Nursing Process/CJM

Question 1

Compare Medical Diagnosis vs Nursing Diagnosis/Pt problem

(Include what it focuses on, time, and provide and example)

Answer 1

Medical diagnoses: focus on diseases

• Long-term/permanent
  -> Right ankle fracture (confirmed via X-ray).

Nursing diagnoses/patient problems: focus on unhealthy responses to health and illness - symptoms

• Can change overtime
  -> Acute pain R/T tissue injury AEB patient rating pain 8/10, grimacing, and guarding the right ankle.

Question 2

Nursing Process

Answer 2

systematic method that directs the nurse to provide care utilize 5 phases: Assessing, Diagnosing/Analysis, Planning, Implementation, Evaluation

Question 3

Nurse-initiated (Independent Intervention)

Answer 3

actions performed by a nurse without a physician’s order

Question 4

Physician-initiated (Dependent Intervention)

Answer 4

actions initiated by a physician in response to a medical diagnosis but carried out by a nurse under doctor’s orders

Question 5

Collaborative Interventions

Answer 5

treatments initiated by other providers and carried out by a nurse

Question 6

The nurse decides to administer tablets of Tylenol instead of the intramuscular Demerol she has previously been providing her orthopedic client, which step of the nursing process does this address?

Answer 6

implementation

Question 7

The nurse has multiple client assignments on the surgical unit. At the beginning of the shift, the nurse needs to determine which post-operative client should be seen first. Of the following, the nurse should go to see the client who:
A) Has a documented blood pressure of 90/50
B) Was medicated for back pain 10 minutes ago
C) Has an order to be out of bed and ambulated
D) Requires instructions for wound care before discharge

Answer 7

A) has a documented blood pressure of 90/50

Question 8

Which of the following is the best example of a nurses use of reflection?
A)The nurse places a client experiencing respiratory difficulties in the high Fowler’s position
B) The nurse calls the provider when the client reports feeling chilled and achy while having an oral temperature of 100.2
C) While caring for a client with a history of asthma, the nurse assesses the clients pulse-ox reading when he doesn’t sound right
D) A nurse tells a client “When you refuse to go to physical therapy earlier today, I believe you were upset about something else besides the appointment time”

Answer 8

D) A nurse tells a client “When you refuse to go to physical therapy earlier today, I believe you were upset about something else besides the appointment time”

Question 9

Which of the following nursing actions is the best example of problem solving?
A) Requesting an IV team to start an antibiotic drip on the client with a history of being a difficult stick
B) Offering to call the kitchen to provide an alternate breakfast for a client who does not like cook cereal
C) Trying several different wound dressings to determine which one the client can apply the most effectively
D) Calling for another pain medication order when the current drug results in the client experiencing nausea

Answer 9

C) Trying several different wound dressings to determine which one the client can apply the most effectively

Question 10

Which of the following nursing interventions is the best example of the implementation step of the nursing process?
A) Determining the clients ankle edema is worse after he ambulates
B) Asking the client to rate his ankle pain after receiving oral pain medication
C) Arranging for the client to receive pain medication 30 minutes before his ordered ambulation
D) Crushing the clients pain medication to facilitate easier swallowing and thus minimizing the risk for choking

Answer 10

D) Crushing the clients pain medication to facilitate easier swallowing and thus minimizing the risk for choking

Question 11

A nurse reviews a patient’s vital signs, listens to lung sounds, and asks the patient about their pain level. The nurse also examines the patient’s chart for lab results and recent medication history

Answer 11

Assessment

Question 12

Nurse identifies that the patient has ineffective airway clearance due to excessive mucus production, as evidenced by a productive cough, crackles in the lungs, and an SpO2 of 92% on room air

Answer 12

Diagnosis/Analyze

Question 13

“The patient will ambulate 50 feet with assistance within 24 hours to prevent complications from immobility.” The nurse also determines interventions such as administering pain medication before activity and assisting the patient with walking.

Answer 13

Planning

Question 14

The nurse assists a patient in repositioning every two hours, administers prescribed pain medication, and provides breathing exercises to help prevent pneumonia.

Answer 14

Implementation

Question 15

The nurse assesses whether the patient’s pain level has decreased from 8/10 to 4/10 as planned and determines whether additional interventions are necessary.

