the five steps of the nursing process

Match the type of nursing diagnoses to the correct example of that diagnosis.

Actual: Objective: skin red with open lesion risk: patient unsteady when walking Health-promotion: patient voices readiness to learn Actual: Subjective- "my head hurts"

12. A nurse determines the patient's goal of decreased reflux by sleeping on a pillow wedge was not totally met. How does the plan need to be revised?

Add a step to avoid eating after 7 p.m.

11. A nurse is caring for a patient with a UTI. Which of these interventions address the patient's short-term goals?

Applying a heating pad to the low back or abdomen., Refraining from sexual intercourse.

5. A nurse is caring for a patient who is cyanotic and has edema. The nurse is making a list of the patient's physical, psychological, emotional, environmental, cultural, and spiritual health. What stage of the nursing process is this?

Assessment

The evaluation phase loops back to which earlier phases of the nursing process when considering new data?

Assessment, Diagnosis, Planning

What type of patient-centered care respects the input of family members and other members of the health care team?

Collaborative

What determines if an assessment is primary or secondary?

Data source

The nursing __________ identifies an actual or potential problem or response to a problem.

Diagnosis

What questions should the nurse ask when evaluating the effectiveness of nursing interventions?

Did the patient meet the goals established during the planning phase?, Should the plan of care be discontinued?, Does the care plan need to be modified in response to patient changes?

Steps of the nursing process serve which purpose?

Enable organization of patient care, Ensure comprehensive patient care, Facilitate evaluation of patient care

13. A nurse is evaluating the care plan for a pregnant patient. What is the main reason the nurse would ask the patient about support systems and eating habits?

Ensure individualized care.

What is the fifth step of the nursing process that includes a decision point on whether to discontinue, continue, or revise the plan of care?

Evaluation

What is the primary purpose for documenting nursing interventions?

Facilitate communication

A nurse is creating a care plan and wants to put direct care items before indirect care items. Which of these is in the correct order?

Help the patient ambulate, and then order occupational therapy to come.

What type of patient assessment takes into account factors such as the patient's physical, psychological, emotional, environmental, cultural, and spiritual health?

Holistic

14. A patient has a painful jaw that clicks during chewing. The nurse developed a care plan and taught the patient how to use a bite guard. What step of the nursing process did the nurse exhibit by teaching use of the bite guard?

Implementation

3. A nurse is admitting a new patient who has heart failure and pitting edema. At each step of the nursing process, what is likely to happen?

Information from other steps will be used to complete the plan of care.

Nursing care can be categorized as direct or indirect, depending on the nursing ___________.

Interventions The nursing interventions are either direct or indirect.

8. A nurse is caring for a patient with a UTI. The nurse's selection of two nursing diagnoses includes acute pain and impaired urinary function. What evidence would lead the nurse to diagnose acute pain?

Low back aching, Burning upon urination

What is the most important aspect of a patient-centered care plan?

Matching the patient's goals and relevant current status

Match the category with its corresponding data source.

Obtained directly from patient: primary Obtained from other healthcare professionals, medical records, test results: secondary Direct quotes describing patient feelings: subjective Blood pressure reading and weight: objective

What does the evaluation phase include?

Patient's achievement of short- and long-term goals.

1. A nurse is ready to set goals for a patient who is recovering from a hip replacement. The nurse sets goals for the first three days and for the first three weeks. What part of the nursing process is this?

Planning

2. What word does the nurse use to describe the five steps?

Process

10. The nurse is receiving a report on a patient recovering from a myocardial infarction with low oxygen saturation. With a nursing diagnosis of low blood oxygen, what other interdisciplinary professionals may be consulted for collaboration of this patient?

Respiratory therapist, cardiologist, and pulmonologist

7. A nurse is caring for a patient who just had a colostomy. What type of nursing diagnosis (actual, risk, or health-promotion) should the nurse select when developing the plan of care?

Risk, since the patient is at risk for infection at the site of the surgical incision.

The nurse establishes the ____ of unlicensed health care team members as a crucial balance between collaboration and overlapping responsibilities.

Scope of practice

Information received from the patient's family members, friends, or other nurses is what type of data?

Secondary, Subjective

Why must nursing diagnoses include up-to-date diagnostic labels as determined by NANDA International?

Standardized language facilitates care recognized by all health care team members.

What types of care plans are used in implementation?

Standing orders that describe specific actions to be taken by a nurse., General protocols that apply to patients with similar clinical needs., Care pathways that combine several areas of health care expertise.

6. A nurse is caring for a 10-year-old tracheotomy patient admitted the previous night. When assessing the patient's pain level, is the nurse assessing subjective or objective data?

Subjective data, because only the patient can experience the pain.

When a patient reports feeling anxious, what is the subjective data called?

Symptom

15. A patient with diabetes reports to the clinic for diabetes education. The nurse learns that the patient's wife prepares the family meals. Why is it important to include the patient's wife in the teaching?

The wife can learn how to follow his new diet too.

4. A nurse is caring for a patient at risk for appendicitis. When considering the assessment, why should the nurse use the five-step nursing process?

To systematically identify actual or potential patient problems

Match type of outcome or goal with its correct definition or example.

Within 1 week, the patient will stand with support to brush teeth.: short-term goal Within 3 months, the patient will stand unsupported for 20 minutes.: long-term goal Classification of patient outcomes evaluating the effects of interventions.: Nursing Intervntions classification (NIC) Classification of interventions that nurses perform on behalf of patients.: Nursing outcomes classifications (NOC)

Place the five steps of the nursing process in the correct order.

assessment, diagnosis, planning, implementation, evaluation

9. A nurse is caring for a patient with decubitus ulcers who is dehydrated and suffering from malnutrition. In the evaluation stage, what evidence about the decubitus ulcers should initiate the nurse to change the nursing care plan?

new decubitus ulcers have formed