Chapter 5---Nursing Process and Critical Thinking

NANDA International meets to reorganize diagnosis labels and language every ______ years.

2

All of the following patients have been admitted to the acute care setting. On admission, which patient should receive a focused assessment? 53-year-old admitted with a perforated ulcer 5-year-old admitted for the implant of grommets in the middle ear 76-year-old admitted for a knee replacement 40-year-old admitted for possible bowel obstruction

53-year-old admitted with a perforated ulcer

Which are acceptable secondary sources for data? (Select all that apply.) a. Patient b. Family members c. Other health professionals d. Diagnostic reports e. Textbooks

B,C,D,E

is a multidisciplinary plan that incorporates evidence-based practice guidelines for high-risk, high-volume, high-cost types of cases while providing for optimal patient outcomes and maximized clinical efficiency.

Clinical pathway

What is an example of an appropriate nursing diagnosis? Constipation Patient complains of constipation Need for laxatives Patient has a duodenal ulcer

Constipation

During a physical examination, the nurse discovers that the patient demonstrates signs of flushed, dry, hot skin; dry oral mucous membranes; and temperature elevation. The nurse should treat this data as the basis of a nursing diagnosis plan. What does this data represent? Symptoms Data clustering Signs of fluid overload Urinary retention

Data clustering

What assists the nurse in the identification of nursing diagnoses? Objective data Subjective data Data clustering Validated data

Data clustering

Which nursing order is complete and correct? May 10: Nursing assistants will ambulate patient. A. Nurse Day nurse will cleanse wound and change dressings every day. May 10, A. Nurse Nursing assistants will serve 8 oz glass of juice at each meal, 5/10. P.M. nurse will ensure that heel protectors are in place before bedtime.

Day nurse will cleanse wound and change dressings every day. May 10, A. Nurse

Which is an example of a medical diagnosis? Constipation Diabetes mellitus Impaired skin integrity Altered nutrition: less than body requirements

Diabetes mellitus

What is an important consideration when developing the care plan? Ensure the number of interventions is limited Ensure the patient is involved in the process Ensure interventions will be easy to implement Ensure evaluation of the nursing diagnoses is possible

Ensure the patient is involved in the process

What objective data should the nurse include after a patient assessment? Headache of 3 days duration Severe stomach cramps Flatulence Anxiety

Flatulence

What type of assessment is performed continuously throughout nurse-patient contact? Complete Body systems Focused Subjective

Focused

Self-actualization (Maslow)

Full use of individual talents.

What is an example of an appropriate nursing diagnosis? Impaired skin integrity Skin breakdown noted Turn patient every 2 hours The patient has scabies on his back

Impaired skin integrity

Which is an example of a nursing diagnosis? Pneumonia Diabetes mellitus Impaired skin integrity Congestive heart failure

Impaired skin integrity

What are the two primary methods used to collect data? Written report by patient and family Review of the chart and the nurses notes Interview and physical examination Review of the physicians orders and the Kardex

Interview and physical examination

What framework does the establishment of priorities of care during the planning phase of the nursing process often use? Eriksons developmental tasks Piagets cognitive table Maslows hierarchy of needs Freuds classifications

Maslows hierarchy of needs

Which data would be considered secondary sources of information? Select all that apply. Medical record Patient Physician Spouse or close relative Nurse's shift report

Medical record Physician Spouse or close relative

The standards that name and measure patient outcomes are referred to as ___________.

NOC (Nursing Outcome Classification) NOC sets up outcome criteria based on a patient problem.

A clinical judgment about individual, family, or community responses to actual or potential health problems/life processes is known as a _____________ ___________.

Nursing diagnosis

Following the gathering of subjective and objective data, performing a health history and a physical assessment, the nurse sets up a plan of care. What is the first step to identify the problem? Medical diagnosis Nursing intervention Nursing diagnosis Evaluation

Nursing diagnosis

What is the basis for designing and selecting nursing interventions to meet patient needs? Nursing diagnosis Care plan Physicians orders Nurses notes

Nursing diagnosis

The results or outcomes of nursing interventions. These outcomes or indicators are influenced by nursing and can be used to judge effectiveness of care and determine best practices.

Nursing-sensitive patient outcomes

Physiologic--Maslow Hierchy

Nutrition, elimination, oxygenation, sexuality

What documentation reflects implementation? Patient selected low-sugar snacks independently. Patient was medicated with Tylenol 500 mg PO for pain. Patient was ambulated for 15 minutes after lunch. Patient participated in group therapy session without reminder.

