Nursing Process

Question 1

Nursing Process

Answer 1

A critical thinking process that professional nurses use to apply the best available evidence to caregiving and promoting human functions and illnesses.

Question 2

Systemic method of providing care to our client

Answer 2

Nursing Process

Question 3

Purposes of Nursing Process

Answer 3

To identify a client’s health status and actual or potential health care problems or needs.
To established plans to meet the identified needs.
To deliver specific nursing interventions to meet those needs.

Question 4

Components of Nursing Process

Answer 4

Assessment, Nursing Diagnosis, Planning, Implementation, Evaluation

Question 5

Characteristics

Answer 5

Cyclic- repeated process
Dynamic in nature- ongoing process
Client centeredness- plan of care is organized
Focus on problem-solving and decision making- informed clients, based on facts, data, and evidences
Interpersonal and collaborative style
Universal Applicability
Use is critical thinking and clinical reasoning

Question 6

Assessment

Answer 6

Systematic and continuous collection, organization, validation and documentation of data.

Question 7

Types of Assessment

Answer 7

1. Initial Nursing Assessment
2. Problem-focused Assessment
3. Emergency Assessment
4. Time-lapse Assessment

Question 8

Initial Nursing Assessment

Answer 8

Performed within specific time
Example: Admission of Client

Question 9

Problem-focused Assessment

Answer 9

Determine the status of a specific problem identified on an earlier assessment.
Example: hourly checking of fever client

Question 10

Emergency Assessment

Answer 10

During emergency situation to identify any life-threatening situation.
Example: Rapid assessment of an individuals airway, breathing status and circulation during cardiac arrest

Question 11

Process of gathering information about a client’s status.

Answer 11

Data Collection

Question 12

Convert data, clear only to the person affected and can be described only by that person.

Answer 12

Subjective Data

Question 13

Overt data, are detachable by an observer or can be measured or tested against an accepted standard.

Answer 13

Objective Data

Question 14

Time-lapse Assessment

Answer 14

To compare the client’s current health status with data previously obtained.

Question 15

Sources of Data

Answer 15

Primary and Secondary

Question 16

It is the direct source of information.
Example: The patient verbalizes, “ My stomach is excruciating”.

Answer 16

Primary Data

Question 17

Indirect source of information.

Answer 17

Secondary Data

Question 18

Methods of DATA COLLECTION

Answer 18

Observation, Interview , and Examination

Question 19

Gathering by using the senses

Answer 19

Observation

Question 20

a planned communication

Answer 20

Interview

Question 21

Types of Interview

Answer 21

Direct interview- highly structured, directly asked
Indirect interview - client controls the interview

Question 22

Stages of an Interview

Answer 22

1. The opening or introduction
2. The body or development
3. The closing

Question 23

A systematic data collection method to detect health problems

Answer 23

Examination

Question 24

Nursing health nursing or history assessment form. Interpretation of data.

Answer 24

Organization of data

Question 25

Validation of data

Answer 25

The information gathered during the assessment is double checked to confirm that it is accurate and complete.

Question 26

To complete the assessment phase, the nurse records client data.

Answer 26

Documentation of data

Question 27

Assessment Process

Answer 27

Collecting, organizing, validating, and documenting data

Question 28

Diagnosis

Answer 28

Nurses use critical thinking skills to interpret assessment data to identify client problem.

Question 29

Clinical judgement concerning a human response to health condition/processes of life, or a vulnerability for that response by an individual, family group, or community

Answer 29

North American Nursing Diagnosis Association

Question 30

Components of NANDA

Answer 30

Problem statement, Etiology, and Defining characteristics

Question 31

Acute Pain- Related to abdominal surgery- As evidences by patient discomfort and pain scale-

Answer 31

Problem statement Etiology Defining characteristics

Question 32

Status of nursing diagnosis

Answer 32

Actual diagnosis, possible diagnosis, risk nursing diagnosis, the syndrome diagnosis, a d wellness diagnosis

Question 33

A client problem that is present at the time of the nursing assessment.

Answer 33

Actual diagnosis

Question 34

A problem may be present, but requires more data collection to rule out or confirm it's existence

Answer 34

Possible diagnosis

Question 35

Clinical judgement that a problem may develop or does not exist, but the presence of risk factors indicates that a problem may develop

Answer 35

Risk nursing diagnosis

Question 36

Clusters of problems predicted to be present because of an event situation

Answer 36

The syndrome diagnosis

Question 37

Health-related problemat which a healthy person obtains nursing assistance to maintain or perform at a higher level

Answer 37

Wellness diagnosis

Question 38

Nursing Diagnosis

Answer 38

Statement of nursing judgement that made by the nurse, their education licensed to treat.

