Introduction to the Nursing Process

2. Place the steps of the nursing process in the order in which each should occur. Planning Assessment Implementation Evaluation Analysis NOT SURE

1. Assessment 2. Analysis 3. Planning 4. Implementation 5. Evaluation STUDY THESE TERMS

3. Match the nursing process characteristic to its description. 1. The nursing process incorporates the interprofessional team. 2. Nurses evaluate patient results to determine effectiveness. 3. Nurses use critical thinking for each step of the nursing process. 4. The nursing process helps ensure that patient care is well planned.

1. Collaborative 2. Outcome-oriented 3. Analytical 4. Organized

3. Match the type of nursing intervention to the example. 1. Patient positioning 2. Foley catheter insertion 3. Respiratory therapy consult Interdependent Independent Dependent

1. Interdependent 2. Dependent 3. Interdependent

2. Match the category of data with its description. 1. Obtained directly from patient 2. Blood pressure reading and weight 3. Direct quotes describing patient feelings 4. Obtained from other health care professionals or medical records Subjective Objective Secondary Primary

1. Primary 2. Objective 3. Subjective 4. Secondary

3. 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. Anticipate and prevent complications. Organize resources and care delivery. Reassess the patient. Review and revise the existing plan of care. Implement nursing interventions.

1. Reassess the patient. 2. Review and revise the existing plan of care. 3. Organize resources and care delivery. 4. Anticipate and prevent complications. 5. Implement nursing interventions. *During the implementation step, the nurse first reassesses the patient. Then the nurse reviews and revises the existing plan of care. Next, the nurse organizes resources and care delivery. Then the nurse anticipates and prevents complications. Finally, the nurse implements nursing interventions.*

2. Which organization defines standards of nursing practice and states that the nursing process forms the foundation for clinical decision making? American Academy of Nursing National Student Nurses Association National League for Nursing American Nurses Association

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.

4. 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? Analysis Evaluation Assessment Implementation

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.

16. Which step of the nursing process considers the effectiveness of nursing care? Planning Analysis Evaluation Implementation

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

15. Which statements reflect the nurse's role during the implementation step of the nursing process? Select all that apply. Be accountable for safe practice. Consult with the health care provider. Collaborate with support services. Perform the steps of intervention accurately. Understand why an intervention is planned.

Be accountable for safe practice. Perform the steps of intervention accurately. Understand why an intervention is planned.

7. Which nursing action occurs during the analysis step of the nursing process? Initiating nursing interventions and treatments Identifying realistic goals that are patient-focused Clustering patient data to identify patient problems Gathering patient data through a variety of sources

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.

8. Which phrase describes the primary purpose of nursing analysis and diagnosis? Resolves patient confusion Communicates patient problems Articulates the nursing scope of practice Describes the medical context of the patient problem

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.

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

Critical thinking - Critical thinking requires that the nurse think logically about the patient's health problems and how best to address them, and it is used throughout the nursing process.

10. During which step of the nursing process would the nurse prioritize nursing diagnoses? Planning Analysis Evaluation Assessment

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

1. Which nursing concept is defined as an actual or potential problem or response to a problem? Plan Outcome Diagnosis Assessment

Diagnosis - A nursing diagnosis is meant to identify an actual or potential problem, or a response to a problem.

2. Which interventions reflect indirect nursing care? Select all that apply. Giving an injection Helping a patient ambulate in the hall Documenting medications administered Collaborating to schedule occupational therapy Working with a social worker to set up home care

Documenting medications administered Collaborating to schedule occupational therapy Working with a social worker to set up home care indirect - not directly physically treating the patient but still providing relevant care in other ways to said patient.

1. Which term describes how the nursing process changes over time in response to patients' individual needs? Dynamic Analytical Organized Adaptable

Dynamic - The dynamic characteristic of the nursing process refers to how the nursing process changes as the patient's condition or needs change.

17. Which step of the nursing process includes a decision point on whether to discontinue, continue, or revise the plan of care? Planning Evaluation Assessment Implementation

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.

1. Which function describes the primary purpose for documenting nursing interventions? Implement policy. Prove task completion. Facilitate communication. Ensure proper record-keeping.

Facilitate communication. - Communication is the most important reason proper documentation is performed. It facilitates communication among all health care team members and decreases the potential for errors.

3. Which examples reflect subjective data? Select all that apply. Signs Feelings Symptoms Perceptions Laboratory findings Health history

Feelings Symptoms Perceptions Health History (pt. interview) - Signs are an example of objective data because they are observable. - Laboratory findings are an example of objective data because they are objectively measurable.

3. Which action reflects a primary task in the analysis step of the nursing process? Initiating nursing actions Forming diagnostic conclusions Identifying realistic patient goals Examining the effectiveness of interventions

Forming diagnostic conclusions - Nurses form diagnostic conclusions according to identified problems that reflect patient conditions requiring nursing care in the analysis step of the nursing process.

