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 this​client? 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 registered​nurses; 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 nursing​interventions? (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 nursing​process, includes specific and detailed information related to interventions using complete​ sentences, considers the​client'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