answers
2 sources of data - CORRECT ANSWERS-primary & 2ndary
3 helpful guides in prioritizing needs - CORRECT ANSWERS-1-Maslow 2- Pt
preference what does the pt think is important 3-Anticipation or future problems
actual dx - CORRECT ANSWERS-Represents a problem that has been validated by the
presence of defining characteristics (signs and
symptoms).
clustering of data often contains - CORRECT ANSWERS-defining characteristics which
are specific assessment findings that support a
nursing diagnosis.
collect the data then BLANK the data - CORRECT ANSWERS-VALIDATE
‐Confirm and verify the information.
‐ Keep it free from errors, bias, or misinterpretation.
components of a correctly written goal - CORRECT ANSWERS-include expected
outcomes or
measurable criteria to evaluate the achievement of the goal.
Data is 1,2,3 - CORRECT ANSWERS-collected, validated, then clustered
define a goal - CORRECT ANSWERS-" a broad statement that describes the desired
change in a client's condition or behavior."
Define the nursing process - CORRECT ANSWERS-a systematic problem solving
approach toward providing individualized nursing care.
during the clustering of data what is used - CORRECT ANSWERS-critical thinking is
used to analyze and synthesize the information that is
collected. The data is then put into specific clusters that describe a specific client
problem.
, Emergency assessment - CORRECT ANSWERS-Performed to identify a life‐
threatening problem (choking, stab wound, heart attack).
focused assessment - CORRECT ANSWERS-Collects data about a problem that has
already been identified. This type of assessment determines whether
the problem still exists, or any changes.
focused assessment questions - CORRECT ANSWERS-‐ What are your symptoms?
‐ When did they start?
‐ What activity were you doing ?
‐ What makes it better or worse?
‐ What are you doing to relieve the symptom?
guidelines to remember when writing goals - CORRECT ANSWERS-1-client centered
2-singular 3-observable 4-measurable 5-time limited 6-mutual 7-realistic
health promotion dx - CORRECT ANSWERS-Clinical judgment of a person, family, or
community desire to enhance their well being and readiness to implement health
behaviors of a higher level. Ex. nutrition
how do you formulate a risk dx? what does a risk dx consist of? - CORRECT
ANSWERS-consist of a problem and the etiology only - there are NO signs & sypmtoms
because it hasn't happened yet
how do you formulate an actual nursing dx; what does it consist of - CORRECT
ANSWERS-A nursing diagnosis consists of 3 parts or what is referred to PES format:
P= Problem
E =Etiology
S =Signs and Symptoms
How does the nurse obtain assessment info? - CORRECT ANSWERS-1- initial (or
admission assessment) 2- focused assessment 3- emergency assesment
How does the nurse obtain assessment info? - CORRECT ANSWERS-past medical hx
- family hx - reason for admission - current meds - previous hospitalizations & surgeries
- psychosocial assessment - nutrition - complete physical assessment
identify how you develop a nursing diagnosis - CORRECT ANSWERS-As you cluster
data, you begin to consider various diagnoses that may relate to the client. You must
remember that if certain defining characteristics do not exist for a specific diagnosis,
then you must not use the diagnosis.
identify how you develop a nursing diagnosis (what is first / next etc) - CORRECT
ANSWERS-1. Complete thorough assessment of the patient.
2.Highlight or underline relevant symptoms (defining
characteristics).