies

Question 21

5 Nonverbal communication strategies

Answer 21

➢Listen attentively and make eye contact frequently
➢Use reassuring gestures (nodding)
➢Watch for nonverbal cues that indicate the patient is uncomfortable
➢Be aware of your nonverbal behaviors
➢Observe the patient closely to see if he understands each question

Question 22

It range from alternating between open-ended and closed-ended questions to employing such techniques

Answer 22

Verbal communication strategies

Question 23

it is a way of encouraging the patient to continue talking, and also gives you a chance to assess his ability to organize thoughts.

Answer 23

silence

Question 24

using such phrases as “please continue”, “go on”, and even “uh-huh” encourages the patient to continue with his story.

Answer 24

Facilitation

Question 25

it helps ensure that you and the patient are on the same track. For example, you might say, “If I understand you correctly, you said..”

Answer 25

Confirmation

Question 26

it is repeating something that the patient has just said to help you obtain more specific information

Answer 26

Reflection

Question 27

when information is vague and confusing, use this technique. For example, if your patient says, “I can’t stand this”, you might respond, “what can’t you stand?”

Answer 27

Clarification

Question 28

this technique ensures that the data you’ve collected are accurate and complete. It signals that the interview is about to end.

Answer 28

summary

Question 29

this gives the patient the opportunity to gather his thoughts and make any pertinent final statements. You can do this by saying, “I think I have all the information I need now. Is there anything you would like to add?”

Answer 29

Conclusion

Question 30

  A complete health history requires information from each of the following categories

Answer 30

Reviewing General Health

Question 31

this includes the name, address, telephone number, birth date, age, marital status, religion and nationality.

Answer 31

Biographic data

Question 32

try to pinpoint why the patient is seeking health care.

Answer 32

Chief complaint

Question 33

ask the patient about past and current medical problems, such as hypertension, diabetes and back pain.

Answer 33

Medical history

Question 34

questioning the patient about his family’s health is a good way to uncover his risk of having certain diseases.

Answer 34

Family history

Question 35

find out how the patient feels about himself, his place in society, and his relationships with others. Ask about his education, economic status, and responsibilities.

Answer 35

Psychosocial history

Question 36

find out what’s normal for the patient by asking him to describe his typical day. Ask about his diet and elimination, exercise and sleep, work and leisure, use of alcohol, tobacco and other drugs, religious observances.

Answer 36

Activities of daily living

Question 37

Factors for Assessment

Answer 37

P- Palliative factors Provocative factors Q- Quality R- Radiation S- Severity T- Temporal factors

Question 38

'What makes it better?' refers to what factor of assessment ?

Answer 38

Palliative factors

Question 39

"What makes it worse?' refers to what factor of assessment ?

Answer 39

Provocative factors

Question 40

'What exactly is it like?" refers to what factor of assessment ?

Answer 40

Quality

Question 41

'Does it spread anywhere?' refers to what factor of assessment ?

Answer 41

Radiation

Question 42

'How severe is it?' / ‘How much does it affect your life?' refers to what factor of assessment ?

Answer 42

Severity

Question 43

‘Is it there all the time or does it come and go?' refers to what factor of assessment ?

Answer 43

Temporal factors

Question 44

is a clinical judgment about individual, family or community responses to actual and potential health problems/life processes.

Answer 44

Nursing Diagnosis

Question 45

Types of nursing diagnosis:

Answer 45

1- An actual diagnosis 2- A risk nursing diagnosis

Question 46

is a client problem that is present at the time of nursing assessment, and is based on the presence of associated signs and symptoms.

Answer 46

Actual Diagnosis

Question 47

is a clinical judgment that a problem does not exit, but the presence of risk factors indicate that a problem is likely to develop unless nurses intervention.

Answer 47

Risk Nursing Diagnosis

Question 48

impaired mobility is an example of _____

Answer 48

actual diagnosis

Question 49

risk for infection is an example of _____

Answer 49

Risk Nursing Diagnosis

Question 50

There are words that have been added to some NANDA label to give additional meaning

Answer 50

Problem: ( diagnostic label )

Question 51

identifies one or more probable causes of the health problem.

Answer 51

Etiology (related factor and risk factor)

Question 52

Are cluster of sign and symptoms that indicate the presence of a particular diagnostic label.  

Answer 52

Defining characteristics

Question 53

3 Nursing Diagnosis process:

Answer 53

1- Analyzing data. 2- Identifying health problem, risks and strengths. 3- Formulating diagnostic statement.

Question 54

Ineffective breathing pattern R/T decreased lung expansion AEB dyspnea is an example of:

Answer 54

Nursing Diagnosis

Question 55

Disturbed body image R/T amputation AEB patient’s verbalization “nahuya ko makita sang tawo nga utod tiil ko” id an example of:

Answer 55

Nursing Diagnosis

Question 56

Risk for electrolyte imbalance R/T purging is an example of:

Answer 56

Nursing Diagnosis

Question 57

words that have been added to some NANDA label to give additional meaning are:

Answer 57

altered , impaired , decrease, ineffective, acute , chronic, Knowledge deficit. Ineffective breathing pattern

Question 58

is a deliberative, systematic phase of nursing process that involve decision making and problem solving

Answer 58

Planning

Question 59

Types of planning:    

Answer 59

1- Initial planning 2- Ongoing planning 3- Discharge planning

Question 60

The process of anticipating and planning for needs after discharge.

Answer 60

Discharge planning

Question 61

Is done by all nurses who work with the client.

Answer 61

Ongoing planning

Question 62

It is the beginning of shift as the nurse plans the care to be given that day.

Answer 62

Ongoing Planning

Question 63

the nurse who performs the admission assessment usually develops the initial comprehensive plan of care.

Answer 63

Initial Planning

Question 64

4 Planning Process:

Answer 64

1- Setting priorities. 2- Establishing client goals/desired out comes. 3- Selecting nursing strategies. 4- Writing nursing orders.

Question 65

Selecting nursing intervention and activities are actions that nurse performs to a achieve client goals.

Answer 65

Implementing

Question 66

The specific strategies chosen should focus on eliminating or reducing the etiology.

Answer 66

Implementing/Intervention

Question 67

Types of Nursing Intervention:

Answer 67

1- Independent intervention 2- Dependent intervention 3- Collaborative intervention

Question 68

are those activities that nurses are licensed to initiate on the basis of their knowledge and skills.

Answer 68

Independent intervention

Question 69

are activities carried out under the physician orders.

Answer 69

Dependent intervention

Question 70

are actions the nurse carries out in collaboration with other health team member.

Answer 70

Collaborative intervention

Question 71

Is the phase in which the nurse puts the nursing care plan into action.

Answer 71

Implementing

Question 72

Process of implementing:

Answer 72

1- Reassessing the client. 2- Determining the nurse need for assistance. 3- Implementing the nursing orders (strategies). 4- Delegating and Supervising. 5- Communicating the nursing actions.

Question 73

Is to judge or to appraise.

Answer 73

Evaluating

Question 74

______ is a planned, ongoing, purposeful activity in which clients and health care professionals determine: - The clients progress toward goals an achievement. - The effectiveness of the nursing care plan.

Answer 74

Evaluating

Question 75

Process of evaluating client responses:

Answer 75

1- Identify the desired out comes. 2- Collecting data related to desired out comes. 3- Compare the data with desired out comes 4- Relate nursing actions to client goals/desired outcomes. 5- Draw conclusions about problem status. 6- Continue to modify or terminate the clients care plan.