ULL Nursing 204 Exam 2 Questions
with Verified Solutions Scored A+
ANA Scope and Standards of Practice Standard 1. Assessment - CORRECT ANSWER-
The RN collects pertinent data and information relative to the healthcare consumer's
health or the situation.
ANA Scope and Standards of Practice Standard 2. Diagnosis - CORRECT ANSWER-
The RN analyzes assessment data to determine actual or potential diagnoses,
problems, and issues
ANA Scope and Standards of Practice Standard 3. Outcome identification - CORRECT
ANSWER-The RN identifies expected outcomes for a plan individualized to the
healthcare consumer or the situation
ANA Scope and Standards of Practice Standard 4. Planning - CORRECT ANSWER-
The RN develops a plan that prescribes strategies to attain expected, measurable
outcomes
ANA Scope and Standards of Practice Standard 5. Implementation - CORRECT
ANSWER-The RN implements the identified plan.
•5A Coordination of Care
5B Health Teaching and Health Promotion
ANA Scope and Standards of Practice Standard 6. Evaluation - CORRECT ANSWER-
The RN evaluates progress toward attainment of goals and outcomes
Nursing Process - CORRECT ANSWER-Dynamic, systematic clinical management tool:
,The primary means of directing the sequence, planning, implementation, and evaluation
of nursing care to achieve specific health goals.
communication plays a major role in the Nursing Process - CORRECT ANSWER-
•Establish & maintain a therapeutic relationship
•Promote, maintain, or restore health, or facilitate a peaceful death
•Manage difficult health care issues
•Provide quality nursing care that is safe and efficient
ADPIE - Nursing Process - CORRECT ANSWER-These phases/steps - flexible &
overlapping
•Because of this - can be modified at any phase
•Starts with first encounter
•Ends with Discharge or Referral/Transfer off unit/Death
Communication is used for all phases/steps.
Assessment - CORRECT ANSWER-Collection, Analysis & Verification of information (is
ongoing)
•Begins: first encounter between nurse & patient/family
•Next step: obtain information about the patient's current and past problems. The entire
experiences are questioned.
********If the current situation changes -
DO ANOTHER ASSESSMENT!
Find out what is going on!
•Ends: with discharge or referral
Assessment-collecting data - CORRECT ANSWER-•History/Interview Patient
,•Past records & tests
•Other members of Health Care Team
•Family
•Nurse's own observations; Physical Exam
•Current tests, measurements
NOTE: strengths, limitations, resources available and changes in
condition or status.
Analysis of collected data - CORRECT ANSWER-*Analyze Data: organizes cluster
behaviors
*Make inferences on the Subjective & the Objective data.
*Combine with personal and scientific nursing knowledge.
-Question to ask: What do I think is going on based on the data I collected?
verification of collected data - CORRECT ANSWER-Ensure validity by verifying the data
and the inferences with the patient.
•?? Is the information I gathered correct ??
Subjective (Stated) data - CORRECT ANSWER-•patient's perception of data & what
patient or family says about the data
Document: Patient states, "..."
Objective (observed) data - CORRECT ANSWER-•data directly observed or verified
through physical exam or tests
Document in specific measurable terms
, Diagnosis - CORRECT ANSWER-Identify health care needs/problems & formulates a
biopsychosocial statement
Analyze assessment information obtained
Identify gaps
•Compare against normal health standards
•Look for functional vs. dysfunctional patterns
-Normal functioning vs. abnormal functioning
-Emotional and/or physically
-Possibly related to disease or impairment
*Formulate appropriate Nursing Diagnoses
Comprehensive Biopsychosocial Statement - CORRECT ANSWER-*critical component
in the nursing process
*captures the essence of the patient's health care needs/problems
•Developed & prioritized based on the patient's most immediate needs in the current
health care situation.
•Describes the patient's human responses to health issues & medical diagnoses.
NANDA nursing diagnosis defined - CORRECT ANSWER-*A clinical judgment about
individual, family or community responses to actual or potential health problems/ life
processes.
