The Nursing Process

The nurse demonstrates knowing the difference between a nursing diagnosis and a medical diagnosis by making which statement?

"A medical diagnosis is concerned with health problems that can be treated with surgery, medications, and other forms of therapy provided or prescribed by the physician. A nursing diagnosis identifies the patient's response to an illness or health condition." It is important for a nurse to differentiate between nursing diagnosis and medical diagnosis. The physician is concerned with health problems that can be treated with surgery, medications, and other forms of therapy provided or prescribed by the physician. Nursing diagnoses identify the patient's response to an illness or health condition.

The nurse is obtaining a health history from the patient. Which information will the nurse document as subjective data?

"I feel nervous, nauseated, and hot. "I feel nervous, nauseated, and hot" is subjective data: these are symptoms that are described or verified by the patient. Objective data is information that is observed or measured by the health care provider. Blood pressure, pulses, and redness and warmth are examples of objective data.

The nurse is assigned to care for a newly admitted patient. Place the steps in the correct order for using the nursing process to provide care.

-Collect patient data. -Diagnose any health problems. -Decide on a plan of action. -Implement the plan of action. -Evaluate the plan's effectiveness Rationale: The first step of the nursing process is to perform an assessment by collecting patient data. Next, the nurse diagnoses health problems and then decides on a plan of action. The plan of action is then implemented, after which the nurse evaluates the plan's effectiveness.

Each member of the health care team has a valuable role to play in the nursing process because both the RN and the LPN will contribute to the nursing process. Place the first steps of the nursing process in order.

-Obtain health history by interviewing the patient, the family, and the caregiver. -Perform a physical assessment. -Document findings -Organize the data into functional health patterns -Assign nursing diagnoses Rationale: The first step in the process is for the nurse to obtain the information and conduct an assessment of the information received both during the interview process and from the physical examination. The interview will precede the examination because it will direct the nurse to areas of concern. After the history and physical examination are completed, the findings must be documented. After the information is documented, the nurse can then organize these data into the functional health patterns and use that information to assign accurate nursing diagnoses to this patient.

What are the actual phases of the nursing process that are used in the critical thinking process? Select all that apply.

-Planning -Evaluation -Data collection -Implementation Rationale: The four phases of the nursing process for LPN/LVNs are data collection, planning, implementation, and evaluation. Creating and understanding are types of cognitive levels in nursing.

Which data are considered objective? Select all that apply.

-Vital signs -Apical pulse -Bowel sounds Rationale: Objective data include data that can be verified by sight, smell, touch, or sound. The vital signs, the apical pulse, and the bowel sounds are considered objective data. Pain and patient complaints are considered subjective data because these are data that the patient provides and that cannot be seen or felt by another person.

The nursing student learns from the instructor that evaluation within the nursing process is best described as what?

A comparison between the actual patient outcome and the expected outcome Rationale: Evaluation during the nursing process is best described as a comparison of actual outcomes of patient care to the expected outcomes. A nurse never diagnoses medically but rather identifies the patient's response to an illness or a health condition. Priority setting is a method of handling problems and tasks according to the importance (priority) of the patient's problems.

The student nurse is studying the nursing process. Which statement best describes the nursing process?

A goal-directed, orderly series of activities Rationale: The nursing process is a series of steps planned and followed in an attempt to achieve a patient goal. It is not a plan to describe nursing functions, an attempt to define nursing practice, or a theory of operative nursing standards.

What defines critical thinking in nursing practice?

A method for solving problems in nursing Rationale: Critical thinking is a method of solving problems. Critical thinking is to be applied to clinical judgment in nursing. Critical thinking is not only used for intensive care patients but for all nursing practice. In addition, critical thinking is not just thinking through the negative consequences of a matter; rather, it is a scientific approach to solving problems in nursing practice. Critical thinking does not mean being negative or critical when answering a question.

A nurse has received a patient from the emergency department and is assisting with the collection and processing of relevant data before appraising the patient's health status. The nurse is participating in which activity

Asessment Rationale: Assessment involves collecting and organizing data to determine a patient's health status. Diagnosis involves putting all the data together and deciding what is the ultimate patient problem. Determinism is the process of setting limits. The nursing process is the standard and the actions by which nurses provide care for patients.

