Nursing Process
Steps of the Nursing Process - what happens during each phase? ADPIE
(1) Assessment: gather info about pt's condition (2) Diagnosis: identify the pt's problems using NANDA (3) Planning: set goals of care and desired outcomes & identify appropriate nursing actions (4) Implementation: perform the nursing actions (5) Evaluation: determine if goals met & outcomes achieved
When making Diagnostic statements:
(1) Verify data & consult resources (2) DON'T be judgemental or use legally liable terms (3) NANDA & etiology SHOULD NOT be the same (ex: acute pain r/t headache)
How do you prioritize nursing diagnosis & nursing actions?
(1) What will kill or harm the pt if you don't do something? (2) ABC: airway, breathing, circulation; pain is often next priority (3) Maslow's hierarchy (4) Priorities should be pt driven--what is most important to the pt, not what is most important to you as the nurse
What is critical thinking in nursing?
Intentional higher level reasoning process delineated by one's worldview, knowledge, and experience. Important component of professional accountability and quality nursing care.
Difference between medical diagnoses & nursing diagnoses?
Medical: identifies a health problem or disease process (ex: COPD); treatable by physicians; deals with actual pathophysiologic changes in body Nursing: identifies response to health problem (ex: response to COPD like anxiety, activity intolerance, & ineffective breathing); treatable by nurses; often deals with pt perception of health status
What is Maslow's hierarchy? (most life-threatening to least)
Physiological needs pain, hunger, thirst, sleep Safety needs - safety & protection Social needs - love & sense of belonging Esteem needs Self-actualization
Risk for Potential Diagnosis
Risk factors evident, but s/sx not yet present
What are subjective & objective data?
Subjective: info the pt tells you (ex: they describe their pain as "sharp" and a level 6 on a pain scale from 0-10) Objective: info that you can gather via observation and factual data (ex: observe facial grimacing, measured BP or temp)
A client recently diagnosed with pancreatic cancer tells the nurse, "I don't see any hope for my future." What would be the most appropriate nursing diagnosis for the nurse to formulate to address this health problem? (a) Hopelessness related to difficulty coping secondary to pancreatic cancer diagnosis (b) Disturbed Self-Concept related to pancreatic cancer diagnosis (c) Ineffective Health Maintenance related to being overwhelmed by cancer diagnosis (d) Knowledge Deficit: Cancer treatment options related to new diagnosis
a
A client who gave birth yesterday refuses to eat the food provided by the hospital. The client reports needing special food brought from home by family. How would the nurse most appropriately address this situation? (a) The nurse should not formulate a nursing diagnosis but should encourage the client to have family bring food from home. (b) The nurse should formulate a possible nursing diagnosis and make further observations. (c) The nurse should formulate an actual nursing diagnosis and plan interventions to correct the problem. (d) The nurse should formulate a collaborative problem and consult with the physician and dietiti
a
A client's diagnosis of breast cancer necessitates a bilateral mastectomy and breast reconstruction with tissue expanders. The nurse recognizes that the client's surgery will have a significant impact on the client's activities of daily living (ADLs) during the period of recovery. When should the nurse begin discharge planning to address this client's ADLs? (a) On the client's admission to the hospital (b) Once the client has received a discharge order (c) As soon as possible after the client's surgery (d) Once the client is admitted to the nursing unit from postanesthetic recovery
a
A newly graduated nurse is unable to determine the significance of data obtained during an assessment. What would be the nurse's most appropriate action? (a) Consult with a more experienced nurse. (b) Continue to collect assessment data. (c) Document the data for future reference. (d) Contact the client's health care provider.
a
A nurse caring for a client admitted with a deep vein thrombosis is individualizing a prepared plan of care that identifies nursing diagnoses, outcomes, and related nursing interventions common to this condition. What type of tool is the nurse using? (a) A standardized care plan (b) An order set (c) Guidelines (d) An algorithm
a
After collecting data from a client with respiratory distress, the nurse prioritizes the client interventions to provide oxygen to the client first. This is an example of which model for organizing data? (a) Hierarchy of Human Needs (b) Functional Health Patterns (c) Human Response Patterns (d) Body Systems Model
a
During examination a client becomes very tired but still needs to answer questions so that the nurse has sufficient data for planning care. Which action by the nurse would be most appropriate in this situation? (a) Ask the client to wake up and try to answer the interview questions. (b) Ask the client's spouse to come in and answer the interview questions. (c) Wait until the next day to obtain the answers to the interview questions. (d) Ask the client whether it is okay to interview the client's spouse for the answers to the interview questions.
