3613 The Nursing Process

Which step of the nursing process does a nurse use when finding blood pressure of 180/75, a heart rate of 90, and a patient complaint of chest pain? Implementation Evaluation Diagnosis Assessment

Assessment

What is the primary purpose of the nursing diagnosis? Resolving patient confusion Communicating patient needs Meeting accreditation requirements Articulating the nursing scope of practice

Communicating patient needs

What nursing skill is essential when utilizing the nursing process? Critical thinking Analysis Observation Time management

Critical thinking

How are the steps of the nursing process utilized? Select all that apply. Diagnose needs and plan goals Assess individuals, families, and communities Identify outcome criteria and implement interventions Follow physician's orders Identify specific nursing interventions

Diagnose needs and plan goals Assess individuals, families, and communities Identify outcome criteria and implement interventions Identify specific nursing interventions

The five steps that make up the nursing process allow it to be: Collaborative Analytical Outcome based Dynamic

Dynamic

Which characteristic of the nursing process refers to changes over time in response to patients' individual needs? Dynamic Analytical Organized Adaptable

Dynamic

A patient reports that his pain level is now 6 out of 10. The patient's goal for a pain level of 3-4 out of 10 is not met. Which step of the nursing process does this statement reflect? Planning Diagnosis Implementation Evaluation

Evaluation

Which step is a part of the nursing process? Preparing Analysis Treatment Evaluation

Evaluation

What analytical questions are asked at each step in the nursing process? Select all that apply. "Is the data collection thorough and accurate?" "Are outcomes general and hopeful?" "Have all underlying factors been addressed in the care plan?" "Are the interventions available?" "Could interventions impact the patient negatively?"

"Is the data collection thorough and accurate?" "Have all underlying factors been addressed in the care plan?" "Could interventions impact the patient negatively?" 1,3,5

A patient comes to the emergency department complaining of fever and diarrhea. What should the nurse ask the patient first? "Do you have a family history of diabetes?" "Are you taking any medications?" "Have you had any surgeries in the past?" "What is the severity and duration of your fever and diarrhea?"

"What is the severity and duration of your fever and diarrhea?"

The nursing process includes _________ steps.

5

The _________characteristic of the nursing process is that nursing care plans can be developed for patients in any care setting, as well as for targeted populations and communities. Dynamic Analytical Organized Adaptable

Adaptable

A nurse is preparing a presentation to the unit on ANA, the organization that identified the five steps of the nursing process. What does ANA stands for? American Nurses Association Active Nurses Academy American Nurses Academy Association Nurses Alive

American Nurses Association

The _____________ characteristic of the nursing process describes when nurses ask questions and demonstrate the use of critical thinking for each step. Organized Outcome-oriented Analytical Dynamic

Analytical

What does the term "dynamic nature" of the nursing process refer to? Change over time in response to the patient's needs Change over time in response to the nurse's needs Change over time in response to the provider's needs Change over time in response to the family's needs

Change over time in response to the patient's needs

What is a part of the assessment process? Data collection Care plan Interventions Prioritize diagnoses

Data collection

Stella Jones, RN, reassesses a patient one hour after giving morphine for the patient's pain. The patient states that she is still in horrible pain, eliciting a response of 8 out of 10. What would be the most appropriate intervention? Check blood pressure. Give additional breakthrough pain medication. Reassess pain level in two hours. Monitor heart rate every 30 minutes.

Give additional breakthrough pain medication.

Who first pioneered the term "nursing process?" Ernestine Wiedenbach Ida Jean Orlando Lydia Hall Dorothy E. Johnson

Lydia Hall

Match the nursing process characteristics to the definition. Nurses use critical thinking for each step of the nursing process. The nursing process changes over time in response to patient needs. The nursing process helps ensure that patient care is well planned. Nurses evaluate patient outcomes to determine effectiveness. Outcome-oriented Analytical Dynamic Organized

Match the nursing process characteristics to the definition. Nurses use critical thinking for each step of the nursing process. Analytical The nursing process changes over time in response to patient needs. Dynamic The nursing process helps ensure that patient care is well planned. Organized Nurses evaluate patient outcomes to determine effectiveness. Outcome-oriented

Which statement illustrates the collaborative characteristic of the nursing process? The nursing process can be used to assess the needs of individuals as well as large communities. The nursing process provides a systematic method of addressing patient needs, and is understood by nurses worldwide. The nursing process allows patient care to be comprehensive and well organized. Nurses may incorporate actions by the patient or family to address patient goals.

