Lesson Introduction to the Nursing Process Chapter 16, Nursing Assessment

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 Assessment is always the first step when managing patient care. The nurse must analyze the data to create nursing diagnoses and a patient-centered care plan.

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.

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

Evaluation Evaluation is the fifth step of the nursing process. The nurse determines if the patient's goals are met, examines the effectiveness of the interventions, and decides whether the plan of care should be discontinued, continued, or revised.

Which intervention reflects direct nursing care?

Giving an injection Giving an injection is an example of direct care, which is care performed on or with patients.

Which type of patient assessment takes into account all factors, such as the patient's physical, psychological, emotional, environmental, cultural, and spiritual health?

Holistic A holistic assessment takes into account the whole person, including numerous factors of the patient's health: physical, psychological, emotional, environmental, cultural, and spiritual.

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

Implementation During the implementation step, the nurse carries out the nursing interventions.

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 Planning includes prioritizing nursing diagnoses and setting patient-focused short- and long-term goals.

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.

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.

Which type of data do the patient's family members, friends, or other nurses provide?

Secondary Secondary data come from sources other than the patient.

Which questions would the nurse ask to evaluate the effectiveness of nursing interventions?

Should the plan of care be discontinued? "Should the plan of care be discontinued?" is an essential question to ask during the evaluation phase. Have new assessment data been identified that should be considered? "Have new assessment data been identified that should be considered?" is an essential question to ask during the evaluation phase to measure the effectiveness of interventions. Does the plan of care need to be modified in response to patient changes? "Does the care plan need to be modified in response to patient changes?" is an essential question to ask during the evaluation phase.