Nursing Process

Subjective

What the client tells the nurse

Time-lapsed assessment

- An assessment that is scheduled to compare a patient's current status to baseline data obtained earlier

List four factors to consider during the evaluation step when clients have not achieved their goals

- An incomplete database - Unrealistic client outcomes - Nonspecific nursing interventions - Inadequate time for the client to achieve the outcomes

SMART goal

- Specific - Measurable - Attainable - Realistic - Timely

Which step of the nursing process determines whether the client understands the health teaching that is provided? A. Evaluation B. Assessment C. Planning D. Implementation

A Evaluation includes observing the client, asking questions, and then comparing the client's behavioral responses with the expected outcomes. Assessment includes determining the client's readiness regarding learning. Planning includes identification of teaching strategies and writing the teaching plan. Implementation is the step during which the teaching plan is put into action.

Which is the priority question for the nurse to consider before implementing a new intervention? A. Does this treatment make sense for this client? B. How much experience do I have with this treatment? C. What equipment do I need? D. Will I need someone to assist me?

A Rationale: All of these questions are important, but the priority is whether the treatment makes sense for the client. If not, answering the other questions is unnecessary.

The purpose of establishing a nursing diagnosis is to A. Describe a functional health problem B. Collaborate with the physician C. Identify medical problems D. Meet accreditation criteria

A Rationale: Establishment of a nursing diagnosis reflects the synthesis of data gathered during a nursing assessment. Gordon suggested a framework for organizing nursing diagnoses based on functional health, thus offering a convenient way to cluster similar diagnoses.

After assessing a client, the nurse formulates several nursing diagnoses. Which of the following would the nurse identify as an actual nursing diagnosis? A. Impaired urinary elimination B. Readiness for enhanced sleep C. Risk for infection D. Possible impaired adjustment

A Rationale: Impaired urinary elimination is an actual nursing diagnosis because it describes a human response to a health problem that is being manifested. Readiness for enhanced sleep is a wellness diagnosis. Risk for infection is a risk diagnosis, and possible impaired adjustment is a possible nursing diagnosis.

List the steps of the nursing process

Assessment Diagnosis Planning Implementation Evaluation

Focused assesment

Assessment conducted to assess a specific problem; focuses on pertinent history and body regions but may be used to address the immediate and highest priority concerns for an individual patient

After assessing a client, a nurse identifies the nursing diagnosis, "Ineffective Airway Clearance related to thick tracheobronchial secretions." The nurse would classify this nursing diagnosis as which type? A. Wellness B. Actual C. Risk D. Possible

B Rationale: "Ineffective Airway Clearance related to thick tracheobronchial secretions" is an actual diagnosis because it describes a human response to a health problem that is being manifested. A wellness diagnosis is a diagnostic statement that describes the human response to levels of wellness in an individual, family, or community that has a potential for enhancement to a higher state. A risk nursing diagnosis describes human responses to health conditions or life processes that may develop in a vulnerable individual, family, or community. A possible nursing diagnosis is made when not enough evidence supports the presence of the problem but the nurse thinks that it is highly probable and wants to collect more information.

A nurse developed a program of increased ambulation for a patient with an orthopedic disorder. This goal setting is a component of the nursing process known as: A. Assessment B. Planning C. Implementation D. Evaluation

B Rationale: Once assessment data are collected, the next step is to plan the teaching intervention, which begins with specifying immediate, intermediate, and long-term goals.

When the nurse is administering Lasix 20 mg to a patient in congestive heart failure, what phase of the nursing process does this represent? A. Assessment B. Planning C. Implementation D. Evaluation

C Rationale: Implementation refers to the action phase of the nursing process in which nursing care is provided.

The nurse formulates the following client outcome: "Client will correctly draw up morning dose of insulin and identify four signs and symptoms of hypoglycemia by September 7." Which error has the nurse made? A. Expressed the client outcomes as a nursing intervention B. Wrote vague outcomes that will confuse other nurses C. Included more than one client behavior in the outcome D. Used verbs that are not observable and measurable

C Rationale: Two client behaviors have been included in the outcome statement---drawing up insulin and identifying four signs and symptoms.

Initial assessment

Comprehensive nursing assessment resulting in baseline data that enables the nurse to make a judgment about a patient's health status, ability to manage one's own health care, and need for nursing, and to plan individualized, holistic health care for the patient

The nurse caring for a client formulates client outcomes based on the understanding that the outcomes should be which of the following? A. General in scope B. Abstract in nature C. No bound to time D. Measurable

D Rationale: The nurse should keep in mind that client outcomes should be measurable, realistic, time bound, and specific to the client. The outcomes are not general, but are specific to the client based on the individual client's problems. The outcomes are realistic and measurable, not abstract. The outcome establishes a definite timeframe for achievement.

Objective

Data the nurse obtains through observation and examination

Emergency assessment

Performed to identify a life‐threatening problem during a physiological or psychological crisis

Nursing Process

The nursing process is a cyclical, critical thinking process that consists of five steps to follow in a purposeful, goal-directed, systematic way to achieve optimal client outcomes.