What are the steps in a nursing process? - ANS✔✔ Assess, Diagnose, Plan, Implement, Evaluate
Once a nurse accesses a client's condition and identifies appropriate nursing diagnosis, a
A. Plan is developed for nursing care
B. Physical assessment begins
C. List of priorities is determined
D. Review of assessment is conducted with other team members - ANS✔✔ A. Plan is developed
for nursing care
Planning is a category of nursing behaviors in which:
A. The nurse determines the health care needed for the client
B. The Physcian determines the plan of care for the client
C. Client-centered goals and expected outcomes are established
D. The client determines the care needed - ANS✔✔ C. Client-centered goals and expected
outcomes are established
Priorities are establish to help the nurse anticipate and sequence nursing interventions when a
client has multiple problesm or alterations. Priorities are determined by the clinet's:
A. Physician
B. Non Emergent, non-life threatening needs
C. Future well-being
D. Urgency of problems - ANS✔✔ D. Urgency of problems
A client centered goal is a specific and measurable behavior or resposne that reflects a client's:
A. Desire for specifc helath care interventions
,B. Highest possible level of wellness and independence in function
C. Physican's goal for the specific client
D. Response when compared to another client with a like problem - ANS✔✔ B. Highest possible
level of wellness and independence in function
Collaborative interventions are therapies that require:
A. Physician and nurse interventions
B. Nurse and client interventions
C. Client and Physician intervention
D. Multiple health care professionals - ANS✔✔ D. Multiple health care professionals
Well formulate - ANS✔✔
Nursing process - ANS✔✔ a systematic problem solving process that guides all nursing actions
Assessment - ANS✔✔ the systematic gathering of information related to the physiological,
psychiological, sociocultural, devlopmental, and spiritual status of an individual, group, or
community.
What is the purpose of an assessment? - ANS✔✔ obtain data to allow you to help the patient
Where do we get Primary sources from? - ANS✔✔ Subjective and Objective
Where do we get secondary sources from? - ANS✔✔ Family/friends, health record, healthcare
team
Subjective Data (Client States)
, Objective Data (Nurse observes) - ANS✔✔ "My throat hurts when i swallow"
"Our children have no place to go after football games. That is why they get into so much
trouble"
White patches noted at the back of the throat and tonsillar area reddened and swollen
In a windshield survey, no public facility was open after football games to allow young people to
socialize under supervision
Primary source ( Client states or Nurse Observes)
Secondarysource (everything else) - ANS✔✔ "My heart feels like it's beating fast"
"I am feeling short of breath at night"
-EKG: Sinus tachycardia rate of 200 beats/min
-In transfer report, nurse states client is on oxygen at night for dyspnea
Who is responsible for assessment of a client?
Nurse
LPN
AIDE - ANS✔✔ Nurse
What activities can a LPN, and Aide do? Select all
A. Assessment
B. Vital signs