Nursing Process
planning process steps
1. Define objectives 2. evaluate situation to predict events 3. formulate planning statement 4. convert plan into action statement
cognitive skills
(intellectual skills) that include problem solving, decision making, critical thinking, and creativity
Nursing Diagnosis
A clinical judgement about individual, family or community responses to actual or potential health problems & life processes.
The nurse is conducting a class for a group of expectant mothers regarding basic infant care techniques. What goal will allow the nurse to best evaluate the mothers' learning? A. The mothers will be able to pass a written test on how to bathe a newborn infant. B. The mothers will be able to set goals for the next class session. C. The mothers will be able to provide a return demonstration of a bath on a newborn doll. D. The mothers will be able to review the major points of the class.
C
Components of Nursing Diagnosis
Diagnostic label, etiology, defining characteristics
4 levels of urgency factors
Non acute acute critical imminent death
NANDA-I
North American Nursing Diagnosis Association International
S.M.A.R.T
Specific, Measurable, Attainable, Realistic, Timely
syndrome diagnosis
a diagnosis that is associated with a cluster of other diagnoses that may result in best patient outcome if addressed at the same time
Evaluation Statement
a statement that consists of three parts: -a conclusion statement about goal - supporting statement (how did/didnt meet goal) -date and time
Nursing Process
five-step systematic method for giving patient care; involves assessing, diagnosing, planning, implementing, and evaluating
objective data
information that is seen, heard, felt, or smelled by an observer; signs, vitals tests, evidence
collaborative interventions
interdependent nursing actions performed jointly by nurses and other members of the health care team
outcome
observable criteria to evaluate if goals were met
problem-focused diagnosis
patient problem present at the time of the assessment
Implementation
phase of nursing process when interventions are performed
Maslow's Hierarchy of Needs
physiological, safety, love/belonging, esteem, self-actualization
Maslow's Hierarchy of Needs (bottom to top)
physiological, safety, love/belonging, esteem, self-actualization
dependent interventions
prescribed by primary care provider and carried out by nurse
Evaluation
reassessment of patient following intervention or therapy
Etiology
relationship between problem and related risk factors
defining characteristics
the cluster of signs and symptoms that indicate the presence of a particular diagnostic label
diagnostic label
the name of the nursing diagnosis as approved by NANDA International
Assessment
the systematic process of gathering information about an individual's background, history, skills, knowledge, perceptions, and feelings.
subjective data
things a person tells you about that you cannot observe through your senses; symptoms
medical diagnosis
used to evaluate the cause and etiology of disease; focus is on the function or malfunction of a specific organ system
health promotion diagnosis
way of thinking to increase individuals health and well being regardless of health, illness, age
A construction worker admitted to the unit with a chest injury and broken ribs from a fall from a ladder has nursing diagnoses of "Disturbed Sleep Pattern," "Ineffective Breathing Pattern," and "Risk for Infection." The client states, "I've never been sick a day in my life and am really worried about how I can support my family while I'm out of work." When evaluating the client's plan of care during the shift, the nurse adds the nursing diagnosis "Anxiety" to the plan of care. Which diagnosis would be the priority for nursing interventions? A. Anxiety B. Risk for Infection C. Disturbed Sleep Pattern D. Ineffective Breathing Pattern
D
A nurse has recently joined an orthopedic unit in the United States that specializes in perioperative care of clients undergoing knee or hip replacement. Which nursing plan of care is this nurse likely to use most often? A. Concept map B. Column plan C. Clinical pathway D. Standardized plan
D
An older adult client with heart failure is experiencing activity intolerance due to dyspnea on exertion. Which nursing intervention is a priority for the client? A. Complete all nursing care in the morning. B. Delegate care for the client to an aide. C. Complete all nursing care at the end of the shift. D. Pace nursing care throughout the shift.
D
A client recovering from knee surgery is being prepared to ambulate for the first time. Prior to getting the client up, what should the nurse do? A. Evaluate the client's level of pain. B. Call for a wheelchair to start the process. C. Conduct a breathing assessment. D. Ask the client about readiness to walk.
