NUR 215 Fundamentals of Nursing |! |! |! |! |!
TEST 1 with verified solutions |! |! |! |!
Nursing Process - Correct answer ✔ADPIE; systemic problem solving process
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that guides all nursing actions
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Nursing Process Assessment - Correct answer ✔Use open ended questions to
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gather subjective data and look at lab tests and a physical assessment for
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objective data which you then cluster together to analyze
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CAN COME FROM OTHER HEALTHCARE PROVIDERS AND THEIR
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OBSERVATIONS AS WELL AS PATIENTS FAMILY |! |! |! |! |!
Nursing Process Diagnoses - Correct answer ✔What statement best fits the
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patients situation and leads us to the intervention phase where we can then
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pick interventions and create goals; diagnosis r/t aeb (PES; problem, etiology
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and symptoms)
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This is where you select a label with information of why you selected and the
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evidence you used to back it up
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Nursing Process Planning - Correct answer ✔Prioritize problems/diagnoses
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(ABC's) and then decide client specific outcomes you want, goals for the
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client to get them there and the interventions you as a nurse will take;
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SMART goals (Specific, Measurable, Attainable, Realistic, and timed)
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,Outcomes and interventions |! |!
Can use NOC list for outcomes or develop a appropriate outcome statement.
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Nursing Process Implementation - Correct answer ✔Phase where you put
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plan into action and involve delegation to other healthcare providers (CNA,
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PCT, PT, LPN, Speech Therapist, etc)
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MAKE SURE THE IMPLEMENTATIONS ARE AGREED UPON BY
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PATIENT AND FAMILY (if needed) |! |! |! |!
Nursing Process Evaluation - Correct answer ✔Did the goal fail or prosper? If
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the goal failed what contributed to the failure. Reassess and go back through
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ADPIE to make sure client care does not need to change.
|! |! |! |! |! |! |! |! |! |!
How to Prioritize Care - Correct answer ✔1. ABC's
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2. Hierarchy of needs
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3. Acute/Chronic
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Sources of Data - Correct answer ✔Subjective: Communicated by client
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Objective: Gathered through assessment/tests and can be observed by a nurse
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Primary: Objective/Subjective obtained from the client
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,Secondary: Secondhand; from a med record, family member, or other
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healthcare provider |!
Types of Assessment - Correct answer ✔Initial: Completed when client first
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walks in (static)
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Ongoing: Preformed as needed (dynamic)
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Comprehensive: Provides holistic data about patients overall health status |! |! |! |! |! |! |! |! |!
(observation, physical assessment and nursing interview |! |! |! |! |!
Focused assessment: preformed to obtain data about a problem with a
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specific body part or system (initial is used to followup with client complaints
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and ongoing is used to evaluate status of existing problems)
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Special Needs Assessment: Type of focused that provides in depth
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information about a particular area of client functioning
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Etiologies are always inferences b/c? - Correct answer ✔B/c you can never
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observe a link b/w etiology and problem
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Types of Planning - Correct answer ✔Formal: Conscious/deliberate critical
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thinking and ends in holistic care plan
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Informal: Occurs during other nursing processes
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, Discharge Planning: Process of planning for self-care and continuity of care
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after the patient leaves healthcare setting
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Critical Pathway - Correct answer ✔Outcome based, interdisciplinary plans
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that sequence patient care according to case type. (emphasis on med
|! |! |! |! |! |! |! |! |! |! |!
problems/interventions)
Integrated Plans of Care: Standardized plans that function as both care plan
|! |! |! |! |! |! |! |! |! |! |! |!
and documentation
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Types of Interventions - Correct answer ✔Direct-care: through interactions
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with client |!
Indirect: preformed away from the client but on behalf of them
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Independent: RN's are licsensed to prescribe, preform or delegate based on
|! |! |! |! |! |! |! |! |! |! |!
their knowledge|!
Dependent: Prescribed by a physician or advanced practice nurse but carried
|! |! |! |! |! |! |! |! |! |! |!
out by bedside nurse
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Collaborative (interdependent): Carried out in collab with other healthcare
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team members |!
TEST 1 with verified solutions |! |! |! |!
Nursing Process - Correct answer ✔ADPIE; systemic problem solving process
|! |! |! |! |! |! |! |! |! |!
that guides all nursing actions
|! |! |! |!
Nursing Process Assessment - Correct answer ✔Use open ended questions to
|! |! |! |! |! |! |! |! |! |! |!
gather subjective data and look at lab tests and a physical assessment for
|! |! |! |! |! |! |! |! |! |! |! |! |!
objective data which you then cluster together to analyze
|! |! |! |! |! |! |! |! |!
CAN COME FROM OTHER HEALTHCARE PROVIDERS AND THEIR
|! |! |! |! |! |! |! |!
OBSERVATIONS AS WELL AS PATIENTS FAMILY |! |! |! |! |!
Nursing Process Diagnoses - Correct answer ✔What statement best fits the
|! |! |! |! |! |! |! |! |! |! |!
patients situation and leads us to the intervention phase where we can then
|! |! |! |! |! |! |! |! |! |! |! |! |!
pick interventions and create goals; diagnosis r/t aeb (PES; problem, etiology
|! |! |! |! |! |! |! |! |! |! |!
and symptoms)
|!