A nurse has received a patient from the emergency department and is assisting with the collection and processing of relevant data before appraising the patient's health status. The nurse is participating in which activity?

Assessment Assessment involves collecting and organizing data to determine a patient's health status. Diagnosis involves putting all the data together and deciding what is the ultimate patient problem. Determinism is the process of setting limits. The nursing process is the standard and the actions by which nurses provide care for patients.

The nurse teaches the nursing student that there are five basic steps in the nursing process. In which order should the nurse perform these tasks?

Assessment (data collection Nursing diagnosis Planning Implementation Evaluation The five basic steps of the nursing process are (1) assessment (data collection), (2) nursing diagnosis, (3) planning, (4) implementation, and (5) evaluation. The LPN/LVN assists the RN with steps 1, 3, 4, and 5. The RN is responsible for formulating the nursing diagnosis in step 2 from the assessment data obtained from all sources.

The nursing instructor teaches that which statement about assessment is true?

During an assessment, accuracy is essential. During an assessment, accuracy is essential. Data collections from the nurse are used by the practitioner to determine treatment and must be carefully obtained from the patient. Assessment uses inspection (looking), olfaction (smelling), palpating (touching), and auscultation (listening). There are times when the patient's nonverbal expression does not match their verbal answers. This patient is said to be having incongruence between nonverbal and verbal expressions.

A nurse palpates a patient's skin during an assessment. Upon doing so, the nurse notices that the touch leaves an indentation. What does this finding indicate in the patient?

If depressing the skin with the fingers leaves an indentation, it indicates the presence of edema, which manifests as swelling due to the presence of excess fluid in the tissue. Dehydration causes dryness of the skin. Cold extremities indicate poor circulation. Presence of hot tissue is the result of localized inflammation

Which part of the physical assessment takes place primarily through observation?

Inspection Rationale: Inspection is the purposeful observation of the person as a whole and then systemically from head to toe. Inspection begins as soon as the nurse meets the patient and continues throughout the examination. Palpation uses the sense of touch to assess various body parts and to confirm findings that are noted during inspection. Percussion involves tapping on the skin to assess underlying tissue and organs. Auscultation involves listening to sounds produced by the body (e.g., heart, lung, and intestinal sounds) with a stethoscope.

Priority is given to which patient needs when determining patient care?

Lifesaving needs Priority is given to lifesaving/physiologic needs in patient care. Although pain relief, the need for food, and spiritual needs are all significant, they do not ever take priority over lifesaving needs.

The nurse knows that Maslow's hierarchy of needs is one thing to consider when prioritizing nursing care. Which patient care skills are among the first level of priority, based on the evolving Maslow's hierarchy of needs adapted by nursing? Select all that apply.

Maslow's hierarchy of needs places physiologic needs as the first priority to consider when prioritizing patient care. The physiologic needs include oxygenation, nutrition, elimination, safety, rest/comfort, hygiene, activity, and sexual procreation. Independence is part of the fourth level, called self-esteem; social interaction is in the third level, called love and belonging.

The registered nurse identifies and labels the patient's response to actual or potential health problems. In which phase of the nursing process will this action take place?

Nursing diagnosis During the nursing diagnosis phase, the registered nurse identifies human responses to actual or potential health problems or life processes. A nursing diagnosis will label concise statements describing a clinical judgment about a patient in response to actual or potential health problems or life processes. During the planning phase, the nursing diagnosis directs the development of patient outcomes and the identification of intervention strategies to resolve or decrease the patient's problem. During the evaluation phase, the nurse determines the effectiveness of the plan of care. If the outcomes were not met, it is necessary to determine why. During the assessment phase, the nurse systematically collects subjective and objective data about the patient and uses this information as a base for the plan of care.

The registered nurse identifies and labels the patient's response to actual or potential health problems. In which phase of the nursing process will this action take place?

Nursing diagnosis Rationale: During the nursing diagnosis phase, the registered nurse identifies human responses to actual or potential health problems or life processes. A nursing diagnosis will label concise statements describing a clinical judgment about a patient in response to actual or potential health problems or life processes. During the planning phase, the nursing diagnosis directs the development of patient outcomes and the identification of intervention strategies to resolve or decrease the patient's problem. During the evaluation phase, the nurse determines the effectiveness of the plan of care. If the outcomes were not met, it is necessary to determine why. During the assessment phase, the nurse systematically collects subjective and objective data about the patient and uses this information as a base for the plan of care.