Answer 15

Evaluation

Question 16

Patient goals must be _________, which stands for…

Answer 16

SMART:

• Specific
• Measurable
• Achieveable
• Realistic
• Time bound

Question 17

Describe each letter of SMART goals

Answer 17

Specific: specific health problem
Measurable: quantifiable indicators
Achievable: consider patient’s condition
Realistic: align with available resources
Time bound: set a clear timeframe

Question 18

Do AS MANY practice questions regarding the nursing process (Be able to identify which nursing actions are a part of Assessment, Identify Problems, Planning, Implementation, and Evaluation)

Question 19

Liste the 5 characteristics of the nursing process. Describe each

Answer 19

• Systematic: part of an ordered sequence of activites
• Dynamic: interation and overlapping among the steps
• Interpersonal: promotes the dignity and respect of pt & establish caring relationships
• Outcome Orientated: nurse and pts work together to identify & reach outcomes
• Universally Applicable: framework for all nursing activities

Question 20

What are the 6 steps to the Clinical Judgement Model?

Answer 20

1. Recognizing Cues
2. Analyzing
3. Prioritize Hypotheses
4. Generate Solutions
5. Take Action
6. Evaluate Outcomes

Question 21

Describe the following step to the Clinical Judgment Model:

Recognizing Cues

(What does it mean?, How does it relate to the Nursing Process)

Answer 21

What does it mean?

• Which cues matter most?

How does it relate to the Nursing Process?

• Assessment

Question 22

Describe the following step to the Clinical Judgment Model:

Analyzing Cues

(What does it mean?, How does it relate to the Nursing Process)

Answer 22

What does it mean?

• What do the cues mean?

How does it relate to the Nursing Process?

• Diagnosis/Analyze

Question 23

Describe the following step to the Clinical Judgment Model:

Prioritze Hypotheses

(What does it mean?, How does it relate to the Nursing Process?)

Answer 23

What does it mean?

• Where do I start?

How does it relate to the Nursing Process?

• Diagnosis/Analyze

Question 24

Describe the following step to the Clinical Judgment Model:

Generate Solutions

(What does it mean?, How does it relate to the Nursing Process?)

Answer 24

What does it mean?

• What can I do?

How does it relate to the Nursing Process?

• Planning

Question 25

Describe the following step to the Clinical Judgment Model: **Take Action** (What does it mean?, How does it relate to the Nursing Process?)

Answer 25

**What does it mean?** - What will I do? **How does it relate to the Nursing Process?** - Implement

Question 26

Describe the following step to the Clinical Judgment Model: **Evaluate Outcomes** (What does it mean?, How does it relate to the Nursing Process?)

Answer 26

**What does it mean?** - Did it help? **How does it relate to the Nursing Process?** - Evaluation

Question 27

**Cognitive Competencies**

Answer 27

use critical thinking

Question 28

**Technical Competencies**

Answer 28

mastering manual skills (manipulating equipment skillfully)

Question 29

**Interpersonal Competencies**

Answer 29

promote dignity/respect of patients and stablish caring relationships

Question 30

**Ethical/Legal Compentencies**

Answer 30

establish personal moral code and professional role responsibilites

Question 31

When formulating a patient problem statement, it must include ________, _________, and ___________.

Answer 31

Problem, Etilogy, Signs & Symptoms (defining characteristics) | PES!

Question 32

Describe each step of a three part statement.

Answer 32

- **Problem:** indentify pt actual problem - **Etiology:** Identify factors causing/maintaining the actual weakness -> Related to (r/t) - **Defining Characteristics:** subjective/objective data -> As evidenced by (AEB)

Question 33

A three part state CANNOT include a _____________.

Answer 33

Medical diagnosis | dx is only by doctor!

Question 34

Evaluative statements in the care plan comminucate that nursing care is not complete until ...