Patient was ambulated for 15 minutes after lunch.

1st Maslow's hierarchy of needs

Physiological Needs

When a nurse selects interventions to assist the patient to meet the needs demonstrated, the nurse is in which phase of the nursing process? Assessment Planning Implementation Evaluation

Planning

Which is an example of a medical diagnosis? Pain Anxiety Pneumonia Impaired skin integrity

Pneumonia

What subjective data does the nurse record following a head-to-toe examination? Rash on back Prolonged nausea Blood pressure of 190/100 White blood cell count of 19,000

Prolonged nausea

2nd in Maslows Hierarchy of Needs

Safety and Security

5th of Maslow's hierarchy of needs

Self Actualization

4th of Maslow's hierarchy of needs

Self Esteem

Esteem (Maslow's Hierarchy of Needs)

Self-respect, self confidence, feeling of self-worth.

evaluation

The determination mage about the extent to which the established outcomes have been achieved in the nursing care plan.

NANDA-I

a professional nursing organization that provides standardized language to identify patient problems and plan customized care North American Diagnosis Association International

provide information about the patient's health history.

biographic data

encompasses the planning, coordination of care, and patient advocacy in providing quality, cost-effective outcomes for the patient.

case management

A multidisciplinary plan that schedules clinical interventions over an anticipated time frame for high-risk, high-volume, and high-cost types of cases is known as a ___________ ____________.

critical pathway

Large store or bank of information, as in forming the patient's nursing diagnosis.

database

is to identify the type and cause of a health condition.

diagnose

Nursing Diagnosis

is a type of health problem that can be identified. It is a clinical judgment about individual, family, or community responses to actual or potential health problems/life processes.

The identification of a disease or condition by a scientific evaluation of physical signs, symptoms, history, laboratory tests, and procedures is known as a _________ _______.

medical diagnosis

is the identification of a disease or condition with evaluation of physical signs, symptoms, patient interview, laboratory tests, diagnostic procedures, review of medical records, and patient history.

medical diagnosis

A clinical judgment that describes human responses to health conditions/life processes that may develop in a vulnerable individual, family, or community.

risk nursing diagnosis

Human responses to health conditions and life processes that may develop in a vulnerable individual, family, or community are known as a(n) __________ __________ ____________.

risk nursing diagnosis

refer to information that is provided by the patient.

subjective data

A clinical judgment describing a specific cluster of nursing diagnoses that occur together, and are best addressed together and through similar interventions.

syndrome nursing diagnosis

Human responses to levels of wellness in an individual, family, or community that have a readiness for enhancement are known as a _____________ ____________ ____________.

wellness nursing diagnosis

a clinical judgment about a person's, family's or community's motivation and desire to increase well being and actualize human health potential as expressed in the readiness to enhance specific health behaviors, and can be used in any health state.

wellness nursing diagnosis

assessment

The American Nurse Association (ANA) defines assessment as a systemic, dynamic process by which the nurse, through interaction with the client, significant others, and health care providers, collects and analyzes data about the client.

From where are the risk for nursing diagnoses identified? The care plan The interventions The assessment The evaluation

The assessment

description of the specific measurable behavior (outcome criteria) that the patient will be able to exhibit after the nursing interventions.

outcome

phase of the nursing process, priorities of care are established and nursing interventions are chosen to best address the nursing diagnosis.

planning

Any health care condition that requires diagnostic, therapeutic, or educational actions is known as a ______________.

problem

Safety and Security-- Maslow Hierchy

stability, protection, security, freedom from fear and anxiety.

a structured vocabulary that provides nurses with a common means of communication.

standardized languages

Statements about nausea and descriptions of pain, fatigue, and anxiety are examples of _________ __________

subjective data

when a patient does not achieve the projected outcome.

variance

A systemic, dynamic process by which the nurse, through interaction with the patient, significant others, and health care providers, collects and analyzes data about the patient is known as ______________________.

assessment

a systematic, dynamic process by which the registered nurse, through interaction with the patient, family, groups, communities, populations, and health care providers, collects and analyzes data.

assessment

When nurses submit nursing diagnoses, the following four components are addressed:

1. Nursing diagnosis title or label 2. Definition of the title or label 3. Contributing, etiologic, or related factors 4. Defining characteristics

What best defines the nursing process? A Method to ensure that the physicians orders are implemented correctly. A series of assessments that isolate a patients health problem. A framework for the organization of individualized nursing care. A preset formula for the design of nursing care.

A framework for the organization of individualized nursing care.