a
The nurse is aware that nursing diagnoses are: (a) within the nursing scope of practice to develop and client-focused. (b) collaborative and depend on the medical diagnosis. (c) based on assessment data and the primary care provider's input. (d) dictated by the medical diagnoses and change day by day.
a
While caring for a client admitted with a Clostridium difficile infection, the nurse notes that the client has had three loose bowel movements in 3 hours. What would be the most appropriate nursing diagnosis to address this health problem? (a) Diarrhea related to infectious processes secondary to C. difficile infection as evidenced by three loose bowel movements in 3 hours (b) Risk for Infection Transmission related to high potential for communicability (c) Fluid Volume Excess related to diarrhea as evidenced by three loose bowel movements in 3 hours (d) Risk for Injury related to urgent need for bowel evacuation
a
The client is about to have blood drawn before seeing the health care provider. The spouse, while smiling and holding the client's hand, states, "Here comes the blood sucker. It is going to hurt bad." This statement is an example of which types of intervention? Select all that apply. (a) Psychosocial (b) Supportive (c) Physical (d) Coordinating (e) Technical
a,b,c
Which elements are important to incorporate into a client's plan of care? Select all that apply. (a) Client participation (b) Care that is realistic and measurable (c) Involvement of support people (d) Standardized care
a,b,c
Quality improvement in care delivery requires which components? Select all that apply. (a) Leadership commitment (b) Continuous improvement (c) Total client care by the nursing unit (d) Focus on data collection (e) Focus on the mission of the organization
a,b,d,e
For which client would a standardized plan of care most likely be appropriate? (a) A client who was admitted for shortness of breath and who has been diagnosed with pneumonia (b) A client who is receiving treatment for liver cirrhosis, esophageal varices, and hepatic encephalopathy (c) A client whose increasing fatigue in recent days has not yet been attributed to a specific health problem (d) A client who has been brought to the emergency department with multiple fractures and a suspected head injury after a motor vehicle accident
a--Standardized care plans are most appropriate for clients who are experiencing a common and specific health problem, such as pneumonia. Clients with multiple pathologies or symptoms of unknown etiology are unlikely to have their unique needs reflected in a standardized care plan.
A nurse is providing care to several assigned clients and decides to delegate the task of morning vital signs to unlicensed assistive personnel. The nurse would assume responsibility and refrain from delegating this task for which client? (a) A client with a high fever receiving intravenous fluids, antibiotics, and oxygen (b) An older adult with pneumonia who is being discharged to the son's home tomorrow (c) A middle-aged client who had abdominal surgery 3 days ago and is ambulating in the hall (d) An adult client who is being treated for kidney stones
a--The client with a high fever receiving intravenous fluids, antibiotics, and oxygen is the least stable of the clients listed and should be assessed by the nurse
A client with end-stage chronic obstructive pulmonary disease (COPD) has the nursing diagnosis "Activity Intolerance." Which expected client outcome most directly demonstrates resolution of the problem? (a) Client will alternate rest periods with exercise throughout the day. (b) Client will increase protein intake in small frequent meals. (c) Client will use oxygen by nasal cannula when short of breath. (d) Client will consistently perform pulmonary exercises.
a--While each of these options will promote health in a client with COPD, the most direct resolution of activity intolerance is for the client to pace activities by alternating rest with exercise throughout the day.
