Fundamentals of Nursing, Nursing Process Exam 2 Questions With Correct Answers

Fundamentals of Nursing, Nursing Process Exam 2 Questions With Correct Answers What is the nursing process? - answerA cyclical, critical thinking process that consists of five steps to follow in a purposeful, goal directed, systematic way to achieve optimal client outcomes 1)Assessment/data collection - answerInvolves systematic collection of information about clients' present health status to identify needs and additional data during an initial assessment, focused assessment and ongoing assessments What are methods of data collection? - answer-Observation -Interviews with clients and families -Medical history -Comprehensive or focused physical examination -Diagnostic and laboratory reports, and collaboration with other members of the health care team How do you collect data effectively? - answer-Nurses must ask clients appropriate questions -Listen carefully to responses -Have excellent head-to-toe physical assessment skills -Employ clinical judgment and critical thinking in accurately recognizing when to collect assessment data prior to interventions What is subjective data? - answerClients: -Feelings -Perceptions -Description of health status -Clients are the only ones who can describe and verify their own symptoms What is objective data? - answer-Nurses observe and measure objective data during a physical examination -They see, feel, hear and smell objective data through observation or physical assessment of the client 2)Analysis/data collection - answer-Nurses use critical thinking skills to identify clients' health status or problems, interpret or monitor the collected database, reach an appropriate nursing judgment about health status and coping mechanisms, and provide direction for nursing care -Complete and accurate documentation is essential, documentation should focus on facts and should be highly descriptive Analysis/data collection requires nurses to look at the data and... - answer-Recognize patterns or trends -Compare the data with expected standards or reference ranges -Arrive at conclusions to guide nursing care 3)Planning - answer-When planning client care or contributing to a clients' care plan, nurses must establish priorities and optimal outcomes of care they can readily measure and evaluate -These established priorities and outcomes of client care then direct nurses in selecting interventions to include in the plan of care to promote, maintain or restore health What are the 3 types of planning nurses do? - answer-Develop a comprehensive plan of care for clients based on comprehensive assessments they complete -Ongoing planning throughout the provision of care. While obtaining new information and evaluating responses to care, they modify and individualize the initial plan of care -Discharge planning is a process of anticipating and planning for clients' needs after discharge. To be effective, discharge planning must begin during admission What do nurses do throughout the planning process? - answer-Set priorities -Determine client outcomes -Select specific nursing interventions What can nurses use as a guideline to set priorities? - answerMaslow's hierarchy of basic needs: 1) Self-actualization 2) Self-esteem