Nurses may incorporate actions by the patient or family to address patient goals.

Which method was developed to advance the nursing profession and how nurses provide care to all patients? Nursing care plan Nursing process Nursing diagnoses Patient-centered care

Nursing process

Which subcategory of planning is recognized by professionals and educators as part of the traditional five-step nursing process? Nursing interventions classification Medical outcome identification Outcome identification Medical interventions classification

Outcome identification

Which option exemplifies a short-term goal the nurse may identify during the planning step of the nursing process? Patient verbalizes a pain level of 4 or 5, out of 10, within 2 hours of receiving prescribed pain medication. Patient verbalizes a pain level of 2 or 3, out of 10, during A.M. care within 24 hours. Patient verbalizes a pain level of 1 out of 10 at the 2-week provider follow-up appointment. Patient verbalizes a pain level of 0 out of 10 at the 1-month provider follow-up appointment.

Patient verbalizes a pain level of 4 or 5, out of 10, within 2 hours of receiving prescribed pain medication.

Place the steps of the nursing process in the order in which each should occur. Planning Assessment Diagnosis Implementation Evaluation

Place the steps of the nursing process in the order in which each should occur. Assessment Diagnosis Planning Implementation Evaluation

A nurse educator is reviewing the steps of the nursing process with the class. While reviewing a case study, the educator asks the students to determine which part of the process a nurse uses when establishing short- and long-term goals with the patient. How should the students respond? Planning Diagnosis Implementation Evaluation

Planning

Which term describes the nurse prioritizing the diagnoses and identifying goals that are realistic, measurable, and patient-focused with specific outcomes? Assessment Planning Diagnosis Evaluation

Planning

Which best describes the diagnosis step of the nursing process? The nurse gathers patient data through observation, interviews, and physical assessment. The nurse analyzes, validates, and clusters patient data to identify patient problems. Patient data clusters are stated in standardized language, which provides clarity and universal understanding by all health care providers. The nurse prioritizes the nursing diagnoses and identifies goals that are realistic, measurable, and patient-focused with specific outcomes. The nurse initiates specific nursing interventions and treatments designed to help the patient achieve established goals and outcomes.

The nurse analyzes, validates, and clusters patient data to identify patient problems. Patient data clusters are stated in standardized language, which provides clarity and universal understanding by all health care providers.

Which actions demonstrate a nurse utilizing critical thinking when her patient complains of increased pain at the surgical site? Select all that apply. The nurse verifies that no pain medications were ordered and calls provider on call for pain medications. The nurse verifies that no pain medications were ordered and tells patient she has no medications ordered. The nurse uses non-pharmaceutical treatment of focused deep breaths to relieve pain for patient. The nurse assesses vital signs and checks to see when patient was last medicated for pain. The nurse assesses the surgical site to determine the cause of the increased pain.

The nurse verifies that no pain medications were ordered and calls provider on call for pain medications. The nurse uses non-pharmaceutical treatment of focused deep breaths to relieve pain for patient. The nurse assesses vital signs and checks to see when patient was last medicated for pain. The nurse assesses the surgical site to determine the cause of the increased pain.

Match the dates to the correct historical development in nursing. The term "nursing process" was first used by Lydia Hall. The nursing process was first used to define steps used in patient care. ANA identified 5 steps of the nursing process in its Standards of Practice. Outcome identification was added to the nursing process by the ANA. 1973 1955 1991 1960s

The term "nursing process" was first used by Lydia Hall. 1955 The nursing process was first used to define steps used in patient care. 1960s ANA identified 5 steps of the nursing process in its Standards of Practice. 1973 Outcome identification was added to the nursing process by the ANA. 1991