Nursing Process, Nursing Diagnosis, and MRM

Question 1

What is the nursing process?

Answer 1

A - assess
D- diagnose
P - plan
I - implement
E - evaluate

Question 2

Clinical reasoning

Answer 2

cognitive process that uses formal and informal thinking strategies to analyze client information, evaluate the significance, and consider alternate actions
Used in determining a diagnosis

Question 3

What is the three part nursing diagnosis?

Answer 3

P - problem (nursing diagnosis label from NANDA-I)
E - etiology (related to phrase contributing to the problem- pathophysiology)
S - symptoms (defining characteristics/symptoms)

Question 4

What is a problem-focused diagnosis?

Answer 4

a clincial judgement converning an undesirable human response to a helath condition or life process

Question 5

Risk nursing diagnosis

Answer 5

clinical judgment concerning the susceptability to developing an undesirable response to a condition
Example: Pt states they feel unbalanced and are afraid of falling down the stairs, but have not falled before

Question 6

Health promotion nursing diagnosis

Answer 6

clinical judgment concerning motivation to increase well being

Question 7

Steps to making a nursing diagnosis

Answer 7

1. determine relevant symptoms
2. make a list of symptoms
3. clluster similar symptoms
4. analyze/interpret the symptoms
5. Select nursing diagnosis form NANDA-I list

Question 8

Symptom pattern recognition

Answer 8

process of identifying symptoms that patients have related to their illness, understanding which require intervention, and identifying the associated time-frame to intervene

Question 9

How should you determine priority nursing diagnosis?

Answer 9

Patient priority and mutual goals
Safety: ABCs and Maslows

Question 10

What are the QSEN competencies?

Answer 10

• Patient-centered care
• Teamwork
• Evidence-based practice
• quality improvement
• safety
• informatics

Question 11

Primary, secondary, and tertiary sources of information

Answer 11

Primary: patient
Secondary: nurse and family
Tertiary: medica lam and chart

Question 12

What are the 4 major categories of data per MRM?

Answer 12

1. description of the situation
2. expectations
3. resource potential
4. goals and life tasks

Question 13

What are the 3 parts of the description of the situation per MRM?

Answer 13

Overview of the situation
Etiology (stressors and distressors)
Therapeutic needs

Question 14

What is the purpose collecting data on expectations?

Answer 14

To develop an undertsanding of the client’s personal orientation in term of their expectations for the present and future.
*can they project themselves into the future? Useful for goal setting

Question 15

What is included in expectations?

Answer 15

Immediate
Long term

Question 16

What are the parts of resource potential?

Answer 16

1. External: Social network, Support system, Health care system
2. Internal: Strengths, Adaptive potential (Feeling states; Pshyiological data)

Question 17

What is included in goals and life tasks?

Answer 17

1. current
2. future

Question 18

What is the purpose of collecting data on goals and life tasks?

Answer 18

To determine current developmental status to understand the client’s personal model

Question 19

The 5 aims of nursing interventions

Answer 19

1. Build trust
2. Promote client’s positive orientation
3. Promote client’s control
4. Affirm and promote client’s strengths
5. Set mutual goals that are health directed

Question 20

What is a nursing diagnosis?

Answer 20

• Prioritizing hypotheses
• Clinical judgment concerning human response to health condition or life processes

Question 21

What should be considered when creating a nursing diagnosis statement?

Answer 21

• Defining characteristics and related factors should be specific to the patient’s situation
• Diagnosis should be from the approved NANDA-I list

Question 22

What is an outcome?

Answer 22

A measurable change in the client’s status

Question 23

What is an intervention?

Answer 23

Things the NURSE does to facilitate achieving the outcome

Question 24

What is the MRM theory of nursing interventions?

Answer 24

1. Humans are individualistic since they model their world uniquely
2. Interventions should be planned in the guidelines of similiarites between people
3. Similarities are reflected in the 5 major principles (MRM Aims of Intervention)

Question 25

What is the principle behind building positive orientation as a nursing intervention aim?

Answer 25

Affiliated-individuation is dependent on the individual's perceiving that they are an acceptable, respectable ,and worthwhile human.

Question 26

What is the principle behind promoting client control?

Answer 26

Human development is dependent on the person's perceiivng that they have control over their life, while also sensing affiliation (dependence is not a bad thing)

Question 27

What is the principle behind affirming a client's strengths?

Answer 27

There is an innate drive toward holistic health that is facilitated by consistent nurturance

Question 28

What is the principle behind setting mutual goals that are health directed?

Answer 28

Human growth is dependent on satisfaction of basic needs and facilitated by growth-need satisfaction

Question 29

Independent nursing interventions

Answer 29

* actions the nurse can initiate without a providers order

Question 30

Collaborative nursing actions

Answer 30

* Actions that require an order from the provider * Could be recommended by the nurse within SBAR

Question 31

What factors should be included in selecting an intervention?

Answer 31

1. Characteristics of the problem (hypothesis) 2. Goals and outcomes 3. Client preference/ability 4. Evidence for interventions 5. Feasibility of intervention 6. Nurses' competence