The Nursing Process Glossary Terms From All
Chapters In The Nursing Process Unit / Study
Guide
What are the 5 steps to the nursing process? Correct Answer -
1. Assessing
2. Diagnosing
3. Planning
4. Implementing
5. Evaluating
Assessing Correct Answer - - collect data
- organize data
- validate data
- document data
Diagnosing Correct Answer - - Analyze data
- Identify health problems, risks and strengths
- Formulate diagnostic statements
Planning Correct Answer - - Prioritize problem/diagnoses
- Formulate goals/desired outcomes
- Select nursing interventions
- Write nursing interventions
Implementing Correct Answer - - Reassess the client
- Determine nurse's need for assistance
- Implement the nursing interventions
- Supervise delegated care
- Document nursing activities
Evaluating Correct Answer - - 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 clients care plan
Characteristics of the nursing process Correct Answer - - Cyclic
and dynamic rather than static
- Client centered: patient advocate *
- Problem-solving and systems theory (systematic) *
- Decision making
- Interpersonal and collaborative
- Universal applicability
- Critical thinking skills
- Components may overlap, but follow order: ASSESSMENT-
DIAGNOSING-PLANNING-IMPLEMENTING-EVALUATING *
- Joint function of nurse & patient *
An essential concept related to understanding the nursing process is
that it:
A. is dynamic rather than static
B. focuses on the role of the nurse
C. is based on the patient's medical problem
D. is used by all allied health professionals Correct Answer - A.
is dynamic rather than static
A nursing student is learning the application of the nursing process
to client care. Why use the nursing process?
A. Includes the disease the client has during treatment of care
B. Helps other health professionals understand the plan of care
C. Helps standardize care for all clients
D. Describes client problems that nurses are licensed to treat
Correct Answer - D. Describes client problems that nurses are
licensed to treat
,Guidelines for Writing Nursing Care Plans Correct Answer - -
Be specific
- Tailor the plan to the client
- Incorporate prevention and health maintenance
- Include ongoing assessment
- Include collaborative and coordination activities (other disciplines
- PT)
- Include discharge planning and home care needs (starts on
admission***)
Standardized Approaches to Care Planning Correct Answer - -
standing order
- protocols
- policies & procedures
- standardized care plans
Standing order Correct Answer - Nurses have authority to
carry out certain actions under certain circumstances (ie-
hyoglycemia)
Protocols Correct Answer - Actions commonly required for
particular group of clients (ie-epidural analgesia)
Policies & procedures Correct Answer - Govern handling of
frequently occurring situations (ie-visiting policy)
Ex. Giving morphine
Standardized care plans Correct Answer - - Pre-developed
guides; what care the client can expect
- Part of permanent medical record
- Detailed interventions from standards of care of agency
- Problem-goals/desired outcomes-nursing interventions-evaluation
- May be individualized
, What is the primary goal of assessment? Correct Answer -
Collect & cluster (group) data
Types of data in assessment Correct Answer - - Subjective:
client states ..."phrase"
- Objective: can be seen, heard, felt, smelled or measured
Subjective data Correct Answer - - Symptoms or covert data
- Apparent only to the person affected
- Can be described only by person affected
- Patient QUOTE
What does subjective data include? Correct Answer - Includes:
sensations, feelings, values, beliefs, attitudes, and perception of
personal health status and life situations
Objective Data Correct Answer - - Signs or overt data
- Detectable by an observer
- Can be measured or tested against an accepted standard
- Can be seen, heard, felt, or smelled
How is objective data obtained? Correct Answer - - Obtained
through observation or physical examination
Which of the following is an example of objective data?
Client ate 50% of lunch.
Client states, "I feel chilled."
Client states, "I need to go to the bathroom."
Client states,"I have no appetite." Correct Answer - Client ate
50% of lunch.
Collecting Data Correct Answer - - Gathering information
about a client's health status
Chapters In The Nursing Process Unit / Study
Guide
What are the 5 steps to the nursing process? Correct Answer -
1. Assessing
2. Diagnosing
3. Planning
4. Implementing
5. Evaluating
Assessing Correct Answer - - collect data
- organize data
- validate data
- document data
Diagnosing Correct Answer - - Analyze data
- Identify health problems, risks and strengths
- Formulate diagnostic statements
Planning Correct Answer - - Prioritize problem/diagnoses
- Formulate goals/desired outcomes
- Select nursing interventions
- Write nursing interventions
Implementing Correct Answer - - Reassess the client
- Determine nurse's need for assistance
- Implement the nursing interventions
- Supervise delegated care
- Document nursing activities
Evaluating Correct Answer - - 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 clients care plan
Characteristics of the nursing process Correct Answer - - Cyclic
and dynamic rather than static
- Client centered: patient advocate *
- Problem-solving and systems theory (systematic) *
- Decision making
- Interpersonal and collaborative
- Universal applicability
- Critical thinking skills
- Components may overlap, but follow order: ASSESSMENT-
DIAGNOSING-PLANNING-IMPLEMENTING-EVALUATING *
- Joint function of nurse & patient *
An essential concept related to understanding the nursing process is
that it:
A. is dynamic rather than static
B. focuses on the role of the nurse
C. is based on the patient's medical problem
D. is used by all allied health professionals Correct Answer - A.
is dynamic rather than static
A nursing student is learning the application of the nursing process
to client care. Why use the nursing process?
A. Includes the disease the client has during treatment of care
B. Helps other health professionals understand the plan of care
C. Helps standardize care for all clients
D. Describes client problems that nurses are licensed to treat
Correct Answer - D. Describes client problems that nurses are
licensed to treat
,Guidelines for Writing Nursing Care Plans Correct Answer - -
Be specific
- Tailor the plan to the client
- Incorporate prevention and health maintenance
- Include ongoing assessment
- Include collaborative and coordination activities (other disciplines
- PT)
- Include discharge planning and home care needs (starts on
admission***)
Standardized Approaches to Care Planning Correct Answer - -
standing order
- protocols
- policies & procedures
- standardized care plans
Standing order Correct Answer - Nurses have authority to
carry out certain actions under certain circumstances (ie-
hyoglycemia)
Protocols Correct Answer - Actions commonly required for
particular group of clients (ie-epidural analgesia)
Policies & procedures Correct Answer - Govern handling of
frequently occurring situations (ie-visiting policy)
Ex. Giving morphine
Standardized care plans Correct Answer - - Pre-developed
guides; what care the client can expect
- Part of permanent medical record
- Detailed interventions from standards of care of agency
- Problem-goals/desired outcomes-nursing interventions-evaluation
- May be individualized
, What is the primary goal of assessment? Correct Answer -
Collect & cluster (group) data
Types of data in assessment Correct Answer - - Subjective:
client states ..."phrase"
- Objective: can be seen, heard, felt, smelled or measured
Subjective data Correct Answer - - Symptoms or covert data
- Apparent only to the person affected
- Can be described only by person affected
- Patient QUOTE
What does subjective data include? Correct Answer - Includes:
sensations, feelings, values, beliefs, attitudes, and perception of
personal health status and life situations
Objective Data Correct Answer - - Signs or overt data
- Detectable by an observer
- Can be measured or tested against an accepted standard
- Can be seen, heard, felt, or smelled
How is objective data obtained? Correct Answer - - Obtained
through observation or physical examination
Which of the following is an example of objective data?
Client ate 50% of lunch.
Client states, "I feel chilled."
Client states, "I need to go to the bathroom."
Client states,"I have no appetite." Correct Answer - Client ate
50% of lunch.
Collecting Data Correct Answer - - Gathering information
about a client's health status
