ch4 the nursing process

Which of these nursing diagnoses is correctly written? 1. readiness for enhanced knowledge related to problems with diabetes 2. Risk for injury related to poor balance when walking 3. risk for falls as manifested by frequent falls in the past 4. anxiety and fear

2. Risk for injury related to poor balance when walking

Which of these is considered subjective data? 1. The patient is resting on his side. 2. The patient complains of a headache. 3. The patient ambulated to the bathroom with assistance 4. The patient mother states that he does not eat well

2. The patient complains of a headache 4. The patient mother states that he does not eat well

Given that all of the following are appropriate nursing diagnoses for your patient, which would be the priority? 1. ineffective coping 2. sedentary lifestyle 3. risk for loneliness 4. self-care deficit: bathing

4. self-care deficit: bathing

Assume you are schedules for clinical tomarrow. How would you obtain information about your patient so that you can begin to develop a plan of care? a. Read the nursing admission assessment and recent nurse's notes. b. read the health-care provider's admission note and recent progress notes. c. listen to the end-of-shift report at the nurses station D. review the medication administration record and any treatment plans or notes

A,B,C,D

Actions the nurse performs that do not require a written order are call

Independent intervention

Activities that a nurse performs that do not involve hands-on or one-on-one patient care but nonetheless have an impact on the patient are called

Indirect patient care

Creating a relationship of mutual trust is called establishing a _____________.

Rapport

Take the following nursing diagnoses and prioritize them according to Maslows hierarchy of human needs. then group them using the hierarchy terms: ineffective airway clearance, spiritual distress, decreased cardiac output, readiness for enhanced power, ineffective breathing pattern, risk for injury, chronic low self-esteem, risk for loneliness, and readiness for enhanced spiritual well-being

Self-transcendence Readiness for enhanced spiritual well-being Spiritual distress Self-actualization Readiness for enhanced power Esteem needs Chronic low self-esteem Belongingness and love needs Risk for loneliness Safety needs Risk for injury Physiological (survival) needs Ineffective breathing pattern Decreased cardiac output Ineffective airway clearance

you are caring for a child with pneumonia. an RN is developing the care plan and asks for you input. discuss three ways you can contribute to the care plan

The LPN/LVN can help develop a care plan in many different ways. He or she can gather data, offer input, implement nursing interventions, and evaluate patient progress toward goal achievement.

T or F A nursing diagnosis may be a one-part, two part, or three-part statement

True

T or F Implementation means putting the plan into action and performing the intervention

True

T or F Improvement in a patients health problem is measured by how much progress the patient makes toward the goal, which is set by the nurse

True

T or F The evaluation step of the nursing process is the step in which the plan of care is either changed or continued

True

T or F Wellness diagnoses are characterized by the phrase "ready for enhanced"

True

T or F When a patient achieves the expected outcome the nursing diagnosis is resolved

True

T or F by using a problem statement, the cause of the problem, and the defining characteristics of the problem, nursing diagnoses help identify intervention to address the problem

True

T or F Specified diagnoses are those that clearly apply to one defined patient need, so that any more description would only be redundant

True

To avoid making decisions based on assumption, nurses __________ the information they obtain.

Validate

which step of the nursing process is concerned with identifying physical findings? a. assessment b. diagnosis c. planning d. implementation e. evaluation

a. assessment

Although nursing intervention vary widely, the initial steps you will take before performing an intervention are somewhat standard. which of the following should be done before any nursing intervention? a. determine if the patient condition has changed in such a way that the order might no longer be appropriate. b. gather needed equipment and supplies c. explain the procedure to the patient d. identify the patient using two methods of identification according to facility policy e. provide privacy f. wash your hands

a. determine if the patient condition has changed in such a way that the order might no longer be appropriate. b. gather needed equipment and supplies c. explain the procedure to the patient d. identify the patient using two methods of identification according to facility policy e. provide privacy f. wash your hands

You are performing the daily assessment of your patients status. you notice some purplish marks on her arm where the bandage for her IV had been and the skin is torn. Which of the following techniques did you use to obtain these data? a. inspection b. palpation c. auscultation d. percussion

a. inspection

In which step of the nursing process do you label problems? a. assessment b. diagnosis c. planning d. implementation e. evaluation

b. diagnosis

your patient has severe peripheral vascular disease (poor circulation) in both lower extremities. you document that the patient pedal pulses are absent. which assessment technique did you use to obtain these date? a. inspection b. palpation c. auscultation d. percussion

b. palpation

subjective data

symptoms knowable only by patient

T or F LPN/LVN do not have a role in determining nursing diagnoses for the care plan

False

T or F Nursing diagnoses all contain the modifier "risk for"

False

T or F Nursing diagnoses and medical diagnoses both use the names of diseases

False

T or F The NANDA-I list of nursing diagnoses is the only source of nursing diagnoses available.

