The nursing process (ADPIE) 2024/2025 Questions and Answers with complete solution

3 types of diagnosis - 1) risk diagnosis 2) syndrome diagnosis 3) health promotion diagnosis 4 aspects of the general survey and 1 - 1. Physical appearance 2. Body structure 3. Mobility 4. Behavior 5. Vital signs A systematic method by which nurses plan and provide care for patients is known as: - Nursing process A well written patient centered goal or desired patient outcome statement: select all that apply 1. Uses measurable verb 2. Is specific for the Soriente and the Patients problem 3. Is realistic for the patient and the patients problem 4. Includes a time frame for the patients reevaluation 5. Uses the word patient as the subject of the statement - All: SMART goal After data is collected: - -validate -interpret - cluster data ANA definition - systematic, dynamic process by which the registered nurse, through interaction with the patient, family, groups, communities, populations, and health care providers collects and analyzes dataauscultation - Listening to sounds produced by the body such as heart and blood vessels lungs and abdomen Behavior survey: - Facial expressions: eye contact, is the expression appropriate for situation Mood and affect: person comfortable and cooperative with examiner Speech: clear and understandable Dress: appropriate to climate, do the clothes fit- can give insight to eating disorder or lack of resources Personal hygiene: well groomed, odor, hair deshevled, bad breath Body structure survey - -stature:height within normal age range) ex:dwarfism -Nutrition: weight appears normal, body fat evenly distributed -symmetry: body parts look equal bilaterally and proportionally -posture: person stands comfortably erect for age (scoliosis, hobos is, slouched, tripod position for repiratory distress) - gross abnormalities: skin lesions, amputations Case management - nursing specialty refers to the assignment of a health care provider to a patient so the care of that patient is overseen by ONE individual -assists patient and family to receive require services, coordinates these services and evaluates the adequacy of the servicesClinical pathways - multidisciplinary plan that schedules clinical intervention over an anticipated time frame for high-risk, high-volume, high-cost types of cases Collaborative intervention - Intervention with other health care team Ex: ensuring client receives and eats evening snack diagnosis: how should you diagnose - Use the diagnosing handbook NANDA -use words like fear, hopelessness, risk for falling - PROPER STRUCTURE: depression related to behavior as evidence by posture and facial expressions Evaluation - Nurses form clinical judgment based on if the client has met the goals and outcomes - if plan did not work, analyze what could have been better and start the ADPIE process over and modifications are made four components of the nursing diagnosis: - -nursing diagnosis name or title -nursing diagnosis definition -contributing or related factors -defining characteristics think about what is used to make a goal into a sentence