Nursing Process chp3-7 EXAM 1

Question 1

The Nursing Process steps:

Answer 1

1. Assessment
2. Diagnosis
3. Planning
4. Interventions
5. Implementation

Question 2

Assessment

Answer 2

gathering info related to the physical, mental, spiritual, socioeconomic, and cultural status.

-1st step in nursing process

Question 3

data is:

Answer 3

observed, measurable and revealed to the nurse in multiple ways

Question 4

types of assessment:

Answer 4

1. Initial- on admission or start of shift. give u baseline
2. Ongoing- reassement/prn assessment
3. Comprehensive- physical exam, Nursing interview (cultural/religious belief) hollistic info, values, beliefs
4. Focused Assessment- initial, ongoing

Question 5

what is the best source of information you can ever obtain?

Answer 5

Your Assessment

Question 6

Sequence of Care Plan Development

Answer 6

1. Nursing Diagnosis- response to medical diagnosis
2. Related to- define medical diagnosis, describe, NOT MEDICAL DIAGNOSIS
3. As Manifested by- assessment info that supports diagnosis
4. Goals
5. Interventions
6. Best Practice- best evidence base that supports intervention
7. Evaluation

Question 7

Nursing Diagnosis

Answer 7

2 in nursing process

• reasoning process used in interpreting assessment dat.
• provides basis for positive outcomes
• primary focus: partnership with pt
• describes response to actual or potential problems

Question 8

Nursing Diagnosis clinical/physical response

Answer 8

body image disturbance/ risk factor 
ineffective airway clearance 
acute pain 
self care deficit 
altered nutrition: greater than body

Question 9

diagnostic reasoning

Answer 9

the thinking process that enables you to make sense of it all.

• Depends on: critical thinking
• analyze
• interpret data, draw conclusions, verify problems with pt
• record the information

Question 10

Prioritizing problems

Answer 10

1. Low priority- problems that require minimal supportive nursing intervention
2. Medium Priority- problems that don’t pose a direct threat to life
3. High Priority- problems that are life threatening or that could have a destructive effect on the pt

Question 11

a diagnostic statement consists of:

Answer 11

a problem and an etiology.. linked by a connective phrase.

Question 12

how to format a diagnostic statement: (3)

Answer 12

1. basic 1-part statement- omitting etiology from certain kinds of diagnostic statements
2. basic 2-part statement- Problem R/T etiology
3. basic 3-part statement- Problem R/T etiology as manifested signs or symptoms

Question 13

Planning

Answer 13

#3 in Nursing process 
- need accurate, complete assessment data and correctly identified and prioritized nursing diagnosis.

Question 14

Interventions

Answer 14

#4 in Nursing Process 
- actions based on clinical judgement and nursing knowledge, that nurses perform to achieve patient outcomes

Question 15

reports developed by scientists using a grading system to review studies and ranks the strength of their evidence

Answer 15

Evidence Based Practice Center (EPC)

Question 16

Statements developed by systematic review of evidence and an assessment of the benefits and harms of care options

Answer 16

Clinical Practice Guidelines

Question 17

Evaluation

Answer 17

Last step in Nursing Process

• planned, ongoing, systematic activity in which ou will make judgements about:
• pts progress toward goal
• effectiveness of nursing care plan
• quality of nursing care in the healthcare setting

Question 18

encompass each step of the nursing process

central source of info needed to guide holistic, goal oriented care to address each pt’s unique needs

Answer 18

Patient care plans

Question 19

Patient care plans:

Answer 19

• ensure care is complete
• provide continuity of care
• promote efficient use of nursing efforts
• provide a guide for assessments and charting
• meet the requirements of accrediting agencies