Answer 34

the patient outcomes have been evaluated

Question 35

**Seperate the following statements into Subjective and Objective data:** 1. I feel nauseous after eating 2. Blood pressure is 150/90 mmHg 3. Patient's skin is cool, pale, and diaphoretic 4. My chest feels tight when I breathe 5. Lung sounds reveal wheezing in both lower lobes 6. I'm so dizzy when I stand up 7. I have a sharp pain in my lower back 8. Patient's gait is unsteady, requiring assistance to walk 9. Abdominal palpation reveals distension and tenderness 10. I feel anxious and can’t sleep at night

Answer 35

**Subjective Data:** 1, 4, 6, 7, 10 **Objective Date:** 2, 3, 5, 8, 9

Question 36

**Seperate the following statements into Subjective and Objective data:** 1. I have a constant headache that won’t go away 2. Patient's temperature is 102°F (38.9°C) 3. Respiratory rate is 28 breaths per minute 4. My stomach cramps get worse after I eat 5. Patient has 3+ pitting edema in both lower extremities. 6. I feel like my heart is racing all the time 7. I have this burning sensation when I urinate 8. I feel so tired even after sleeping all night 9. Skin is jaundiced with yellowing of sclera 10. Blood glucose level is 250 mg/dL 11. My joints ache, especially in the morning 12. Wound on left foot is red, warm to touch, and has purulent drainage 13. I keep forgetting things, and it’s getting worse 14. I get short of breath after walking just a few steps 15. Patient's gait is wide-based and unsteady, requires assistance. 16. Urine output is 150 mL in 8 hours, dark amber in color 17. Patient’s speech is slurred, and right side of the face is drooping 18. I feel really down and don’t want to do anything 19. My feet tingle all the time, and it’s hard to feel them 20. Heart rate is irregular at 110 bpm

Answer 36

**Subjective Data:** 1, 4, 6, 7, 8, 11, 13, 14, 18, 19 **Objective Date:** 2, 3, 5, 9, 10, 12, 15, 16, 17, 20

Question 37

# starting from bottom to top: List the levels of Maslow's hierarchy of needs:

Answer 37

1. Physiological Needs 2. Safety Needs 3. Love & Belonging Needs 4. Esteem Needs 5. Self Actualization

Question 38

**Which level of Maslow's hierarchy of needs is the priority in this case?** A 70-year-old homeless man is brought to the emergency department with signs of dehydration and malnutrition. He is weak, disoriented, and states he hasn’t eaten in two days.

Answer 38

**Physiological Needs:** The patient's most urgent needs are food and water for survival.

Question 39

**Which level of Maslow's hierarchy of needs is the priority in this case?** A 35-year-old woman is admitted to the hospital after a domestic violence incident. She expresses fear that her abuser will find her. She refuses to give her home address and frequently looks over her shoulder.

Answer 39

**Safety Needs** The patient's most urgent need is ensuring physical safety.

Question 40

**Which level of Maslow's hierarchy of needs is the priority in this case?** A 55-year-old man recovering from a stroke has limited mobility and is feeling isolated. He frequently talks about missing his family and expresses sadness that he doesn’t have visitors.

Answer 40

**Love & Belonging Needs** The patient is struggling with emotional connection and loneliness.

Question 41

**Which level of Maslow's hierarchy of needs is the priority in this case?** A 40-year-old woman with an amputation feels useless because she can no longer work as she used to. She states, "I feel like I have no purpose anymore."

Answer 41

**Esteem Needs** The patient is struggling with self worth and independence.

Question 42

**Which level of Maslow's hierarchy of needs is the priority in this case?** A 28-year-old patient who recently recovered from cancer decides to start a nonprofit organization to support others undergoing treatment. He expresses fulfillment in helping others and dedicated his life to helping those who are also going through cancer.

Answer 42

**Self-Actualization Needs** The patient achieved personal growth and is now dedicated to helping others.

Question 43

**A nurse is reviewing a set of nursing diagnoses written by a student nurse. Which of the following nursing diagnoses are correctly written, following guidelines for avoiding common errors?** (Select all that apply) A) Impaired Skin Integrity related to prolonged immobility and pressure on bony prominences. B) Risk for Infection related to presence of an indwelling urinary catheter. C) Anxiety related to a need for emotional support. D) Ineffective Airway Clearance related to accumulation of secretions in the lungs. E) Self-Care Deficit related to cerebrovascular accident (CVA). F) Imbalanced Nutrition: Less than Body Requirements related to inadequate dietary intake.

Answer 43

A, B, D, F

Question 44

**A nurse is formulating a nursing diagnosis for a patient experiencing impaired mobility due to a recent stroke. Which of the following nursing diagnoses is correctly written while avoiding common errors?** A) Impaired Physical Mobility related to left-sided weakness and cerebrovascular accident (CVA). B) Need for assistance with ambulation related to left-sided weakness. C) Impaired Physical Mobility related to decreased muscle strength and coordination. D) Impaired Physical Mobility related to inability to walk and muscle atrophy.

