CH 16 Intro to the Nursing Process
which step the nursing process considers the effectiveness of nursing care?
evaluation
Which action reflects a primary task in the analysis step of the nursing process?
forming diagnostic conclusions
What is the order of the nursing process?
Assessment, diagnosis, planning, implementation, evaluation
which intervention reflects direct nursing care?
giving an injection
which type of patient assessment takes into account all factors, such as the patient's physical, psychological, emotional, environmental, cultural and spiritual health?
holistic
which organization defines standards of nursing practice and states that the nursing process forms the foundation for clinical decision making?
American Nurses Association
which phrases describe the role of International Classification for Nursing Practice (ICNP) in the nursing process?
Provides a standardized nursing language , identifies common labels for nursing diagnoses, provides point of care documentation for clinical activity
which nursing action occurs during the analysis step of the nursing process?
clustering patient data to identify patient problems
which step of the nursing process does the nurse use when obtaining the following patient info: blood pressure of 180/75, pulse of 90 and a complaint of chest pain?
assessment
which phrase describes the primary purpose of nursing analysis and diagnosis?
communicates patient problems
which function describes the primary purpose fro documenting nursing interventions?
facilitate communication
Which examples reflect subjective data?
feelings, symptoms, perceptions, health history
which statements reflect the nurse's role during the implantation step of the nursing process?
be accountable for safe practice, perform the steps of intervention accurately understand why an intervention is planned
Which nursing skill is essential to utilize throughout the nursing process?
critical thinking
Which nursing concept is defined as an actual or potential problem or response to a problem?
diagnosis
Which interventions reflect indirect nursing care?
documenting medications administered, collaborating to schedule occupational therapy, working with a social worker to set up home care
which term describes how the nursing process changes over time in response to patient's individual needs?
dynamic
which step of the nursing process includes a decision point on whether to discontinue, continue or revise the plan of care?
evaluation
which step of the nursing process involves carrying out nursing actions designed to meet a patient's unique needs?
implementation
which statement defines collaborative interventions?
involve the expertise of health care team members
which questions are critical for the nurse to ask during each step in the nursing process?
is collected data thorough and accurate, could inventions affect the patient negatively, are all underlying factors addressed in the plan of care
which characteristics of the nursing process allow the nurse to effectively apply critical thinking to patient care?
its organized, it is outcome oriented, it allows nurses to apply knowledge, it requires nurses to think analytically, it incorporates an inter-professional team
during which step of the nursing process would the nurse establish long-term goals with the patient?
planning
during which step of the nursing process would the nurse prioritize nursing diagnosis?
planning
which part of the nursing process involves the nurse setting short-term goals for the patient?
planning
During the implementation step of the nursing process, a nurse reviews and revises a patient's plan of care. Place the steps of review and revision in the order in which each should occur.
reassess the patient, review and revise the existing plan of care, organize resources and care delivery, anticipate and prevent complications, implement nursing interventions
which critical-thinking functions must the nurse perform to effectively evaluate patient goals during the final step of the nursing process?
recognizing errors, comparing achieved effect with goals, examining results according to clinical findings
which type of data do the patient's family members, friends or other nurses provide
secondary
which questions would the nurse ask to evaluate the effectiveness of nursing interventions?
should the plan of care be discontinued, have new assessment data been identified that should be considered, does the plan of care need to be modified in response to patient changes
Which component determines whether an assessment is primary or secondary?
source of data
which aspect would the nurse consider as a component of the evaluation step of the nursing process?
the patient's achievement of short and long term goals
which questions would the nurse ask when revising the plan of care because of unmet patient goals?
were the original goals realistic, what unanticipated events occurred, what steps in the process can be handled differently, what barrier did the patient encounter that prevented goal attainment?
