283 exam 1
what are the steps in the nursing process - correct answer assessment, diagnosis, outcome identification,
planning, implementation, evaluation
what is the nursing process by def - correct answer The nursing process is a method of organizing and
delivering appropriate nursing care to a client
what is the function of nursing - correct answer Diagnosis and Treatment of Human Responses to Actual
or Potential Health Problems including Physical, Psychosocial, Spiritual & Health Promotion.
what do written guides for patient care include? - correct answer Nursing Diagnoses
Goals/Expected Outcomes
Specific Interventions
Evaluation
what is the purpose of written guides for patient care? - correct answer -Promote Continuity of Care
-Outcome Criteria for Evaluation
what is the primary source in assessment? - correct answer patient
what is the secondary source of assessment - correct answer family, health professionals
What does assessment include? - correct answer •evaluating the patients condition by collecting and
verifying data from the
primary source and secondary sources
what is the purpose of assessment - correct answer is to Establish a Database, baseline
,what is in the baseline information of assessment - correct answer subjective (patients perspective)
objective (observation/measurment you make, EX: vital signs)
ROS - correct answer review of systems
what is included in data collection in assessment? - correct answer •Interview and health history
•Physical Examination
•Observation of client's behavior
•Diagnostic and Laboratory data
•Medical Record
what is group data - correct answer asking other nurses for what they think, this can be logical and
organized
why do you classify and organize data? - correct answer to provide a framework for developing individual
nursing diagnosis
what is the final step in assessment - correct answer documentation
What does NANDA stand for? - correct answer North American Nursing Diagnosis Association
what is the def of nursing diagnosis - correct answer Clinical Judgment about Individual, Family, or
Community Responses to Actual and Potential Problems or Life Process
what is included in life processes - correct answer PHYSICAL; PSYCHO-SOCIAL; SPIRITUAL
what do you identify in a nursing diagnosis - correct answer a disease /condition based on a specific
evaluation of signs based on a specific evaluation of S/Sx ; HISTORY; DIAGNOSTIC PROCEDURES
, what are the steps in data analysis during nursing diagnosis - correct answer 1. Recognize pattern
(CLUSTER OF CUES OR DEFINING CHARACTERISTICS
EX: Unable to Turn)
2. Compare with Normal Standards(ARE SIGNS/SYMPTOMS NORMAL FOR THIS PATIENT
Ex: Can Turn Self)
3. Make a Connection to cause, body system, situation (Identify Patterns of Clustering to Determine if
Client Centered Needs Emerge EX: stage 1 skin pressure ulcer)
what are the 4 types of nursing diagnosis - correct answer 1.Actual
2.Potential = at risk for
3.Possible (I added)
4.Health-promotion
s/sx - correct answer signs and symptoms
what are the three parts of actual nursing diagnosis - correct answer •NANDA: diagnostic label
•Etiology (possible cause): "related to" (R/T)
•Signs and symptoms: "as evidenced by" (AEB)
Etiology - correct answer cause of disease
what is the planning part of the nursing process - correct answer The development of an individualized
plan of care
what is the planning portion of nursing process based on - correct answer on assessment and nursing
diagnosis
what do you do during nursing process of the planning step - correct answer -Determine Immediate
Priorities
-Establish Goals of Care / Expected -Outcomes
what are the steps in the nursing process - correct answer assessment, diagnosis, outcome identification,
planning, implementation, evaluation
what is the nursing process by def - correct answer The nursing process is a method of organizing and
delivering appropriate nursing care to a client
what is the function of nursing - correct answer Diagnosis and Treatment of Human Responses to Actual
or Potential Health Problems including Physical, Psychosocial, Spiritual & Health Promotion.
what do written guides for patient care include? - correct answer Nursing Diagnoses
Goals/Expected Outcomes
Specific Interventions
Evaluation
what is the purpose of written guides for patient care? - correct answer -Promote Continuity of Care
-Outcome Criteria for Evaluation
what is the primary source in assessment? - correct answer patient
what is the secondary source of assessment - correct answer family, health professionals
What does assessment include? - correct answer •evaluating the patients condition by collecting and
verifying data from the
primary source and secondary sources
what is the purpose of assessment - correct answer is to Establish a Database, baseline
,what is in the baseline information of assessment - correct answer subjective (patients perspective)
objective (observation/measurment you make, EX: vital signs)
ROS - correct answer review of systems
what is included in data collection in assessment? - correct answer •Interview and health history
•Physical Examination
•Observation of client's behavior
•Diagnostic and Laboratory data
•Medical Record
what is group data - correct answer asking other nurses for what they think, this can be logical and
organized
why do you classify and organize data? - correct answer to provide a framework for developing individual
nursing diagnosis
what is the final step in assessment - correct answer documentation
What does NANDA stand for? - correct answer North American Nursing Diagnosis Association
what is the def of nursing diagnosis - correct answer Clinical Judgment about Individual, Family, or
Community Responses to Actual and Potential Problems or Life Process
what is included in life processes - correct answer PHYSICAL; PSYCHO-SOCIAL; SPIRITUAL
what do you identify in a nursing diagnosis - correct answer a disease /condition based on a specific
evaluation of signs based on a specific evaluation of S/Sx ; HISTORY; DIAGNOSTIC PROCEDURES
, what are the steps in data analysis during nursing diagnosis - correct answer 1. Recognize pattern
(CLUSTER OF CUES OR DEFINING CHARACTERISTICS
EX: Unable to Turn)
2. Compare with Normal Standards(ARE SIGNS/SYMPTOMS NORMAL FOR THIS PATIENT
Ex: Can Turn Self)
3. Make a Connection to cause, body system, situation (Identify Patterns of Clustering to Determine if
Client Centered Needs Emerge EX: stage 1 skin pressure ulcer)
what are the 4 types of nursing diagnosis - correct answer 1.Actual
2.Potential = at risk for
3.Possible (I added)
4.Health-promotion
s/sx - correct answer signs and symptoms
what are the three parts of actual nursing diagnosis - correct answer •NANDA: diagnostic label
•Etiology (possible cause): "related to" (R/T)
•Signs and symptoms: "as evidenced by" (AEB)
Etiology - correct answer cause of disease
what is the planning part of the nursing process - correct answer The development of an individualized
plan of care
what is the planning portion of nursing process based on - correct answer on assessment and nursing
diagnosis
what do you do during nursing process of the planning step - correct answer -Determine Immediate
Priorities
-Establish Goals of Care / Expected -Outcomes
