test 2

Question 1

Steps of nursing process in order

Answer 1

1. Assessment
2. Diagnosis (nursing)
3. Planning
4. Implementation
5. Evaluation

Question 2

• Systemic problem-solving process that guides all nursing actions
• Help nurse provide goal-directed, client centered care

Answer 2

Nursing Process

Question 3

• Systemic gathering of data and ongoing process
• Categorizing data (cluster cues)
• Recording data

Answer 3

Assessment

Question 4

• Identifying client’s actual or portentously health needs, problems, and strengths
• Pt’s response to their illness

Answer 4

Diagnosis

Question 5

Data about client’s motivation, family, and available resources help you and the client formulate realistic goals

Answer 5

Planning

Question 6

Decide goals you want to achieve with your nursing activities, keep pt in mind

Answer 6

Planning outcomes

Question 7

Assess data to choose interventions to help the client achieve stated goals

Answer 7

Planning interventions

Question 8

Putting plan into action and making sure pt is able to do it
- gather data by observing the client’s response as interventions are performed

Answer 8

Implementation

Question 9

Types of nursing knowledge

Answer 9

Theoretical, Practical, Self, and Ethical

Question 10

• Knowing “why”
• EBP facts/theories from nursing and other disciplines
• Understanding why you need to do something with research to back it up

Answer 10

Theoretical

Question 11

Knowing “what to do and how to do it”
- basically what we’re doing in the skills lab

Answer 11

Practical

Question 12

Knowing yourself and your beliefs, understanding your self
- Help decrease bias and errors in planning individual care

Answer 12

Self

Question 13

Our obligation, knowing right from wrong
- Doing the right thing

Answer 13

Ethical

Question 14

Assessment focused on disease and pathology; doctor does the orders
- Diseased process related

Answer 14

Medical diagnosis

Question 15

• Assessment that focus on client’s response to illness
• Considered to be the symptoms, the nurse’s role is to make interventions to alleviate symptoms

Answer 15

Nursing diagnosis

Question 16

The different types of assessment

Answer 16

Comprehensive, initial focused, and ongoing focused

Question 17

Global, nursing/patient database, admission

Answer 17

Comprehensive assessment

Question 18

• Used to follow up on symptoms or findings from first examination
• First time seeing and focusing on it

Answer 18

Initial focused assessment

Question 19

Evaluate the status of existing problems and goals

Answer 19

Ongoing focused assessment

Question 20

Maslow’s hierarchy of needs from bottom to top

Answer 20

• Physiological
• Safety
• Love/belonging
• Esteem
• Self-actualization

Question 21

Breathing, food, water, sex, sleep, homeostasis, excretion

Answer 21

Physiological of Maslow’s Hierarchy

Question 22

Security of…
body, employment, resources, morality, family, health, and property

Answer 22

Safety of Maslow’s Hierarchy

Question 23

Friendship, family, and sexual intimacy

Answer 23

Love/belonging of Maslow’s Hierarchy

Question 24

Self-esteem, confidence, achievement, respect of others, respect BY others

Answer 24

Esteem of Maslow’s Hierarchy

Question 25

Morality, creativity, spontaneity, problem solving, lack of prejudice, acceptance of facts

Answer 25

Self-actualization of Maslow’s Hierarchy

Question 26

Grouping given data

Answer 26

Cluster cues

Question 27

Goal that needs to be achieved within a few hours or days - By end of shift, end of day

Answer 27

Short-term

Question 28

Goal that needs to be achieved over a longer period of time (week, month, or more) - by discharge

Answer 28

Long-term

Question 29

SMART goal

Answer 29

Specific - define goal as much as possible: who, what, where, why, and which Measurable - track progress and measure outcome Attainable/achievable - goal is reasonable enough to be accomplished; goal isn’t out of reach or below standard performance Relevant - goal is worthwhile and will meet the needs Timely - time limit; establish sense of urgency and prompt nurse for time management

Question 30

Why do we write and develop goals for the patient?

Answer 30

We want to have a positive change

Question 31

- Within RN scope of practice/license - Doesn’t require order - Done in response to nursing dx

Answer 31

Independent interventions

Question 32

- Ordered by doctor/provider, implement by RN - Nurse is still responsible for the assessment/evaluation of the dependent intervention — make sure order is safe for the pt

Answer 32

Dependent intervention

Question 33

Done with collaboration of health team members

Answer 33

Interdependent intervention

Question 34

How to communicate task with the 5 rights of delegation

Answer 34

Right… - Task, Circumstances, Person, Direction/communication, Supervision

Question 35

5Rs - Delegable for a specific pt

Answer 35

Right Task

Question 36

5Rs - Appropriate pt setting, available resources, and other relevant factors considered

Answer 36

Right circumstances

Question 37

5Rs - Delegating the right task to the right person to be performed on the right person

Answer 37

Right person

Question 38

5Rs - Clear, concise description of the task, including its objective, limits, and expectations

Answer 38

Right direction/communication

Question 39

5Rs - Appropriate monitory, evaluation, intervention, and feedback

Answer 39

Right supervision

Question 40

Who is responsible for the evaluation of the task delegated?

Answer 40

Nurse

Question 41

- Evaluation that hasn’t been met - Evaluation done while implementing care, immediately after care, and at each pt contact

Answer 41

Ongoing evaluation

Question 42

Evaluation at specified stages, time, or intervals

Answer 42

Intermittent evaluation

Question 43

- Evaluation that has ended, mark it as met and take it off the care plane - The progress or status at discharge - Includes forms or special instructions

Answer 43

Terminal evaluation