What organized approach might the nurse use when performing a complete physical examination? Maslows hierarchy of needs A head-to-toe assessment Subjective data collection Objective data collection

A head-to-toe assessment

What is a nursing diagnosis considered when a problem is suspected but data to support it are lacking? A syndrome nursing diagnosis An actual nursing diagnosis A risk for diagnosis A possible nursing diagnosis

A possible nursing diagnosis

problem

A problem is any health care condition that requires diagnostic, therapeutic, or educational actions.

The patient is confined to bed rest, which contributes to immobility. What is bed rest considered in this situation? Contributing to the patients recovery A risk factor Difficult to maintain A nursing responsibility

A risk factor

Which are official categories of nursing diagnoses? (Select all that apply.) a. Actual b. Risk c. Wellness d. Syndrome e. Potential

A,B,C.D

Which are considered phases of the nursing process? (Select all that apply.) a. Diagnosis b. Prediction c. Assessment d. Evaluation e. Implementation f. Outcome identification

A,C,D,E,F

The four main types of nursing diagnosis are:

Actual Risk Syndrome Health promotion

is a clinical judgement about human experience/ responses to health conditions/life processes that exist in an individual, family, or community.

Actual Nurse Diagnosis

Love and Belongingness--Maslow Hierchy

Affection, acceptance by peers and community.

What is the order of the Nursing process?

Assess Diagnose Plan Implement Evaluate

Which nurse-prescribed intervention is written correctly for the diagnosis of: Acute pain r/t deep vein thrombosis m/b redness, swelling, warmth, positive Homan? Assess level of pain Complete bed rest with right leg elevated on two pillows at all times Monitor lab values Assess vital signs

Complete bed rest with right leg elevated on two pillows at all times

Evaluate

Determine if goals met and outcomes achieved.

congestive heart failure (CHF) pneumonia diabetes mellitus hepatitis B

Examples

Assess

Gather information about the patient's condition

diagnose

Identify the patient's problems

Considering Maslow's hierarchy of needs, what would be the highest priority nursing diagnosis? Deficient knowledge Acute pain Risk for impaired skin integrity Imbalanced nutrition

Imbalanced nutrition

A patient is admitted to the hospital with a sacral wound that has a foul odor, purulent drainage, and necrotic tissue in the center. It measures 4 cm in circumference by 2 cm deep. What is the most appropriate nursing diagnosis? Risk for infection Impaired skin integrity Chronic pain Impaired peripheral circulation

Impaired skin integrity

The nurse reads the order: "Ambulate the patient three times a day at 0900, 1400, 1900 as tolerated" and identifies this as what part of the nursing process? Nurse-prescribed intervention Nursing diagnosis Patient goal Evaluation

Nurse-prescribed intervention

During an admission assessment, the nurse collects objective and subjective data. What is an example of objective data? The patient complains of feeling depressed. The patient states, I hear voices in my head. The patient complains of auditory hallucinations. The patient is pacing back and forth while chanting.

The patient is pacing back and forth while chanting.

phase of the nursing process, the nurse and other members of the team put the established plan into action to promote outcome achievement.

implementation

Who is the person responsible for analyzing and interpreting data to arrive at a nursing diagnosis? Physician LPN/LVN RN Technician

RN

3rd in Maslows Hierarchy of Needs

Relationships, Love and Affection

What expected outcome exemplifies accepted criteria? Nurse will assess vital signs every day Resident will observe safety guidelines while smoking Resident will take part in one activity daily for the next 90 days Nurse will monitor O2 saturation to maintain at greater than 90%

Resident will take part in one activity daily for the next 90 days

A nurse is formulating a nursing diagnosis. What is an example of an appropriately written nursing diagnosis? Risk for impaired skin integrity related to physical immobilization Physical immobilization secondary to risk for impaired skin integrity Risk for impaired skin integrity related to diagnosis of decubitus ulcers Physical immobilization secondary to decreased cognitive ability

Risk for impaired skin integrity related to physical immobilization

What is classified as information provided by the family when a patient is unable to provide data during assessment? Primary Secondary Unreliable Biased

Secondary

Which are necessary elements of a patient outcome statement or goal? Select all that apply. Specific to the patient Given a time frame for completion Indicative of an increase of the problem Realistic for the patient Listing of all interventions required in meeting the goal

Specific to the patient Given a time frame for completion Realistic for the patient

During an admission assessment, the nurse collects objective and subjective data. What is an example of subjective data? The patient is coughing. The patient has cyanosis of the lips. The patient experiences tachypnea. The patient complains of generalized discomfort.