Question 39

Made by a physician

Answer 39

Medical diagnosis

Question 40

Ineffective breathing Activity intolerance Acute oain Disturbed body image

Answer 40

Asthma Cerebrovascular accident Appendicitis Amputation

Question 41

Planning

Answer 41

Process of prioritizing, identifying, selecting, ND documenting. Process of formulating client's goals and deciding the nursing interventions required to prevent, reduce, or eliminate the client's health problems.

Question 42

Types of planning

Answer 42

1. Initial planning 2. ongoing planning 3. Discharged planning

Question 43

Done after the initial assessment

Answer 43

Initial planning

Question 44

Continuous planning. Done by individual nurses

Answer 44

Ongoing planning

Question 45

Needs after the discharge. Process or anticipating client after discharge, medication of clients.

Answer 45

Discharged planning

Question 46

1. Setting Priorities Prioritization 2. Establishing client goals/ desired outcomes Goal Outcome

Answer 46

Planning Process

Question 47

Planning by deciding which nursing diagnosis requires attention first, second and so on.

Answer 47

Setting Priorities

Question 48

1. High Priority- first priority, life threatening condition 2. Medium Priority- health threatening condition 3. Low Priority- Physiological needs, long term period

Answer 48

Maslow's Pyramid

Question 49

Nurses set goals for each nursing diagnosis

Answer 49

Establishing client goals/ desired outcomes

Question 50

Expected or desired outcomes, management of diagnosis if it is appropriate

Answer 50

Goal

Question 51

Kinds of goals

Answer 51

Short term goals and long term goals

Question 52

Outcomes achievable in a few days to 1 week or a few hours

Answer 52

Short term goals

Question 53

Characteristics of short term goals

Answer 53

Specific, Measurable, Accompanied by a target date, Realistic, Time-bound, Client-centered

Question 54

Takes weeks or months

Answer 54

Long term goal

Question 55

Clients needs consistency and continuity of care to achieve goals.

Answer 55

Communicating the Plan of z CARE

Question 56

-Carrying out the plan -Consists of doing and documenting the activities

Answer 56

Implementation

Question 57

The process of implementation

Answer 57

-Implementing the nursing interventions Selecting Nursing Intervention

Question 58

Any treatment that the nurse performs to improve patient health

Answer 58

Nursing Intervention

Question 59

Types of Nursing Interventions

Answer 59

1. Independent Interventions 2. Dependent Interventions 3. Collaborative Interventions

Question 60

Independent Interventions

Answer 60

Activities that nurses are licensed to initiate on the basis of their knowledge and skills

Question 61

Activities carried out under the orders or supervision of a licensed physician

Answer 61

Dependent Interventions

Question 62

Actions that nurses carries out in collaboration with other health team members.

Answer 62

Collaborative Interventions

Question 63

Nursing Care Plan

Answer 63

A written or computerized information about the client's care.

Question 64

A planned, ongoing, purposeful activity in which the murse determines

Answer 64

Evaluation

Question 65

The client's progress towards achievement, goals/outcomes and the effectiveness of the nursing care plan.

Answer 65

Evaluation outcome

Question 66

Nursing Health Assessment

Answer 66

Gathering of information about the physiological, sociological, and Spiritual by a client. Holistic/overall aspect of an individual.

Question 67

-In conducting a comprehensive health assessment nurses encompasses the physical, psychological, social, and spiritual health. -A comprehensive health assessment can be performed as client makes contact within the health care system. -A comprehensive health assessment can be performed as client makes contact within the health care system.

Answer 67

Theoretical Basis of Health Assessment

Question 68

Basic functions: eating, walking, breathing. Factors: lifestyle, diet, physical activity, behavior

Answer 68

Physical health

Question 69

Involves the intellect but how your client response to your questions. Emotions and behavior of client.

Answer 69

Psychological health

Question 70

Relation to your family, friends, and colleagues. Relationships and interactions with other.

Answer 70

Social dimension of health

Question 71

A comprehensive that focuses on the belief of the higher being, personal interventions, meaning of life, and moral decisions of life.

Answer 71

Spiritual Health

Question 72

Components of focus health assessment

Answer 72

General survey, taking vital signs , and assessing specific areas that relate to the problem.

Question 73

Goal of Health Assessment

Answer 73

To establish a data base for the client's normal ability, risk factors, and current alteration.

Question 74

A complete assessment can provide?

Answer 74

An adequate database

Question 75

Framework of Health Assessment

Answer 75

1. Functional health framework 2. Head to toe Framework 3. Body System Framework

Question 76

-Evaluates the effects of the mind, body, and environment in relation to person's ability to perform the ADL. -Marjorie Gordon's 11 functional health patterns

Answer 76

Functional Health Framework

Question 77

A system for collecting data in an organized manner, starting from the head and proceeding systemically downward to their toes

Answer 77

Head to toe Framework

Question 78

Medical practitioners commonly used it as it focuses on the pathophysiology involved within specific organ body systems.

Answer 78

Body System Framework