A
A goal of care for a client with congestive heart failure (CHF) is for serum sodium levels to be within normal limits. Which information documented in the medical record would indicate that the client is not meeting this goal? A. The client is experiencing dependent edema. B. The client is experiencing wheezing respirations. C. The client experiences joint pain. D. The client is constipated.
A
An older adult client is experiencing confusion, a temperature of 101.5°F, bruising to the arms and legs, and decreased urine output. The medical diagnosis is a urinary tract infection. Which is the most appropriate nursing diagnosis for thisclient? A. Risk for Injury. B. Activity Intolerance C. Ineffective Breathing Pattern D. Impaired Memory
A
The nurse is collecting data about a client's current health status. Which statement would assist in gathering subjective data about the client? A. "Tell me why you have difficulty sleeping." B. "Your skin appears to be dry and irritated." C. "I see that you have bruises on your legs." D. "Your eyelid is red and swollen."
A
The nurse is teaching a new nurse about developing an appropriate nursing diagnosis for a client. Which information should the nurse use to accurately describe nursing diagnosis? (Select all that apply.) A. Nursing diagnosis is flexible and changes based on client responses. B. Nursing diagnosis describes responses to a health problem. C. A nursing diagnosis is a judgment statement. D. A nursing diagnosis is a condition that nurses are licensed to treat. E. Nursing diagnosis is uniform between clients.
A, B, C, D
The nursing instructor is evaluating a concept map created by a student for a client's plan of care. Which characteristics on the map indicate that the student created the map appropriately? Select all that apply. A. Legend created identifying nursing process phases and client information categories B. Lines drawn between assessment data and associated nursing diagnoses C. A column entitled "evaluation" located on the outer edge of the document D. Different colors used to represent the phases of the nursing process E. A checklist located at the bottom of the document
A, B, D
The nurse has assessed a client and determined the appropriate nursing diagnoses. Which activity should the nurse perform next? (Select all that apply.) A. Set priorities and goals in collaboration with the patient. B. Write down the desired goals. C. Reassess the patient to update the database. D. Relate nursing actions to patient outcomes. E. Write priority nursing interventions.
A, B, E
Which statements accurately reflect the distinction between nursing diagnoses and medical diagnoses? Select all that apply. A. A nursing diagnosis changes as the client's responses to an illness or health situation change; a medical diagnosis remains the same as long as the disease process persists. Your answer is correct. B. A nursing diagnosis requires the nurses to consider standards and norms as well as cues from clients in discerning an appropriate nursing diagnostic label; a medical diagnosis uses standards and norms only. C. A nursing diagnosis describes a client's physical, sociocultural, psychological, and spiritual responses to an illness or health condition; a medical diagnosis refers to disease processes. D. A nursing diagnosis is determined following an assessment and analysis of data gathered only by registerednurses; a medical diagnosis is determined following an assessment and analysis of data gathered only by physicians. E. A nursing diagnosis considers the etiology of the health problem to give direction to required nursing care; a medical diagnosis does not consider the etiology of the health problem to give direction to medical care.
