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Nursing Process Exam 1

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Diagnostic Reasoning happens in the format of? - ansAssessment Data, Clustering Data, Identifying Inconsistencies, Draw Conclusions During assessment what should the nurse look for when collecting data? - ansDiscrepancies Excoriation is? - ansThe breakdown of tissue due to compacted fecal matter. Guidelines for delegation are set by what act in Oklahoma? - ansOklahoma Nurse Practice Act How is assessment relevant to the rest of the nursing process? - ansIt is the foundation for the remainder of the process, it provides data needed to identify actual or potential health problems. Nursing diagnosis focuses on? - anssigns and symptoms, effects of disease Older adults (65+ y/o) have a higher risk for what accidental injury? - ansFalls Once a patient has had a fall they are? - ansAutomatically at risk for a fall Personal hygiene is influenced by? - ansPersonal Preference, Culture and Religion, Economic Status, Developmental level, and Knowledge Safety is part of the _________ level of Maslow's Hierarchy of Needs. - ansPhysiologic Syndrome diagnosis is a diagnosis that involves? - ansA series of Dx. that usually occur together The comprehensive assessment is composed of 3 points, they are? - ansObservation, Physical Exam, and Nursing interview The most basic need in Maslow's Hierarchy is? - ansPhysiologic The most prevalent cause of accidental death in the U.S. across the lifespan is? - ansMVC ( motor vehicle crash) What are 4 features common to the assessment process? - anscollecting data, ongoing and systematic, categorization of data, recording data What are the 4 common assessment techniques? - ansInspection, Palpation, Percussion, Auscultation What are the 5 types of nursing diagnoses? - ansRisk (potential), Actual, Possible, Wellness, and Syndrome What are the four types of data sources? - ansprimary, secondary, subjective, objective. What is Maslow's Hierarchy of needs? - ansnon-nursing model that is holistic based used to help prioritize data collected. What is the basic format for a diagnosis statement? - ansP.E.S. (Problem r/t Etiology as evidenced by S/S) What is the purpose of a nursing assessment? - ansTo collect data relevant to delivering nursing care.

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Nursing Process Exam 1
A medical diagnosis focuses on the__________ of the disease. - ansPathophysiology



A wellness diagnosis is used when there is no present illness but, the pt. is? - ansReady to move to a new level
of wellness



ADL's promote what for a patient? - ansSelf-esteem, Independence, Promote increased activity



ADPIE is the step by step clinical layout of the nursing process, it consists of? - ansAssessment, Diagnosis,
Planning Interventions, Implementation, and Evaluating Outcomes.



An actual diagnosis is/ - ansThe problem that exists



Chain of Infection is a continuous cycle, the levels include? - ansInfectious agent, Reservoir, Portal of Exit, Mode
of Transmission, Portal of Entry, Susceptible Host



Define a Possible Diagnosis. - ansit is when intuition leads the nurse to suspect a problem



Define a Risk Diagnosis. - ansis an evaluation of a problem that could happen, also known as a potential
diagnosis.



Define Etiology. - ans- Cause of the Problem



Define objective data. - ansIt is information gathered through your 5 senses.



Define primary data. - ansComes directly from the source.



Define subjective data. - ansIt is information gathered directly from the pt.

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