This is where you select a label with information of why you selected and the
|! |! |! |! |! |! |! |! |! |! |! |! |! |!
evidence you used to back it up
|! |! |! |! |! |! |!
Nursing Process Planning - Correct answer ✔Prioritize problems/diagnoses
|! |! |! |! |! |! |! |!
(ABC's) and then decide client specific outcomes you want, goals for the
|! |! |! |! |! |! |! |! |! |! |! |!
client to get them there and the interventions you as a nurse will take;
|! |! |! |! |! |! |! |! |! |! |! |! |! |!
SMART goals (Specific, Measurable, Attainable, Realistic, and timed)
|! |! |! |! |! |! |!
,Outcomes and interventions |! |!
Can use NOC list for outcomes or develop a appropriate outcome statement.
|! |! |! |! |! |! |! |! |! |! |!
Nursing Process Implementation - Correct answer ✔Phase where you put
|! |! |! |! |! |! |! |! |! |!
plan into action and involve delegation to other healthcare providers (CNA,
|! |! |! |! |! |! |! |! |! |! |!
PCT, PT, LPN, Speech Therapist, etc)
|! |! |! |! |! |!
MAKE SURE THE IMPLEMENTATIONS ARE AGREED UPON BY
|! |! |! |! |! |! |! |!
PATIENT AND FAMILY (if needed) |! |! |! |!
Nursing Process Evaluation - Correct answer ✔Did the goal fail or prosper? If
|! |! |! |! |! |! |! |! |! |! |! |!
the goal failed what contributed to the failure. Reassess and go back through
|! |! |! |! |! |! |! |! |! |! |! |! |! |!
ADPIE to make sure client care does not need to change.
|! |! |! |! |! |! |! |! |! |!
How to Prioritize Care - Correct answer ✔1. ABC's
|! |! |! |! |! |! |! |!
2. Hierarchy of needs
|! |! |!
3. Acute/Chronic
|!
Sources of Data - Correct answer ✔Subjective: Communicated by client
|! |! |! |! |! |! |! |! |!
Objective: Gathered through assessment/tests and can be observed by a nurse
|! |! |! |! |! |! |! |! |! |! |!
Primary: Objective/Subjective obtained from the client
|! |! |! |! |!
,Secondary: Secondhand; from a med record, family member, or other
|! |! |! |! |! |! |! |! |! |!
healthcare provider |!
Types of Assessment - Correct answer ✔Initial: Completed when client first
|! |! |! |! |! |! |! |! |! |! |!
walks in (static)
|! |!
Ongoing: Preformed as needed (dynamic)
|! |! |! |!
Comprehensive: Provides holistic data about patients overall health status |! |! |! |! |! |! |! |! |!
(observation, physical assessment and nursing interview |! |! |! |! |!
Focused assessment: preformed to obtain data about a problem with a
|! |! |! |! |! |! |! |! |! |! |!
specific body part or system (initial is used to followup with client complaints
|! |! |! |! |! |! |! |! |! |! |! |!
and ongoing is used to evaluate status of existing problems)
|! |! |! |! |! |! |! |! |! |!
Special Needs Assessment: Type of focused that provides in depth
|! |! |! |! |! |! |! |! |! |!
information about a particular area of client functioning
|! |! |! |! |! |! |!
Etiologies are always inferences b/c? - Correct answer ✔B/c you can never
|! |! |! |! |! |! |! |! |! |! |! |!
observe a link b/w etiology and problem
|! |! |! |! |! |!
Types of Planning - Correct answer ✔Formal: Conscious/deliberate critical
|! |! |! |! |! |! |! |! |!
thinking and ends in holistic care plan
|! |! |! |! |! |!
Informal: Occurs during other nursing processes
|! |! |! |! |!
, Discharge Planning: Process of planning for self-care and continuity of care
|! |! |! |! |! |! |! |! |! |! |!
after the patient leaves healthcare setting
|! |! |! |! |!
Critical Pathway - Correct answer ✔Outcome based, interdisciplinary plans
|! |! |! |! |! |! |! |! |!
that sequence patient care according to case type. (emphasis on med
|! |! |! |! |! |! |! |! |! |! |!
problems/interventions)
Integrated Plans of Care: Standardized plans that function as both care plan
|! |! |! |! |! |! |! |! |! |! |! |!
and documentation
|!
Types of Interventions - Correct answer ✔Direct-care: through interactions
|! |! |! |! |! |! |! |! |!
with client |!
Indirect: preformed away from the client but on behalf of them
|! |! |! |! |! |! |! |! |! |!
Independent: RN's are licsensed to prescribe, preform or delegate based on
|! |! |! |! |! |! |! |! |! |! |!
their knowledge|!
Dependent: Prescribed by a physician or advanced practice nurse but carried
|! |! |! |! |! |! |! |! |! |! |!
out by bedside nurse
|! |! |!
Collaborative (interdependent): Carried out in collab with other healthcare
|! |! |! |! |! |! |! |! |!
team members |!