14. Which intervention reflects direct nursing care? Giving an injection Asking the health care provider to prescribe a special diet Documenting nursing interventions Working with a social worker to set up home care

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

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

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.

13. Which step of the nursing process involves carrying out nursing actions designed to meet a patient's unique needs? Planning Analysis Evaluation Implementation

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

2. Which statement defines collaborative interventions? Involve independent nursing interventions Establish the effectiveness of nursing actions Require a prescription from the health care provider Involve the expertise of health care team members

Involve the expertise of health care team members - Collaborative interventions are interdependent interventions that require the combined knowledge, skill, and expertise of multiple health care providers; tasks are coordinated with members of the health care team (ex: respiratory therapy).

3. Which questions are critical for the nurse to ask during each step in the nursing process? Select all that apply. Were patient goals met? Can interventions be universally applied? Is collected data thorough and accurate? Could interventions affect the patient negatively? Are all underlying factors addressed in the plan of care?

Is collected data thorough and accurate? Could interventions affect the patient negatively? Are all underlying factors addressed in the plan of care? READ CLOSELY

1. Which characteristics of the nursing process allow the nurse to effectively apply critical thinking to patient care? Select all that apply. It is organized. It is outcome-oriented. It necessitates observation skills. It allows nurses to apply knowledge. It requires nurses to think analytically. It incorporates an interprofessional team.

It is organized. It is outcome-oriented. It allows nurses to apply knowledge. It requires nurses to think analytically. It incorporates an interprofessional team.

11. During which step of the nursing process would the nurse establish long-term goals with the patient? Planning Analysis Evaluation Implementation

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.

12. which part of the nursing process involves the nurse setting short-term goals for the patient? Planning Diagnosis Evaluation Assessment

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

9. Which phrases describe the role of the International Classification for Nursing Practice (ICNP) in the nursing process? Select all that apply. Provides a standardized nursing language Outlines categories for patient information Categorizes priorities based on importance Identifies common labels for nursing diagnoses Provides point-of-care documentation for clinical activity

Provides a standardized nursing language Identifies common labels for nursing diagnoses Provides point-of-care documentation for clinical activity

2. Which critical-thinking functions must the nurse perform to effectively evaluate patient goals during the final step of the nursing process? Select all that apply. Recognizing errors Gathering patient cues Documenting patient progress Comparing achieved effect with goals Examining results according to clinical findings

Recognizing errors Comparing achieved effect with goals Examining results according to clinical findings -

5. Which type of data do the patient's family members, friends, or other nurses provide? Primary Objective Secondary Comprehensive

Secondary - Secondary data come from sources other than the patient.

18. Which questions would the nurse ask to evaluate the effectiveness of nursing interventions? Select all that apply. Should the plan of care be discontinued? Which nursing diagnosis covers this cluster of signs and symptoms? Have new assessment data been identified that should be considered? Did the patient meet the goals established during the implementation phase? Does the plan of care need to be modified in response to patient changes?

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? - Did the patient meet the goals established during the implementation phase? During the evaluation phase, nurses ask whether the patient met goals established during the planning phase, not the implementation phase. - Which nursing diagnosis covers this cluster of signs and symptoms? "Which nursing diagnosis covers this cluster of signs and symptoms?" is a good question for the analysis phase, not the evaluation phase.

1. Which component determines whether an assessment is primary or secondary? Source of data Types of data Categories of data Objectivity of the data

Source of data - The source of the data determines whether the assessment is primary (directly from a patient) or secondary (from other places).

1. Which aspect would the nurse consider as a component of the evaluation step of the nursing process? The patient being discharged from the hospital The patient's achievement of short- and long-term goals The nurse's completion of interventions in the plan of care The nurse's view on the patient's desire to perform interventions

The patient's achievement of short- and long-term goals - The evaluation phase is specifically when the nurse determines whether the patient's short- and long-term goals were met.

2. Which aspects do nurses make judgments about when determining initial nursing diagnoses? Select all that apply. Vulnerabilities Patient problems Health promotion Risk for problems Evaluative measures

Vulnerabilities Patient problems Health promotion Risk for problems - Nursing diagnoses reflect clinical judgments about health promotion.

3. Which questions would the nurse ask when revising the plan of care because of unmet patient goals? Select all that apply. Were the original goals realistic? What unanticipated events occurred? Were the original goals collaborative? What steps in the process can be handled differently? What barriers did the patient encounter that prevented goal attainment?

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? - Were the original goals collaborative? Determining whether goals were collaborative would not help in revising patient goals. A more appropriate question might be to ask if the goals should be collaborative to promote success.