False

Which steps of the nursing process does the LPN/LVN directly participate in? 1. assessment 2. diagnosis 3. planning 4. implementation 5. evaluation

1. assessment 4. implementation 5. evaluation

Which are examples of independent nursing intervention? 1. placing a patient on intake and output measurement 2. assessing the abdomen when a patient is constipated 3. encouraging high fiber foods for a patient who is constipated 4. administering an enema to a constipated patient 5. administering a laxative and stool softer to a constipation patient

1. placing a patient on intake and output measurement 2. assessing the abdomen when a patient is constipated 3. encouraging high fiber foods for a patient who is constipated

Which of the following are examples of activities in which a nurse would need to use critical thinking? 1. prioritizing patient care 2. administering medication 3. writing nursing orders 4. questioning the appropriateness of an order 5. starting an IV infusion

1. prioritizing patient care 2. administering medication 3. writing nursing orders 4. questioning the appropriateness of an order 5. starting an IV infusion

Number in order the steps of the nursing process 1. Planning 2. assessment 3. evaluation 4. diagnoses 5. implementation

ADPIE 2. assessment 4. diagnoses 1. Planning 5. implementation 3. evaluation

It is important to remember that the nursing process is not static but dynamic. in other words, you do not perform a single step at a time beginning with assessment and ending with evaluation. use the following scenario to discuss the dynamic nature of the nursing process: you enter a patient room to find the patient ashen, short of breath, and complaining of chest pain. your first action include checking vital signs, measuring pulse oximetry, giving nitroglycerin, applying oxygen, and notifying the health-care provider. Explain which steps of the nursing process you are performing.

Answers will vary, but here is one example: As I see the patient in distress I would immediately begin taking in information (assessment) through my senses, particularly sight and hearing. At the same time, especially because this is an emergency, I'd be making some plans, such as notifying the physician as soon as I'm able. I would unconsciously diagnose the patient as having impaired gas exchange, as evidenced by his ashen skin color and shortness of breath, as well as acute pain, based on his report. I would also be thinking of interventions. I would immediately go to the patient and check his heart rate, blood pressure, respiratory rate, and pulse oximetry while simultaneously interviewing him about his status. If he had oxygen, I would put the delivery device on, probably nasal cannula, and set the flow rate. I would administer the nitroglycerin and reassess his chest pain after 1 to 3 minutes. I would be rechecking his vital signs and, if his blood pressure dropped too much from the nitroglycerin (a potential side effect), I would recognize that as a new problem (diagnosis). I would call his physician to report the situation and the patient's ongoing status, and I would plan other interventions until he stabilized or was transferred to a higher level of care. By this example, you can see that the steps of the nursing process overlap and that you will, especially in urgent situations, perform the steps almost simultaneously.

Using a physical problem you understand well (common cold, flu, or broken bone) list the common signs and symptoms and identify whether they represent subjective or objective data. list any further explanation on the blank lines

Answers will vary; however, following are objective and subjective data for a gastrointestinal infection: subjective= nausea, cramping, weakness objective= vomiting, Hyperactive bowel sounds, diarrhea, dehydration, Hypokalemia

provide a rational for why each step of the nursing process is important. although it may seem that the importance of the steps is obvious, write at least one sentence for each step detailing how the step help in making decision about patient care.

Assessment—Gathering data is important because it is not possible to make a good decision if you do not have all the information you need. Making decisions with insufficient data could result in misdiagnosis, which would lead to applying incorrect and possibly harmful treatments. Diagnosis—Diagnosis is important in decision making about patient care because failing to accurately describe the problem can result in choosing the wrong interventions. Planning—Setting goals and outcomes is important in decision making because it is what drives the activities. Goals and outcomes provide direction. Implementation—Implementation is important in decision making because only implementation can provide feedback about the effectiveness of all the other decisions. Evaluation—Evaluation is important to decision making because one must find out what is working and what is not.

A documented strategy that includes the health-care providers order, nursing diagnoses, and nursing orders is called the ___________.

Care Plan

___________ is using competent reasoning and logical thought processes to determine the merits of a belief or action.

Critical thinking

Refer to the real-world connection feature called critical thinking in patient care located in ch4 in your textbook. what did the nurse and the therapist do that is characteristic feature of critical thinking? a. they made important observations b. they made a difference in patient care c. they thought they could get to the bottom of the problem d. they made a conscious decision to think in a new way about the problem

D. they made a conscious decision to think in a new way about the problem

The signs an symptoms experienced by the patient that directly influences the nursing diagnoses are called ______________.

Defining Characteristics

Actions the nurse performs that require a written order are called

Dependent intervention

When an individual nurse performs hands-on or one-on-one nursing interventions, its is called

Direct patient care

The ________________ is the overall direction that will indicate improvement in a problem.

Expected Goal

_______________ are statements of measurable action for the patient within a specific time frame in response to nursing intervention.

Nursing Goals

The _____________ is an overlapping, five step method for decision making.

Nursing Process

The concise statement of a problem that the patient is experiencing as a result of his or her medical diagnoses is called the _____________.