Answer 44

C

Question 45

**A nurse is caring for a patient diagnosed with pneumonia who has impaired gas exchange as the priority physiological problem. Which nursing interventions should the nurse include in the individualized care plan?** (Select all that apply.) A. Administer oxygen therapy as prescribed. B. Encourage deep breathing and coughing exercises. C. Monitor oxygen saturation and respiratory rate closely. D. Limit fluid intake to prevent fluid overload. E. Position the patient in high Fowler’s position. F. Teach the patient to avoid ambulation to conserve energy.

Answer 45

A, B, C, E

Question 46

A nurse is developing an individualized nursing care plan for a patient with Type 2 Diabetes Mellitus who has uncontrolled blood glucose levels as the priority physiological problem. Which nursing intervention is the most important to include in the care plan? A. Educate the patient on the importance of proper foot care. B. Monitor blood glucose levels regularly and administer insulin as prescribed. C. Encourage the patient to limit all carbohydrates from the diet. D. Advise the patient to avoid physical activity to prevent hypoglycemia.

Answer 46

B

Question 47

What are the 5 rights of delagation?

Answer 47

- **Right task** -> Task falls within delegates job description - **Right circumstance** -> Pt health condition is stable - **Right person** - **Right directions/communication** -> Licensed nurse communicates specifiic intstruciton and delegatee asks clarifying questions - **Right supervision and evaluation** -> Licenses nurse responsible for: --> monitoring the delegated activity --> following up with delegatee --> evaluating pt outcomes

Question 48

**Describe the Nursing Intervention Classification (NIC):** (What is it?, Why is it important?, What does it include?)

Answer 48

**What is it?** - comprehensive list of treatments/actions that nurses perform **Why is it important?** - helps to standardize nursing knowledge, improve communication, and show impact of nursing care **What does it includes?** - includes actions for treating illnesses, preventing problems, and promoting health -> Covers both direct and indirect care -> Actions can be directed toward individuals, families, or entire communities

Question 49

As an RN, you can not delegate what you can T.A.P.E.. What does each letter mean?

Answer 49

Teach Assess Plan Evaluation

Question 50

What is the purpose of the evaluation phase in the nursing process?

Answer 50

The evaluation phase determines whether patient outcomes have been: - Met: continue or discontinue interventions - Partially met: modify interventions as needed - Not met: Reassess, revise the care plan

Question 51

In revising/modifying a care plan, why is it imporant to collect new assessment data?

Answer 51

to have the most accurate and updated information about a patients condition

Question 52

In revising/modifying a care plan, why is it imporant to rewrite outcomes?

Answer 52

rewrite outcomes to make them more realistic/achievable for the patient

Question 53

In revising/modifying a care plan, why is it imporant to change nurse order?

Answer 53

revise interventions to be more effective and patient centered

Question 54

In revising/modifying a care plan, why is it imporant to increase evaluation frequency?

Answer 54

monitor patient’s progress more closely and make timely adjustments

Question 55

In revising/modifying a care plan, why is it imporant to adjust time criteria?

Answer 55

assess if the patient needs more time

Question 56

Evidence-Based Practice (EBP)

Answer 56

integrate current evidence with clinical expertise, and patient/family preferences to deliver optimal health care

Question 57

# Evidence Based Practice What are variables to consider when constructing nursing interventions?

Answer 57

- Appropriate for the pt problem -> (include etiology/pathophysiology, assessment data) - Consistent with research findings - Realistic for pt and nurse - Compatible with pt’s values and other components of care - Specificity: frequency, time and method

Question 58

A 72-year-old patient recovering from hip surgery is experiencing difficulty walking, requiring assistance with a walker. The patient reports muscle weakness and expresses fear of falling when attempting to move independently. Create a three part statement including: **Problem:** What is the patient’s main issue? **Etiology:** What is causing the problem? **Symptoms:** What are the signs/symptoms that support this diagnosis?

Answer 58

**Problem:** - Impaired physical mobility **Etiology:** - Muscle weakness - Post-op pain **Symptoms:** - Difficulty walking - requiring a walker - fear of falling

Question 59

A 58-year-old patient with chronic bronchitis has persistent coughing, labored breathing, and increased mucus production. The nurse observes wheezing on auscultation and notes the patient has difficulty clearing secretions. Create a three part statement including: **Problem:** What is the patient’s main issue? **Etiology:** What is causing the problem? **Symptoms:** What are the signs/symptoms that support this diagnosis?

