Sherpath Nursing Process

Which organization defines standards of nursing practice and states that the nursing process forms the foundation for clinical decision making?

American Nurses Association The American Nurses Association defines the standards of nursing practice and states that the nursing process, as a critical-thinking model, demonstrates competency in nursing practice and forms the foundation for clinical decision making.

Which step of the nursing process does the nurse use when obtaining the following patient information: blood pressure of 180/75, pulse of 90, and a complaint of chest pain?

Assessment

Place the steps of the nursing process in the order in which each should occur.

Assessment Analysis Planning Implementation Evaluation

Which statements reflect the nurse's role during the implementation step of the nursing process?

Be accountable for safe practice. Nurses are accountable for safely and effectively performing interventions based on personal level of knowledge and clinical competency. Perform the steps of intervention accurately. Nurses must understand the steps required to perform the intervention accurately to safely provide care. Understand why an intervention is planned. Nurses must understand why an intervention is planned to ensure that the planned intervention is appropriate for the patient's unique circumstances.

Which nursing action occurs during the analysis step of the nursing process?

Clustering patient data to identify patient problems The analysis step of the nursing process occurs when the nurse analyzes, validates, and clusters patient data to identify patient problems. Patient data clusters are stated in standardized language, which provides clarity and universal understanding by all health care providers.

Match the nursing process characteristic to its description. The nursing process incorporates the interprofessional team. Nurses evaluate patient results to determine effectiveness. Nurses use critical thinking for each step of the nursing process. The nursing process helps ensure that patient care is well planned. Outcome-oriented Collaborative Organized Analytical

Collaborative Outcome-oriented Analytical Organized

Which phrase describes the primary purpose of nursing analysis and diagnosis?

Communicates patient problems In the analysis step, patient data are analyzed, validated, and clustered to identify patient problems. Each problem is then stated in standardized language as a specific nursing diagnosis to provide greater clarity and universal understanding by all health care providers.

Which nursing skill is essential to utilize throughout the nursing process? Analysis Observation Critical thinking Time management

Critical thinking

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

Evaluation

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 patients' individual needs?

Dynamic

Which step of the nursing process considers the effectiveness of nursing care?

Evaluation During the evaluation step, the nurse reviews patient outcomes to determine achievement of patient goals and effectiveness of nursing care.

Which function describes the primary purpose for documenting nursing interventions?

Facilitate communication

Which examples reflect subjective data?

Feelings Symptoms Perceptions Health history

Which action reflects a primary task in the analysis step of the nursing process?

Forming diagnostic conclusions

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 step of the nursing process involves carrying out nursing actions designed to meet a patient's unique needs?

Implementation

Match the type of nursing intervention to the example. Patient positioning Foley catheter insertion Respiratory therapy consult Interdependent Independent Dependent

Independent dependent Interdependent

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?Completeness and accuracy of collected data is important to address during each step of the nursing process to ensure that all critical data are considered. Could interventions affect the patient negatively?The nurse must think through the planned interventions and ensure that each one is safe for the patient. Are all underlying factors addressed in the plan of care?Comprehensive and accurate information is important to address during each step of the nursing process to ensure that appropriate decisions are made for the individual patient.

Which characteristics of the nursing process allow the nurse to effectively apply critical thinking to patient care?

It is organized.Organizing and clustering information is an important way nurses apply critical thinking in the nursing process. It is outcome-oriented.Determining outcomes and if the outcomes were met is an essential critical-thinking function that occurs during the nursing process. It allows nurses to apply knowledge.Nurses apply knowledge of disease/injury and knowledge gained from other patient care experiences to critically appraise the patient's situation during the nursing process. It requires nurses to think analytically.The nursing process requires nurses to think analytically and critically throughout the steps of the process. It incorporates an interprofessional team.The collaborative influence of the nursing process is an important factor in applying critical thinking and individualizing care in the nursing process.

During which step of the nursing process would the nurse establish long-term goals with the patient?

Planning During the planning step of the nursing process, the nurse prioritizes the nursing diagnoses and identifies short- and long-term goals that are realistic, measurable, and patient-focused, with specific outcome identification for evaluation purposes.

Which part of the nursing process involves the nurse setting short-term goals for the patient?

Planning

During which step of the nursing process would the nurse prioritize nursing diagnoses?

Planning Planning occurs when the nurse prioritizes the nursing diagnoses and identifies goals that are realistic, measurable, and patient-focused, with specific outcomes.

Match the category of data with its description. Obtained directly from patient Blood pressure reading and weight Direct quotes describing patient feelings Obtained from other health care professionals or medical records Subjective Primary Objective Secondary

Primary Subjective Objective Secondary

Which phrases describe the role of the International Classification for Nursing Practice (ICNP) in the nursing process?

Provides a standardized nursing language The ICNP is a standardized nursing language system used for point-of-care documentation for patient data and clinical activity. Identifies common labels for nursing diagnoses ICNP language can be used to identify diagnoses, interventions, and outcomes. ICNP publishes a Nursing Diagnosis and Outcome Statements Catalogue available online in multiple languages that identifies common labels for nursing diagnoses and subsets for select health priorities. Provides point-of-care documentation for clinical activity The ICNP is a standardized nursing language system used for point-of-care documentation for patient data and clinical activity.

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 acheived 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 aspects do nurses make judgments about when determining initial nursing diagnoses?

Vulnerabilities Patient problems Health Promotion Risk for problems

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 barriers did the patient encounter that prevented goal attainment?