Nursing diagnoses

you are caring for a male patient who had a total hip replacement 3 days earlier. you have not cared for the patient before and are assessing him to establish a baseline of information about his health status. The patient states he felt feverish during the night and broke into a sweat. you check his temperature readings from the previous night and see that it was 99.2F at midnight and 98.2F at 6am. it now is 99F. which of the following action represents the best response to his statement and gives the best explanation for the action as it relates to critical thinking? a. tell him not to worry because his temperature was only 99.2F this action shows that you understand normal trends in postoperative are and are applying them to unique situation. b. make a mental note to check his temperature a few more times this shift. this action shows that you understand that assessment is the first and most important step in the nursing process. c. assess him for signs and symptoms of an infection. this action shows that you are looking for data to validate the patients comment. d. tell him that a low-grade fever is normal after surgery. this shows that you are aware of common clinical conditions.

c. assess him for signs and symptoms of an infection. this action shows that you are looking for data to validate the patients comment.

To assess bowel sounds, which assessment technique will you use? a. inspection b. palpation c. auscultation d. percussion

c. auscultation

You have passed you NCLEX-PN examination and have just been employed as a LPN on a medical surgical unit. the registered nurse in charge asks you to do the admission assessment on a new patient who has just arrived by ambulance from a long-term care facility. the patient had undergone a total hip replacement withing the previous 2 weeks and has developed a fever. you tell the nurse you thought an LPN could not do the admission assessment or, at most could do only certain portion of it. the nurse, who is very busy says "please just do it". Ill cosign it, so it will be fine"which of the following action should you take next? a. call the supervisor to discuss the nurses instruction to you. b. refuse to do the admission assessment but offer to get the patient settled in take his vital signs and review the chart for orders. c. check the facility policy manual d. do the assessment as requested

c. check the facility policy manual

Your patient was admitted to the hospital with severe abdominal pain. It was determined that he had pancreatitis as a result of severely elevated triglycerides. He was also diagnosed with type 2 diabetes, and you plan to teach him about his diagnosis. he is not allowed anything by mouth yet because of the pancreatitis, is receiving IV fluids, and requires pain medication every 3 to 4 hrs. you enter the room and let him know you want to discuss his health condition with him. he responds by saying. "Not now, please, I just got my pain shot." Which of the following explains how the patient comment reflects Maslows hierarchy of needs? a. He has to have his safety and security needs met before he can address cognitive needs. b. cognitive needs are less important than physical needs c. he cannot deal with learning new issues while he feels physically uncomfortable d. his discomfort is preventing him from cooperating.

c. he cannot deal with learning new issues while he feels physically uncomfortable

how is Maslows hierarchy of human needs used by nurses in a clinical setting? a. it serves as a reminder of human growth and development across the life span. b. it is a framework for thinking critically c. it helps in prioritizing nursing diagnoses and care d. it outlines the basic psychological needs that people have when they are hospitalized and feeling vulnerable.

c. it helps in prioritizing nursing diagnoses and care

In which step of the nursing process are priorities set? a. assessment b. diagnosis c. planning d. implementation e. evaluation

c. planning

You are accepting a patient who is being transferred to your general care unit after 3 days in the intensive care unit following a stroke. many of the stroke symptoms have resolved, and the patient needs only minimal physical and occupational therapy. because the care is uncomplicated and you are busy with patients who are sicker, you ask the unlicensed assistant to develop the care plan, after which you will assess it and revise it as needed. which of the following statement about your action is true? a. this is fine you may delegate care planning as long as a licensed nurse review it. b. this is fine as long as you choose the nursing diagnoses. c. this is not allowed because nursing decisions and care planning cannot be delegated. d. this is not allowed because the patient is coming from an ICU.

c. this is not allowed because nursing decisions and care planning cannot be delegated.

Nursing actions that involve working with other disciplines such as physical therapy or social services are called

collaborative intervention

you enter the room to find your patient ashen and gasping for breath. which part of the nursing process should you perform, formally or informally, in the first 5 minutes? a. assessment b. diagnosis c. planning d. implementation e. evaluation d. all of the above

d. all of the above

which step of the nursing process is most associated with action? a. assessment b. diagnosis c. planning d. implementation e. evaluation

d. implementation

you are assisting the nurse practitioner with her assessment of an elderly, confused woman. you watch as the NP places her hand on the woman back and then taps her own middle finger with her other hand. this assessment technique is called. a. inspection b. palpation c. auscultation d. percussion

d. percussion

A student in your class is given the name of a patient for whom she will provide care the following day in clinical. she goes to the unit, which specializes in diabetes care, to find out information and sees the patient sitting in a wheelchair with his chart in his lap. he is on his way to radiology for an x-ray. she notes that his left leg is amputated just below the knee and that his right foot is bandaged. your class has been studying diabetes and the student knows that vascular problems and amputations are unfortunate complications of diabetes. she plans to study about diabetic foot care tonight so that she will be prepared for clinical the next day. Which of the follwing represent an accurate statement about her decision to study diabetic foot care? a. it reflects careful observation and good planning b. the amputation and bandage are pretty obvious, so her plan is just common sense. c. she should read the patient specific foot care program before reading about general diabetic foot care. d. she has made a serious thinking error.

d. she has made a serious thinking error.

secondary data

data obtained from a source other than patient

Primary data

data provided by the patient

objective data

data that can be assessed through the sences

In which step of the nursing process would you look at outcomes? a. assessment b. diagnosis c. planning d. implementation e. evaluation

e. evaluation