Answer 59

**Problem:** - Impaired airway clearance **Etiology:** - Increased mucus production - Chronic bronchitis **Symptoms:** - Persistent coughing - Wheezing - Difficulty clearing secretion

Question 60

A 35-year-old patient with Crohn’s disease reports poor appetite, weight loss, and fatigue over the past month. The nurse notes pale skin, dry mucous membranes, and a BMI of 17. Lab results indicate low albumin levels. Create a three part statement including: **Problem:** What is the patient’s main issue? **Etiology:** What is causing the problem? **Symptoms:** What are the signs/symptoms that support this diagnosis?

Answer 60

**Problem:** - Imbalanced Nutrition **Etiology:** - Poor appetite - Crohn's disease **Symptoms:** - Weight loss - Fatigue - Pale skin - Dry mucus membranes - Low albumin levels

Question 61

A 45-year-old patient recovering from abdominal surgery reports severe pain (8/10) at the incision site, guarding the area when moving. The nurse observes shallow breathing and facial grimacing. Create a three part statement including: **Problem:** What is the patient’s main issue? **Etiology:** What is causing the problem? **Symptoms:** What are the signs/symptoms that support this diagnosis?

Answer 61

**Problem:** - Acute pain **Etiology:** - surgical incision **Symptoms:** - Pain rated 8/10 - Guarding behavior - Shallow breathing - Facial grimacing

Question 62

A 76-year-old bedbound patient has developed a Stage II pressure ulcer on their sacrum. The nurse observes red, open skin with drainage and notes that the patient has been unable to reposition themselves due to severe weakness and immobility. Create a three part statement including: **Problem:** What is the patient’s main issue? **Etiology:** What is causing the problem? **Symptoms:** What are the signs/symptoms that support this diagnosis?

Answer 62

**Problem:** - Impaired skin integrity **Etiology:** - Prolonged immobility - Pressure on bony prominences **Symptoms:** - Stage II pressure ulcer on sacrum - Open skin with drainage - Inability to reposition self

Question 63

A 65-year-old patient with prolonged vomiting and diarrhea is weak, lightheaded, and unable to stand without assistance. The nurse notes dry mucous membranes, decreased urine output, and a blood pressure of 88/56 mmHg. Create a three part statement including: **Problem:** What is the patient’s main issue? **Etiology:** What is causing the problem? **Symptoms:** What are the signs/symptoms that support this diagnosis?

Answer 63

**Problem:** - Deficient fluid volume **Etiology:** - Excessive fluid loss from vommiting and diarrhea **Symptoms:** - Weakness - Lightheaddedness - Dry mucous membranes - Decreased urine output - Hypotension (88/56)

Question 64

A 45-year-old hospitalized patient reports having difficulty falling and staying asleep due to frequent hospital noises, stress about their condition, and discomfort from their IV line. The patient appears fatigued and irritable during morning rounds. Create a three part statement including: **Problem:** What is the patient’s main issue? **Etiology:** What is causing the problem? **Symptoms:** What are the signs/symptoms that support this diagnosis?

Answer 64

**Problem:** - Disrupted sleep pattern **Etiology:** - Frequent hospital noises - Stress about condition - Discomfort from IV line **Symptoms:** - difficulty falling and staying asleep - Fatigued - Irritable

Question 65

What is a **Care Plan**?

Answer 65

personalized document outlining specific interventions & goals for a pt

Question 66

The nursing process is a _______, while the care plan is the _____________________________

Answer 66

**Nursing process** = framework **Care plan** = result of applying framework to a specific pt

Question 67

Compare Direct vs Indirect Care

Answer 67

- **Direct care**: treatments performed through interaction with pt -> Elevating pt right foot - **Indirect care**: treatments performed away from the pt -> Contacting physical therapy

Question 68

Compare the different types of priority (High, Medium, Low)

Answer 68

**High Priority**: greatest threat to pt well-being **Medium priority**: non threatening problems **Low priority**: problem not specifically related to current health problems

Question 69

Describe this type of assessment: **Patient-Centered Assessment Methods** (What does it use/entail?)

Answer 69

use of interviews, observations, and physical exams that capture subjective and objective data