Week 1

Question 1

What is the Nursing process

Answer 1

ADPIE

Question 2

Assessment

Answer 2

Collect and analyze data

Question 3

Medical diagnosis

Answer 3

Focuses on disease and pathology

Question 4

Nursing diagnosis

Answer 4

Focuses on patient response to illness

Question 5

How is data used

Answer 5

By other disciplines

For Nursing Care

To ensure clients receive
-proper care
-by qualified individuals
-at the correct time

Question 6

Cana RN delegate assessment

Answer 6

No.

CNA and LPNs can collect data such as vital signs. However it is the RNs responsibility to assign those tasks, confirm accuracy of data, conduct interview and do physical assessment.

Question 7

What are the types of data

Answer 7

Objective, subjective, primary, and secondary

Question 8

Objective data

Answer 8

Data the nurse observes.

Data that comes from lab, etc.

Can be measured

Question 9

Subjective data

Answer 9

What the patient reports

Question 10

Primary data

Answer 10

Obtained directly from the patient or observed the patient.

Vitals.

Question 11

Secondary data

Answer 11

From someone other than patient. Includes patient record.

Question 12

Skills of the nursing assessment/how to obtain data

Answer 12

Observation

Physical assessment

Interviewing

Question 13

Nursing interview

Answer 13

Structured communication

To gather subjective data

Can be done direct or nondirect

Question 14

Directive interview

Answer 14

Closed ended. Nurse in charge

Question 15

Nondirective interview

Answer 15

Open ended.

Patient in charge.

Question 16

When to verify data

Answer 16

Subject and objective data conflict

Clients statement are inconsistent

Data is far out of normal range

Factors that impact accuracy are present

Question 17

Documentation Guidelines

Answer 17

-do so soon as possible

-rarely use acronyms

-use patient’s own word when possible

-use concrete specific information

-document cues but not inferences

Question 18

Diagnosis

Answer 18

Analyze and interpret the data

Draw conclusion

Very conclusion

Prioritize problems

Question 19

Health problem

Answer 19

Disease or illness that requires intervention

Question 20

Nursing Diagnosis

Answer 20

Health problem that nurse identifies, prevents, or treats independently.

Question 21

Diagnostic reasoning

Answer 21

Use critical thinking to analyze and interpret data

Draw conclusions about health status

Verify problems with client

Record diagnostic statement

Question 22

Prioritizing problem

Answer 22

Maslows hierarchy of needs guides priority for nurses. Multiple problems can be addressed at once.

Question 23

Priority levels

Answer 23

High-life threatening

Med-may causes serious physical or emotional changes

Low-requires minimal nursing intervention

Question 24

Planning

Answer 24

Select standard care plan

Create individualized care plan

Identify outcomes and goals

Question 25

Initial planning

Answer 25

-Begins at first client contact -Done shortly after initial assessment -development of initial comprehensive care plan

Question 26

Ongoing planning

Answer 26

Changes made as client responds to care

Question 27

Discharge planning

Answer 27

-self care and continuity of care after discharge -Begins with initial assessment -Requires collaboration

Question 28

Process for writing individualized care plan

Answer 28

Make list of problems Identify which problems can be addressed with standardized care plan Individualize standard care plan Include ADLs and basic care needs Develop individualize care plans for the problems not addressed by standardized care plan

Question 29

Goals/outcome

Answer 29

Goals: Change in health status that we hope to achieve Nursing sensitive outcomes: can be influenced by nursing interventions

Question 30

Long term goals

Answer 30

Achieved over week or more

Question 31

Short term goal

Answer 31

Few hours to few days

Question 32

Planning intervention

Answer 32

Review diagnosis and outcome Select standardized intervention Individualize to meet patient needs

Question 33

Nursing intervention classification

Answer 33

Has label, definition, and list of activities Are linked to Nanda-1 diagnosis and NOV outcome labels

Question 34

Nursing orders

Answer 34

Date Subject Verb Times and limits Signature

Question 35

What is a nursing order

Answer 35

Instructions on how and when nursing interventions will be implemented Usually on nursing care plan Possibly can be delegated RN may delegate but remains accountable for the patient

Question 36

Safe Nursing orders

Answer 36

Provide goal directed, client centered care Use evidence based care Provide safe quality care

Question 37

Implementation

Answer 37

Promote client participation May delegate but remain accountable(most include supervision) Can not delegate intervention that requires independent specialized nursing skill

Question 38

Five rights of delegation

Answer 38

Right task Right curcumstance Right person Right direction Right supervision

Question 39

Final step of implementation

Answer 39

Documentation. Record nurses activities and client response.

Question 40

Evaluation

Answer 40

Evaluate clients progress to goals Effectiveness of nursing care plan Quality of care in health care setting

Question 41

Types of evaluation

Answer 41

Structure Process Outcomes

Question 42

Structure

Answer 42

Focuses on setting where care is provided. Explores how the organizations policies and procedures impact quality of care.

Question 43

Process

Answer 43

Focuses on the way care is provided. The activities by RN and other members of teams. Was care relevant, appropriate, etc.

Question 44

Outcomes

Answer 44

Focuses on measurable change in clients health as result of care

Question 45

Frequency and time of evaluation

Answer 45

Ongoing Intermittent Terminal

Question 46

Ongoing

Answer 46

Will continuously evaluate while implementing, after interventions, and every patient contact

Question 47

Internittent

Answer 47

Done at specific times

Question 48

Terminal

Answer 48

Describes patient health and progress towards goal when they are discharged.

Question 49

How to evaluate client progress

Answer 49

Review outcomes Collect reassessment data Judge goal achievement Record evaluative statement Evaluate collaborative problems

Question 50

Evaluating and revising care plan

Answer 50

Goals met-if all goals met discontinue care plan Goals partially met-can revise care plan or give more time to achieve goal Goals not met- examine entire care plan and see if revision is necessary Revise care plan-must review each step of nursing process to decide how to revise care plan

Question 51

Checklist for evaluating care plan

Answer 51

Review assessment- changes may have occurred in data or client condition Review diagnosis- diagnosis may require update Review planning outcomes-outcome might need to be revised Review planning interventions-might need to modify nursing orders Review implementation-can be failure to implement or issues with how implementation occurred.

Question 52

Types of assessments

Answer 52

Initial and ongoing-are as their definition Comprehensive -hollistic Focused -targets specific problem Special needs assessment

Question 53

Special needs assessment

Answer 53

Type of focused assessment that focuses on one area Nutritional assessment Pain asessment Cultural assessment Spiritual health assessment Psychosocial assessment Etc.

Question 54

Nursing health history

Answer 54

Is done during assessment. Usually includes: chief complaint History of present illness Past health history

Question 55

Different problem types (diagnostic reasoning)

Answer 55

Medical diagnosis Collaborative problem Actual nursing diagnosis Risk nursing diagnosis Possible nursing diagnosis Syndrome nursing diagnosis Patient stregths Wellness nursing diagnosis