Which step of the nursing process is the exclusive responsibility of the registered nurse?

Nursing diagnosis Rationale: The registered nurse is exclusively responsible for formulating nursing diagnoses from the assessment data obtained from all sources. The licensed practical nurse assists the registered nurse with evaluation, data collection or assessment, and implementation.

What is the systematic way for nurses to assess a patient's current health status and to plan, implement, and evaluate the patient called?

Nursing process Rationale: Nursing process is the language of nursing. Nursing process is an advanced problem-solving method used to collect and analyze data to plan, implement, and evaluate patient care in a systematic way. Critical thinking is directed, purposeful mental activity by which the nurse evaluates ideas, constructs plans, and determines desired outcomes. Clinical judgment is the result of critical thinking applied to clinical situations. A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse has accountability.

The nurse completes the patient health history and then measures the patient's blood pressure, pulse, and respirations. The nurse is collecting which type of information?

Objective data Rationale: Objective data can be observed or measured; it can be obtained using inspection, palpation, percussion, and auscultation. Primary data are not relevant to the types of data collected by the nurse. Subjective data are pieces of information collected during the interview; they include information that can be described or verified by the patient. The medical history involves information contributed by the health care provider. The nurse conducts a patient history and physical examination as part of the nursing assessment to collect data.

The nurse completes the patient health history and then measures the patient's blood pressure, pulse, and respirations. The nurse is collecting which type of information?

Objective data can be observed or measured; it can be obtained using inspection, palpation, percussion, and auscultation. Primary data are not relevant to the types of data collected by the nurse. Subjective data are pieces of information collected during the interview; they include information that can be described or verified by the patient. The medical history involves information contributed by the health care provider. The nurse conducts a patient history and physical examination as part of the nursing assessment to collect data.

What is the most important concept relating to the evaluation phase of the nursing process?

Ongoing process that aids in determining if patient goals are met The important concept that nurses need to know about the evaluation phase is that it is an ongoing process that aids in determining patient goal attainment. Evaluation can occur at any point in the nursing process. During the assessment phase, patient data are collected to aid in identifying patient strengths or problems that lead to nursing diagnoses and the data are reviewed and validated to determine their accuracy and relevancy. During the implementation phase, nursing interventions are put into action.

The LPN/LVN is assisting the RN in planning care for a patient. Which patient needs should receive the highest priority?

Oxygenation Oxygenation status should be given priority. Although the patient's comfort, mobility, and skin status are important, they are a lower priority than oxygenation status.

The nurse is collecting data about a patient. Which of these techniques, using the sense of touch, will the nurse use to assess texture, moisture, swelling, tenderness, and pain?

Palpation Rationale: Palpation is the examination of the body using touch. The sense of touch allows the health care provider to assess the texture, moisture, swelling, tenderness, and pain of a body part or region. Inspection is the visual examination of a part or region of the body to assess normal conditions and deviations. Percussion is a technique that produces sound and vibration to obtain information about the underlying area. Auscultation involves listening to sounds produced by the body using a stethoscope to assess normal conditions and deviations from normal.

The nurse is working with a newly hired nurse who is learning to prioritize care. The new nurse demonstrates the prioritization of patient care by performing which vital actions? Select all that apply.

Performing the most urgent tasks first Determining when to give medications Deciding in what sequence to perform patient care The prioritization of patient care is the most important step of planning competent and timely patient care. It includes the nurse determining which tasks are urgent, in what order to perform patient care, and when to give medications. If a task is prescribed, it is necessary to perform, but the nurse may determine that the task can wait and is not urgent. The nurse cannot disregard orders to check a patient's blood glucose level.

Establishing patient goals occurs during which phase of the nursing process?

Planning Establishing patient goals occurs during the planning phase of the nursing process. The development of nursing diagnoses occurs after the data collected has been analyzed and problems, potential problems, and strengths are identified. Assessment involves the systemic collection of data related to the patient. Implementation is when the plan of care is put into action.

When discussing the nursing process, the student nurse correctly states, "The nursing process is designed to provide a means for measuring __________."

Pt outcomes Rationale: The nursing process allows for measurement of patient outcomes by evaluating whether established patient goals have been met. The nursing process is not used to measure expenses associated with care, appropriate tasks for delegation, or acuity of patients on a nursing unit.

