NUR 155 Foundations to Nursing exam questions and answers 2023/24

What is the nursing process? Systematic, rational method of planning and proving individualized care. What do you do in the nursing process? 1. Assessing 2. Nursing Diagnosing 3. Planning 4. Implementing 5. Evaluating What is the Decision-Making Process? -Choosing the best actions to meet a desired goal -Make value decisions -Time management decisions -Scheduling decisions -Priority decisions The Nursing Process: Assessing -Collecting, organizing, validating and documenting a patient's health data -collect data -organize data -validate data -Document data The Nursing Process: Diagnosing -Analyze date -Identify health problems, risks, and strengths -formulate diagnostic statements The Nursing Process: Planning -Prioritize problems/diagnoses -Formulate goals/desired outcomes -Select nursing interventions -Write nursing interventions The Nursing Process: Implementing -Reassess the client -Determine the nurse's need for assistance -Implementing the nursing interventions -Supervise delegated care -Document nursing activités The Nursing Process: Evaluating -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 the client's care plan What is subjective? What the patient says Ex: "I have pain, nausea, fear" What is objective? -Measurable Ex: vital signs, labs, drainage, etc. Methods of data collection? -Observing -Interviewing Directive Approach to Interviewing? -Nurse establishes purpose -Nurse controls the interview -Used to gather and give information when time is limited, e.g., in an emergency Nondirective Approach to Interviewing -Rapport-building -Client controls the purpose, subject matter, and pacing -Combination of directive and nondirective approaches usually appropriate during the information-gathering interview Types of questions: Closed If you can answer a question with only a "yes" or "no" response, then you are answering a close-ended type of question. Examples of close-ended questions are: Are you feeling better today? May I use the bathroom? Is the prime rib a special tonight? Should I date him? Will you please do me a favor? Types of questions: Open Open-ended questions are ones that require more than one word answers. The answers could come in the form of a list, a few sentences or something longer such as a speech, paragraph or essay. Here are some examples of open-ended questions: What were the most important wars fought in the history of the United States? What are you planning to buy today at the supermarket? How exactly did the fight between the two of you start? Planning the Interview -Time -Place -Seating -Distance -Language What are the stages of an Interview? 1. The opening 2. The body of the interview 3. The closing What is a physical examination? -Use techniques of inspection, auscultation, palpation, and percussion -Systematic manner -Ongoing nursing data collection and examination focuses on the body systems in which there is a problem or potential problem The Nursing Process: Assessing (Organizing Data) -Systematically -Nursing health history, nursing assessment, or nursing data base -Differentiate normal from abnormal The Nursing Process: Assessing (Validating Data) -Assessment complete -Objective and related subjective data agree -Additional data overlooked -Differentiate between cues and inferences -Data that is extremely abnormal -Avoiding jumping to conclusions What is a nursing diagnoses? "...a clinical judgment about individual, family, or community responses to a actual or potential health problem/life processes. A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable." Types of nursing diagnoses -Actual -At-Risk -Health Promotion -Wellness Diagnoses -NANDA-I nursing diagnoses Types of nursing diagnoses: Actual diagnoses -An actual nursing diagnosis addresses an issue pertaining to the human response within the patient, family or community to a disease, life situation, or other health condition -Examples: Pain or Hypothermia Must be followed by defining characteristics or factors that relate to the "actual" portion of the diagnosis Types of nursing diagnoses: Risk Diagnoses -An at-risk nursing diagnosis encompasses potential or likely risk factors in which a patient is vulnerable to -Example: At risk of infection -Must be followed by the risk factors pertinent to the "at risk" portion of the diagnosis --Note that NANDA does not permit "at-risk" nursing diagnoses to be interchangeable with "actual" nursing diagnoses; for instance, it's not acceptable to swap out "pain" with "at-risk for pain" (NANDA International, n.d.) Types of nursing diagnoses: Health Promotion -Readiness for enhances family coping -A health promotion nursing diagnosis is a clinical judgment that encompasses a patient's desire and motivation for a readiness of enhanced state of health or factor that may lead to improved level -A health promotion nursing diagnosis does not require a current level of wellness -Example: Readiness for enhanced learning Types of nursing diagnoses: Wellness Wellness nursing diagnoses focus on the patient's progress or potential progress towards healthier behaviors rather than on a problem. They were created to remedy a situation in which only negative issues were addressed, leaving out diagnoses for patients in a healthy setting. A wellness diagnosis indicates a readiness to advance from the current level of health to a higher level. Components of a Nursing Diagnoses -Problem statement (diagnostic label) Describes the client's health problem or response Use of qualifiers -Etiology (related factors and risk factors) Identifies one or more probable causes of the health problem Do not use medical diagnosis Components of a Nursing Diagnoses Defining characteristics for actual problems Cluster of signs and symptoms indicate the presence of a particular diagnostic label Have signs and symptoms Constipation R/T medication use AEB infrequent passage of stool and hard, dry stool. Components of a Nursing Diagnoses Defining characteristics for risk problems For risk for nursing diagnoses have no signs/symptoms Factors that cause the client to be more vulnerable to the problem form the etiology or a risk for nursing diagnoses Risk for Infection R/T break in skin integrity. Differentiating Nursing Diagnosis from Medical Diagnosis -Nursing Diagnosis Nursing judgment Describes human response Changes as client responds -Medical Diagnosis Made by physician Disease process Stays the same Steps in Diagnostic Process 1. Analyzing Data -Compare data against standards -Cluster cues -Identify gaps and inconsistencies 2.Identifying health problems, risks, and strengths 3.Formulating diagnostic statements Writing Nursing Diagnoses -Basic Two-Part Statement (at risk) Problem (P) Etiology (E) -Basic Three-Part Statement (actual) Problem (P) Etiology (E) Signs and symptoms (S)