The patient complains of generalized discomfort.

During an admission assessment, the nurse collects objective and subjective data. What is an example of subjective data? The patient complains of nausea. The patient is vomiting. The patient experiences tachycardia. The patent is pacing the halls.

The patient complains of nausea.

During an admission assessment, the nurse collects objective and subjective data. What is an example of objective data? The patient is jaundiced. The patient states, I am nervous. The patient complains of palpitations. The patient denies dizziness when ambulating.

The patient is jaundiced.

During an admission assessment, the nurse collects objective and subjective data. What is an example of objective data? The patient complains of chest pain. The patient states, I feel nauseous. The patient complains of feeling faint. The patient is short of breath on exertion.

The patient is short of breath on exertion.

During an admission assessment, the nurse collects objective and subjective data. What is an example of subjective data? The patient is asleep. The patient is tearful. The patient has facial grimacing. The patient states, I hurt all over.

The patient states, I hurt all over.

What is an appropriate outcome statement for a patient with a nursing diagnosis of ineffective airway clearance related to thick secretions? The patient will increase intake to 1000 mL daily to liquefy secretions. The patient will cough more frequently within 3 days. The patient will breathe better within 3 days. The patient will perform deep-breathing exercises four times daily.

The patient will increase intake to 1000 mL daily to liquefy secretions.

By definition, if the nurse is not able to prescribe the primary treatment, the problem (is or not) a nursing diagnosis.

The problem is not a nursing diagnosis

goal

The purpose to which an effort is directed.

The nurse writes two nursing diagnoses: (1) inadequate nutritional intake related to vomiting as manifested by a 3-lb weight loss and (2) risk for impaired skin integrity related to inadequate nutrition. What is the major difference between these diagnoses? The second diagnosis needs no defined nursing interventions. The second diagnosis needs medical intervention. The second diagnosis will not need to be evaluated. The second diagnosis reflects a problem that does not yet exist.

The second diagnosis reflects a problem that does not yet exist.

What is the role of the licensed practical nurse in writing a nursing diagnosis? To assist with the determination of an accurate nursing diagnosis To leave the writing of the nursing diagnosis to the RN To be responsible for writing the nursing diagnosis Is not involved in the nursing process

To assist with the determination of an accurate nursing diagnosis

What is the primary purpose of nursing orders? To support physicians orders To provide direction for all caregivers To provide broad, general statements To clarify nursing principles

To provide direction for all caregivers

A patient with a urinary tract infection is assessed using a clinical pathway. When a projected outcome is not met by a predetermined date, it is determined that what has occurred? Omission Variance Failure Error

Variance

The human responses to health conditions/life processes that exist in an individual, family, or community are known as a(n) _________ _______________ _____________.

actual nursing diagnosis

defining characteristics

clinical cues, signs, and symptoms that furnish evidence that a problem exists.

The document that outlines a multidisciplinary plan for care interventions over a specified time frame is a _______ ________.

clinical pathway critical path action plans care maps

are health-related problems that the nurse anticipates based on the condition or diagnosis of a patient.

collaborative problems

is a piece or pieces of data that often indicates that an actual or potential problem has occurred or will occur.

cue

is a determination made about the extent to which the established outcomes have been achieved.

evaluation

Readiness for enhanced self-health management

example of a wellness nursing diagnosis

A patient has returned from surgery and has a history of smoking. The physician has orders for the use of incentive spirometry (IS) every 2 hours. The patient asks why he has to do IS so often. The nurse teaches the patient about the importance of breathing deeply to clear any secretions and prevent pneumonia. What is this teaching an example of? a nursing diagnosis an outcome statement implementation of a nursing intervention the nursing process

implementation of a nursing intervention

A health care system that provides control over health care services for a specific group of individuals in an attempt to control cost is known as ___________ ______________.

managed care

A health care system whose goals are to provide cost effective quality care. Control costs.

managed care

clinical pathway

multidisciplinary plan that schedules clinical interventions over an anticipated time frame for a high-risk, high-volume, high-cost type of case

activity performed by nurses that should promote the achievement of the desired patient outcome.

nursing interventions

A systematic method by which nurses plan and provide care for patients is known as the _________ ____________.

nursing process

is a systematic method by which nurses plan and provide care for patients.

nursing process

Observe capillary refill, measure a patient's blood pressure, and observe and measure edema are examples of _______ _________.

objective data

are observable and measurable signs.

objective data

Implement

perform the nursing actions identified in planning

Plan and Identify Outcomes

set goals of care and desired outcomes and identify appropriate nursing actions