A nurse has taken several steps to improve critical thinking skills. Which actions indicate that the nurse is beginning to achieve excellence in critical thinking? Select all that apply.

Self-correcting Striving to improve Reevaluating one's own actions Critical thinking applied to clinical judgment in practical/vocational nursing can be described as constantly reevaluating, self-correcting, and striving to improve. Excellence in critical thinking involves those difficult yet important things that help a nurse improve and use their best clinical judgment. Critical thinking is not achieved through being negative or seeking management positions.

Which statement about the responsibility of the licensed practical nurse (LPN) is correct?

The LPN is responsible for ongoing assessments for assigned patients. The LPN is responsible for ongoing assessments of the patients assigned to the LPN. This data helps the registered nurse update the nursing care plan as needed. The registered nurse is responsible for the initial admission assessment though the LPN may assist with parts of it. The registered nurse is responsible for formulating the problem statements expressed in the nursing diagnosis. The LPN can assist the registered nurse in the development of expected outcomes and interventions for a patient's plan of care.

The LPN/LVN is reviewing the plan of care developed by the RN. The LPN/LVN recognizes that the etiology is what part of the nursing diagnoses statement?

The cause of the patient problem identified. The etiology is the cause of the patient problem identified. For example, if the patient has a skin tear from a fall, the problem identified would be impaired skin integrity related to shearing forces. The etiology is the shearing forces. Medical diagnoses are not part of a nursing diagnostic statement. The signs and symptoms that the patient is displaying would be included in the nursing diagnoses statement to support the statement through evidence produced by the patient.

The nursing student understands that which statement is an appropriate patient outcome statement?

The patient will state a pain level decreased to <4/10 during the next 4 hours. An appropriate patient outcome statement includes an action that can be measured or observed—a measureable outcome—with a time frame in which the objective is to be met. Each statement that begins with "The nurse" is not appropriate because the question asks about an outcome expected from the patient, not the nurse. "The patient will understand her new cardiac diet" is too vague; the term understand is passive and not measureable, and no time frame is stated with regard to when the action will be met.

After assisting with data collection for a patient, the nurse records the findings in the chart. Which is an example of an objective finding that the nurse would record?

The patient's pulse is 98 bpm, and the heart rate is regular. Rationale: Objective data are data that the nurse has directly observed or inspected during physical examination, such as the vital signs. A pulse of 98 bpm and a heart rate that is regular are examples of objective data. Subjective data are data that the nurse has received directly from the patient, such as a list of current prescriptions or any allergies. The patient's statement of "I feel weak and fatigued" is an example of subjective data.

Critical thinking is based on what? Select all that apply.

The scientific method Principles of the nursing process Rationale: Critical thinking applied to clinical judgment in practical/vocational nursing can be described as involving the principles of the nursing process and the scientific method. Both logic and intuition—in addition to knowledge, skills, and the professional experience of the nurse—are relied upon for optimal critical thinking. The professional nurse should always make decisions with ethical conviction and without prejudice.

What is important to consider when interviewing an older adult patient?

They may need more time to answer. Plan extra time for an interview with a patient who is an older adult. The older adult person who is ill may think and speak more slowly than expected and often has a longer health history to relate than a younger person. Speaking loudly and pausing between each word for an older adult person is often offensive, unless he or she has cognitive or hearing problems. Furthermore, speaking loudly distorts sounds even for those who are not hearing impaired.

What attributes do nurses who think critically possess? Select all that apply.

They think beyond the noticeable. They recognize that there may be more than one way to do the right thing. Critical thinking involves expanding one's thinking beyond the obvious. The critical thinker considers other ideas, recognizes that there may be more than one way to do the right thing, and realizes that there may not be a perfect solution.

The LPN/LVN is assigned to a patient whom she has not cared for previously. For which of these reasons is it essential for the nurse to do a brief chart review and read the nurse's notes for the past 24 hours?

To establish priorities for care to be given on this shift Reviewing the chart will help the nurse to determine what has occurred on the previous shift, which will help in determining priorities for the present shift. The patient may not require the same care on this shift if outcomes were met in previous shifts or if the patient's needs have changed. At this point, it is not necessary to determine the identity of the patient's health care providers.