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NUR 155 Foundations To Nursing EXAM 2 – Questions With Verified Solutions

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NUR 155 Foundations To Nursing EXAM 2 – Questions With Verified Solutions

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NUR 155 Foundations To Nursing EXAM 2 – Questions
With Verified Solutions

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Terms in this set (163)



What is the nursing process? Systematic, rational method of planning and proving
individualized care.


What do you do in the nursing process? 1. Assessing
2. Nursing Diagnosing
3. Planning
4. Implementing
5. Evaluating


What is the Decision-Making Process? -Choosing the best actions to meet a desired goal


-Make value decisions
-Time management decisions
-Scheduling decisions
-Priority decisions

,The Nursing Process: Assessing -Collecting, organizing, validating and documenting a
patient's health data


-collect data
-organize data
-validate data
-Document data


The Nursing Process: Diagnosing -Analyze date
-Identify health problems, risks, and strengths
-formulate diagnostic statements


The Nursing Process: Planning -Prioritize problems/diagnoses
-Formulate goals/desired outcomes
-Select nursing interventions
-Write nursing interventions


The Nursing Process: Implementing -Reassess the client
-Determine the nurse's need for assistance
-Implementing the nursing interventions
-Supervise delegated care
-Document nursing activités


The Nursing Process: Evaluating -Collect data related to outcomes
-Compare data with outcomes
-Relate nursing actions to client goals/outcomes
-Draw conclusions about problem status
-Continue, modify, or terminate the client's care plan


What is subjective? What the patient says
Ex: "I have pain, nausea, fear"


What is objective? -Measurable
Ex: vital signs, labs, drainage, etc.

,Methods of data collection? -Observing
-Interviewing


Directive Approach to Interviewing? -Nurse establishes purpose


-Nurse controls the interview


-Used to gather and give information when time is
limited, e.g., in an emergency




Nondirective Approach to Interviewing -Rapport-building


-Client controls the purpose, subject matter, and pacing


-Combination of directive and nondirective approaches
usually appropriate during the information-gathering
interview


Types of questions: Closed If you can answer a question with only a "yes" or "no"
response, then you are answering a close-ended type
of question.


Examples of close-ended questions are:


Are you feeling better today?
May I use the bathroom?
Is the prime rib a special tonight?
Should I date him?
Will you please do me a favor?

, Types of questions: Open Open-ended questions are ones that require more than
one word answers. The answers could come in the form
of a list, a few sentences or something longer such as a
speech, paragraph or essay.


Here are some examples of open-ended questions:


What were the most important wars fought in the history
of the United States?
What are you planning to buy today at the
supermarket?
How exactly did the fight between the two of you start?


Planning the Interview -Time
-Place
-Seating
-Distance
-Language


What are the stages of an Interview? 1. The opening
2. The body of the interview
3. The closing


What is a physical examination? -Use techniques of inspection, auscultation, palpation,
and percussion


-Systematic manner


-Ongoing nursing data collection and examination
focuses on the body systems in which there is a
problem or potential problem


The Nursing Process: Assessing -Systematically
(Organizing Data)
-Nursing health history, nursing assessment, or nursing
data base


-Differentiate normal from abnormal

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