Interventions
are actions performed to measure or achieve patient outcomes (resolve NANDA)
"The client will verbalize appropriate cast care on discharge" represents which type of outcome? (a) Psychomotor (b) Cognitive (c) Affective (d) Physical change
b
A client in the intensive care unit with a nursing diagnosis of Risk for Impaired Skin Integrity has a nursing intervention that states the client is to be turned and repositioned every 2 hours. As the nurse is turning the client to the client's left side, the nurse notices that the client has a nonblanching, reddened area over the right trochanter. What would be the most appropriate action for the nurse to take? (a) The nurse repositions the client to the client's back and documents the intervention in the client's record. (b) The nurse repositions the client to the client's left side and updates the plan of care to turn and reposition the client every hour. (c) The nurse repositions the client to the left side and plans to return in 2 hours to reassess the reddened area on the client's right trochanter. (d) The nurse repositions the client to the client's back and documents the condition of the client's skin in the medical record.
b
The client has a diagnosis of Risk for Injury related to falls. How would the nurse know if the intervention was successful? (a) The client calls for assistance to get out of bed. (b) The client is free of falls. (c) The client is taught safety precautions. (d) The client verbalizes risks for injury.
b
The nurse is planning to do a physical assessment on a newly admitted client. The assessment will be a review of systems. This means the nurse plans to: (a) examine certain body systems. (b) complete an exam of all body systems. (c) perform a review of the problem areas. (d) focus on only the systems that the client is comfortable with.
b
The nurse recognizes that health problems that the nurse can address by independent nursing interventions are called: (a) dependent nursing diagnoses. (b) actual or potential nursing diagnoses. (c) collaborative nursing diagnoses. (d) syndrome nursing diagnoses.
b
When performing an assessment on an older adult client, the nurse discovers that the client needs a cane when walking and has problems seeing in the night. Under which stage of Maslow's Hierarchy of Needs Theory should the nurse cluster this data? (a) Physiologic (b) Safety and security (c) Love and belonging (d) Self-esteem (e) Self-actualization
b
A client admitted for a surgical procedure tells the nurse, "I am very worried because I am allergic to latex. I want to make sure that everyone knows this." To ensure the safety of the client, which nursing diagnosis should the nurse assign to this client and address in the care plan? (a) Anxiety related to surgical procedure (b) Knowledge Deficit related to surgical procedure (c) Risk for Allergy Response related to latex allergy (d) Risk for Injury related to latex allergy
c
A client with HIV has been admitted to a health care facility. Which nursing diagnosis should be the priority, keeping in mind the client's condition? (a) Risk for Activity Intolerance (b) Risk for Ineffective Coping (c) Risk for Infection (d) Risk for Imbalanced Nutrition
c
A new chemical plant is being built in the community. The nurse is concerned about the possibility of environmental pollution adversely affecting the health of the residents. What nursing diagnosis would the nurse use to address this concern? (a) Knowledge Deficit related to effects of chemical plant pollution (b) Deficient Community Health related to chemical plant (c) Risk for Community Contamination related to possible environmental pollution (d) Risk for Infection related to community contamination
c
A nurse documents the following nursing diagnosis on a client's plan of care: "Readiness for Enhanced Breast-Feeding." The nurse has identified which type of nursing diagnosis? (a) Problem-focused (b) Risk (c) Health promotion (d) Syndrome
c
A nurse is caring for a client diagnosed with arthritis. The client is experiencing pain, which is interfering with the client's ability to ambulate. The nurse accurately documents which nursing diagnosis in the client's records? (a) Ineffective Movement related to arthritis (b) Impaired Movements due to pain (c) Impaired Physical Mobility related to pain (d) Ineffective Physical Mobility due to pain
c
A nurse is preparing to interview a client as part of the assessment. The nurse demonstrates knowledge of communication skills when the nurse: (a) agrees with each of the client's statements. (b) attempts to write down everything the client says. (c) uses broad, open statements to communicate with the client. (d) reassures the client of good outcomes.
c
During the interview component of the health assessment, how does the nurse convey to the client that the information is important? (a) Nodding frequently during the interview (b) Sitting at eye level with the client (c) Standing next to the client while interviewing (d) Limiting questions to those with yes or no answers
c
The nurse is caring for a 14-year-old client who has just delivered a baby. The client reports living with an aunt and having no other family around. The delivery was uncomplicated and the newborn is healthy. Which would be the primary nursing diagnosis for this client? (a) Risk for Loneliness (b) Acute Pain (c) Risk for Impaired Parenting (d) Ineffective Breastfeeding (e) Ineffective Infant Feeding Pattern
c
The surgeon is insisting that a client consent to a hysterectomy. The client refuses to make a decision without the consent of the client's spouse. What is the nurse's best course of action? (a) Remind the client that the client is responsible for the client's own health care decisions. (b) Ask the client whether the client is afraid that the spouse will be angry. (c) Ask the surgeon to wait until the client has had a chance to talk to the spouse. (d) Inform the surgeon that the nurse will not sign the informed consent form.