*Nursing diagnosis provide the basis for selection of nursing interventions to achieve
outcomes for which the nurse has accountability
with Verified Solutions Scored A+
ANA Scope and Standards of Practice Standard 1. Assessment - CORRECT ANSWER-
The RN collects pertinent data and information relative to the healthcare consumer's
health or the situation.
ANA Scope and Standards of Practice Standard 2. Diagnosis - CORRECT ANSWER-
The RN analyzes assessment data to determine actual or potential diagnoses,
problems, and issues
ANA Scope and Standards of Practice Standard 3. Outcome identification - CORRECT
ANSWER-The RN identifies expected outcomes for a plan individualized to the
healthcare consumer or the situation
ANA Scope and Standards of Practice Standard 4. Planning - CORRECT ANSWER-
The RN develops a plan that prescribes strategies to attain expected, measurable
outcomes
ANA Scope and Standards of Practice Standard 5. Implementation - CORRECT
ANSWER-The RN implements the identified plan.
•5A Coordination of Care
5B Health Teaching and Health Promotion
ANA Scope and Standards of Practice Standard 6. Evaluation - CORRECT ANSWER-
The RN evaluates progress toward attainment of goals and outcomes
Nursing Process - CORRECT ANSWER-Dynamic, systematic clinical management tool:
,The primary means of directing the sequence, planning, implementation, and evaluation
of nursing care to achieve specific health goals.
communication plays a major role in the Nursing Process - CORRECT ANSWER-
•Establish & maintain a therapeutic relationship
•Promote, maintain, or restore health, or facilitate a peaceful death
•Manage difficult health care issues
•Provide quality nursing care that is safe and efficient
ADPIE - Nursing Process - CORRECT ANSWER-These phases/steps - flexible &
overlapping
•Because of this - can be modified at any phase
•Starts with first encounter
•Ends with Discharge or Referral/Transfer off unit/Death
Communication is used for all phases/steps.
Assessment - CORRECT ANSWER-Collection, Analysis & Verification of information (is
ongoing)
•Begins: first encounter between nurse & patient/family
•Next step: obtain information about the patient's current and past problems. The entire
experiences are questioned.
********If the current situation changes -
DO ANOTHER ASSESSMENT!
Find out what is going on!
•Ends: with discharge or referral
Assessment-collecting data - CORRECT ANSWER-•History/Interview Patient
,•Past records & tests
•Other members of Health Care Team
•Family
•Nurse's own observations; Physical Exam
•Current tests, measurements
NOTE: strengths, limitations, resources available and changes in
condition or status.
Analysis of collected data - CORRECT ANSWER-*Analyze Data: organizes cluster
behaviors
*Make inferences on the Subjective & the Objective data.
*Combine with personal and scientific nursing knowledge.
-Question to ask: What do I think is going on based on the data I collected?
verification of collected data - CORRECT ANSWER-Ensure validity by verifying the data
and the inferences with the patient.
•?? Is the information I gathered correct ??
Subjective (Stated) data - CORRECT ANSWER-•patient's perception of data & what
patient or family says about the data
Document: Patient states, "..."
Objective (observed) data - CORRECT ANSWER-•data directly observed or verified
through physical exam or tests
Document in specific measurable terms
, Diagnosis - CORRECT ANSWER-Identify health care needs/problems & formulates a
biopsychosocial statement
Analyze assessment information obtained
Identify gaps
•Compare against normal health standards
•Look for functional vs. dysfunctional patterns
-Normal functioning vs. abnormal functioning
-Emotional and/or physically
-Possibly related to disease or impairment
*Formulate appropriate Nursing Diagnoses
Comprehensive Biopsychosocial Statement - CORRECT ANSWER-*critical component
in the nursing process
*captures the essence of the patient's health care needs/problems
•Developed & prioritized based on the patient's most immediate needs in the current
health care situation.
•Describes the patient's human responses to health issues & medical diagnoses.
NANDA nursing diagnosis defined - CORRECT ANSWER-*A clinical judgment about
individual, family or community responses to actual or potential health problems/ life
processes.
*Nursing diagnosis provide the basis for selection of nursing interventions to achieve
outcomes for which the nurse has accountability