A, C
The nurse is developing a plan of care for a client admitted with congestive heart failure who has fluid overload. Which characteristic should be common to all goals? (Select all that apply.) A. Being relevant to the client B. Measuring nursing interventions C. Being identified for each nursing diagnosis D. Describing a single action E. Stating nursing actions
A, C, D
The nurse is orienting a new nurse and teaching about plans of care. At which time should the nurse instruct the new nurse for evaluating the nursing care? (Select all that apply.) A. During the implementation of an intervention B. At the end of a scheduled shift C. When discharging a client from nursing care D. During a time-specified interval E. Upon admission to the hospital
A, C, D
The nurse is selected to participate on a committee to write clinical pathways for a specific set of medical diagnoses. Which are advantages of using this approach when providing client care? Select all that apply. A. List medical treatments to be performed by other providers B. Link nursing diagnoses with specific assessment data C. Identify interventions, time frames, and expected outcomes D. Sequence the care that is to be given on a particular day E. Provide specific columns for diagnosis, interventions, and evaluation
A, C, D
The nurse is writing a plan of care for a client. Which criterion should the nurse include when writing nursinginterventions? (Select all that apply.) A. Being specific and concise B. Being general and brief C. Ensuring relevancy to situation D. Being realistic E. Including priorities of care
A, C, D, E
The nurse is collecting, analyzing, and synthesizing data. Which activity should be included as a step in this phase of the nursing process? (Select all that apply.) A. Determining a client's strength and risks B. Selecting nursing strategies and or interventions C. Documenting priority nursing diagnoses D. Determining a client's problems E. Formulating diagnostic statements
A, C, D, E
risk factors
Actions or behaviors that represent a potential health threat
Independent interventions
Activities that nurses are licensed to initiate on the basis of their knowledge and skills
The novice nurse is writing his first nursing plan of care. He includes category headings for each phase of the nursingprocess, includes specific and detailed information related to interventions using complete sentences, considers theclient's preferences in the chosen interventions, and incorporates preventive and restorative interventions. He then signs and dates the nursing plan of care. What did the nurse do wrong when creating the plan of care? A. He should not have used category headings for each phase of the nursing process. B. He should have used approved abbreviations and key words rather than complete sentences. C. He should not have included preventive measures in the care plan until restorative goals were met. D. He should have included the physician's preferences for care rather than the client's preferences.
B
A client who has just been diagnosed with type 2 diabetes mellitus is being instructed by the nurse regarding diet and exercise. Which client statements indicate that further teaching is required? Select all that apply. A. "I will test my blood sugar before meals and at bedtime." B. "I should eat a candy bar when my energy is low." C. "I don't need to watch my diet as long as I take my insulin." D. "I need to limit the amount of fat in my diet." E. "I should talk to the doctor about an exercise program."
B, C
A nurse enters a client's room to evaluate the response to IV pain medication administered by request 20 minutes earlier. The nurse finds the client in the same position as when the medication was administered. The client states, "I do not want to move." The nurse asks the client to rate the current level of pain. Which aspects of the nursing process do these action represent? Select all that apply. A. Planning B. Evaluation C. Assessment D. Implementation E. Diagnosis
B, C, D
The nurse is creating a four-column plan of care for a client. For which areas should the nurse prepare to document when creating this care plan? Select all that apply. A. Medications B. Interventions C. Goals D. Evaluation E. Nursing diagnosis
B, C, D, E
Which should be the nurse's next action following the collection of assessment data? (Select all that apply.) A. Comparing the data with suspected medical problems B. Analyzing the data for gaps and inconsistencies C. Clustering cues to generate tentative hypotheses D. Identifying strengths and resources E. Measuring the data against standards to identify significant cues
B, C, E
The nurse decides to use a standardized plan of care to address a client's health problems. Which criterion differentiates this plan of care from other types? Select all that apply. A. Has various shapes connected with lines B. Has blank lines C. Includes different colors D. Has checklists E. Is preprinted
B, D, E
The nurse develops a nursing diagnosis of Self-Care Deficit related to the client's inability to perform activities of daily living (ADLs) due to left-sided weakness secondary to cerebrovascular accident. Which component of the nursing diagnosis was noted? (Select all that apply.) A. Data clusters B. Defining characteristics C. Variations D. Etiology E. Diagnostic label
B, D, E
During a health history, a client becomes upset because the nurse is asking many questions. Which response by the nurse is the most appropriate in this situation? A. "I cannot help you if you do not answer me." B. "I am sorry the questions disturb you." C. "I use the answers to determine your current health needs." D. "I will skip the questions that bother you."
C
7 Axes of nursing diagnosis
Focus, Subject, Nursing judgement, Location, Age, Time, Status
ABC
airway, breathing, circulation
risk nursing diagnosis
clinical judgment that a problem does not exist, but the presence of risk factors indicates that a problem is likely to develop unless nurses intervene