c
Which group of terms best defines assessing in the nursing process? (a) Problem-focused, time-lapsed, emergency-based (b) Designing a plan of care, implementing nursing interventions (c) Collection, validation, communication of client data (d) Nurse-focused, establishing nursing goals
c
Which is the primary reason for a nurse collecting data continuously on a client? (a) It gives the nurse more information to document on the client. (b) It makes the client feel as if the nurse is spending more time with the client. (c) The client's health status can change quickly. (d) Most facilities require it for reimbursement.
c
Which statement by a new nurse regarding validation of data collected during client assessment indicates a need for further training? (a) Validation is an important part of assessment. (b) Validation helps to keep data as free from error as possible. (c) All data collected need to be validated. (d) Validation is the act of confirming or verifying.
c
As part of a quality improvement initiative nurses are asked to complete a structure evaluation. Which information should the nurse include in this work? Select all that apply. (a) The procedure for insertion of intravenous catheters has not been reviewed for two years. (b) There is a potential for errors when clients are transferred from the emergency department to the nursing unit during shift change. (c) Because there is no door on the unit's diet kitchen, client families feel free to walk in and serve themselves coffee. (d) Newly purchased beds are difficult to move through client room doors. (e) The unit's rate of catheter-associated urinary tract infections has risen sharply in the last year.
c,d--Structural evaluations have to do with the physical structure of the unit, so lack of a door on the unit's diet kitchen and difficulty moving beds through doors are structural issues
All of the activities listed are related to evaluation, but which activity is the priority concern for nurses? (a) Measuring client outcome achievement (b) Helping targeted groups of clients to achieve their specific outcomes (c) Measuring the competence of individual nurses (d) Meeting the care needs of clients
d
The nurse is performing an assessment on a newly admitted client and understands the importance of validating all data. When is the best time to validate such data? (a) During the collection of data only (b) At the end of the data-gathering process (c) In the middle of the data-gathering process (d) Both during the collection and at the end of the collection
d
When a nurse assists a postoperative client to the chair, which type of nursing intervention does this represent? (a) Maintenance (b) Surveillance (c) Psychomotor (d) Psychosocial
d
Which example of client care is not the responsibility of the nurse? (a) Monitoring for changes in health status (b) Promoting safety and preventing harm; detecting and controlling risks (c) Tailoring treatment and medication regimens for each individual (d) Confirming a medical diagnosis
d
Which would be an appropriate nursing diagnosis for a client with cachexia and decreased weight? (a) Anorexia Nervosa (b) Lack of Adequate Nutrition (c) Weight Loss (d) Imbalanced Nutrition: Less than Body Requirements
d
While auscultating a client's lung sounds, the nurse notes crackles in the left lower lobe, which were not present at the start of the shift. The nurse is engaged in which type of nursing intervention? (a) Educational (b) Psychomotor (c) Maintenance (d) Surveillance
d
A client who recently became quadriplegic as the result of a motor vehicle accident is experiencing multiple physical and emotional problems. To guide the care planning for this client, what type of nursing diagnosis would be most appropriate for the nurse to select? (a) A problem-focused nursing diagnosis (b) A possible nursing diagnosis (c) A risk nursing diagnosis (d) A syndrome nursing diagnosis
d--bc the client is experiencing multiple problems beyond the scope of a single nursing diagnosis, a syndrome diagnosis is indicated.
Actual diagnosis
defining characteristics or s/sx actually present
Wellness Diagnosis
human response to levels of wellness; pt expresses desire to transition to higher level of wellness (ex: "Readiness for enhanced spiritual well-being")
Health Promotion Diagnosis
pt expresses desire to improve current health status (ex: wants to quit smoking, "Readiness for enhanced nutrition")