CH 16 Intro to the Nursing Process

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

evaluation

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

forming diagnostic conclusions

What is the order of the nursing process?

Assessment, diagnosis, planning, implementation, evaluation

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

American Nurses Association

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

Provides a standardized nursing language , identifies common labels for nursing diagnoses, provides point of care documentation for clinical activity

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

clustering patient data to identify patient problems

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

assessment

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

communicates patient problems

which function describes the primary purpose fro documenting nursing interventions?

facilitate communication

Which examples reflect subjective data?

feelings, symptoms, perceptions, health history

which statements reflect the nurse's role during the implantation step of the nursing process?

be accountable for safe practice, perform the steps of intervention accurately understand why an intervention is planned

Which nursing skill is essential to utilize throughout the nursing process?

critical thinking

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 patient's individual needs?

dynamic

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

evaluation

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

implementation

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, could inventions affect the patient negatively, are all underlying factors addressed in the plan of care

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

its organized, it is outcome oriented, it allows nurses to apply knowledge, it requires nurses to think analytically, it incorporates an inter-professional team

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

planning

during which step of the nursing process would the nurse prioritize nursing diagnosis?

planning

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

planning

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 achieved 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 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 barrier did the patient encounter that prevented goal attainment?


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