NUR3031 - FOUNDATIONS OF NURSING - EXAM 1

NUR3031 - FOUNDATIONS OF NURSING - EXAM 1

Systematicywayyofygatheringyandyusingyinformationytoyplanyandyprovideyindividualiz
edypatientycarey-yCORRECTyANSWER-Nursingyprocess

Whatyareythey5ystepsytoyorganizeyandyprioritizeypatientycarey-yCORRECTyANSWER-
Assessing,ydiagnosing,yplanning,yimplementing,yevaluating

-systematic,ydynamicywayytoycollectyandyanalyzeydatayaboutyayclienty
-primaryysourceyofyinformationyisyfromytheyclienty-yCORRECTyANSWER-Assessment

Analyzingypatientydataytoyidentifyypatientystrengthsyandyproblemsy-
yCORRECTyANSWER-Diagnosing



Specifyingypatientyoutcomesy(goals)yandyrelatedynursingyinterventionsy-
yCORRECTyANSWER-Planning



Carryingyoutytheyplanyofycare;yTheyphaseyofytheynursingyprocessyinywhichytheynursin
gycareyplanyisyputyintoyactiony-yCORRECTyANSWER-Implementing

Measuringyextentytoywhichypatientyachievedyoutcomesy-yCORRECTyANSWER-
Evaluating

Whatyareysomeyofytheycharacteristicsyofytheynursingyprocess?y-yCORRECTyANSWER-
Systemic,ydynamic,yinterpersonal,youtcomeyoriented,yuniversallyyapplicable

BenefitsyofytheynursingyprocessytoytheyPATIENT:y-yCORRECTyANSWER-
Scientificallyybase,yholisticyindividualizedypatientycare.yContinuityyofycare.yClear,yeffi
cient,ycost-effectiveyplanyofyaction.

BenefitsyofytheynursingyprocessytoyotheryNURSES:y-yCORRECTyANSWER-
Opportunityytoyworkycollaborativelyywithyotheryhealthcareyworkers,ysatisfactionyofy
makingyaydifferenceyinylivesyofypatients,yopportunityytoygrowyprofessionally.

Typesyofyassessment:y-yCORRECTyANSWER-Initial,yfocused,yemergency,ytime-lapse

Performedyshortlyyafterytheypatientyisyadmittedytoyayhealthycareyagencyyoryservice.y
Mostyinstitutionsyhaveypoliciesyspecifyingytheytimeyintervalywithinywhichythisyassess
mentymustybeycompleted.yTheypurposeyofythisyassessmentyisytoyestablishyaycompletey
databaseyforyproblemyidentificationyandycareyplanning.y-yCORRECTyANSWER-
Initialyassessment

Assessmentyusedytoyidentifyynewyoryover-
ylookedyproblems.yTheynurseygathersydatayaboutyayspecificyproblemythatyhasyalready

ybeenyidentified.yHelpfulyquestionsyinclude:

,yWhatyareyyourysignsyandysymptoms?
yWhenydidytheyystart?
yWereyyouydoingyanythingydifferentythanyusualywhenythey

started?
yWhatymakesyyourysymptomsybetter?yWorse?

yAreyyouytakingyanyyremediesy(medicalyorynatural)yforyyour

symptoms?y-yCORRECTyANSWER-Focusedyassessment

Anyassessmentyusedytoyidentifyylife-ythreateningyproblems.yEx:yAylong-
termycareyfacilityyresidentywhoybeginsychokingyinytheydiningyroom,yaybleedingypatien
tybroughtytoytheyemergencyydepartmentywithyaystabywound.y-yCORRECTyANSWER-
Emergencyyassessment

Anyassessmentyscheduledytoycompareyaypatient'sycurrentystatusytoytheybaselineydatay
obtainedyearlier.

Ex:yMostypatientsyinyresidentialysettingsyandythoseyreceivingynursingycareyoverylonge
ryperiodsyofytime,y-yCORRECTyANSWER-Time-lapsedyassessment

Informationyperceivedyonlyybyytheyaffectedyperson;ytheseydataycannotybeyperceivedy
oryverifiedybyyanotheryperson.yExamples:yfeelingynervous,ynauseated,yorychilly,yandye
xperiencingypain.ySymptomsyorycovertydata.y-yCORRECTyANSWER-Subjectiveydata

Observableyandymeasurableydataythatycanybeyseen,yheard,yfelt,yorymeasuredybyysome
oneyotherythanytheypersonyexperiencingythem.yDataythatyisyobservedybyyoneypersony
canybeyverifiedybyyanotherypersonyobservingytheysameypatient.yExamplesyofyobjectiv
eydatayareyanyelevatedytemperatureyreadingy(e.g.,y101°F),yskinythatyisymoist,yandyrefu
salytoylookyatyoryeatyfood.y-yCORRECTyANSWER-Objectiveydata

Whoyisytheyprimaryyandyusuallyytheybestysourceyofyinformationytoycollectydata?y-
yCORRECTyANSWER-Patient



Providesycommonylanguageyforynurses.yAnyassociationythatyidentifies,ydevelops,yandy
classifiesynursingydiagnosesy-yCORRECTyANSWER-NANDA-I

Describesypatientyproblemsynursesycanytreatyindependentlyy-yCORRECTyANSWER-
NursingyDiagnosis

Describesyproblemsyforywhichytheyphysicianydirectsytheyprimaryytrreatmenty-
yCORRECTyANSWER-MedicalyDiagnosis



physiologicalyneeds-->safetyyneeds-->love-->esteem-->self-actualization.y-
yCORRECTyANSWER-Maslow'syHierarchyyofyneeds



Determineytheypatient'synewyorycontinuingyneedyforyassistance.
Promoteyself-care.

, Assistytheypatientytoyachieveyvaluedyhealthyoutcomes.y-yCORRECTyANSWER-
Implementing

Cognitive—increaseyinypatientyknowledge
Askingypatientytoyrepeatyinformationyoryapplyynewyknowledge
Psychomotor—patient'syachievementyofynewyskills
Askingytheypatientytoydemonstrateynewyskill
Affective—changesyinypatientyvalues,ybeliefs,yandyattitudes
Observingypatientybehavioryandyconversation
Physiologic—physicalychangesyinytheypatient
Usingyphysicalyassessmentyskillytoycollectyandycompareydatay-yCORRECTyANSWER-
FouryTypesyofyOutcomes:yEvaluating

WhatyisytheypurposeyofyVS?y-yCORRECTyANSWER-
Toymonitorytheyfunctionsyofytheybody

WhatydoesyVSyconsistyofy-yCORRECTyANSWER-BodyyTemperature
Pulse
Respirations
BloodyPressure
PainyandyPulseyOximetry

Whenytoyassesyvitalysignsy-yCORRECTyANSWER-
1.yOnyadmissionytoyanyyhealthycareyagencyyoryinstitution
2.yBasedyonyagencyyoryinstitutionalypolicyyandyprocedures
3.yAnyytimeythereyisyaychangeyinytheypatientsycondition
4.yAnyytimeythereyisyaylossyofyconsciousness
5.yBeforeyandyafteryanyysurgicalyoryinvasiveydiagnosticyprocedure
6.yBeforeyandyafteryactivityythatymayyincreaseyrisk,ysuchyasyambulationyafterysurgery
7.yBeforeyadministeringymedicationsythatyaffectycardiovascularyandyrespiratoryyfunc
tion

TyoryF.yNursesyobtainyvitalysignsyasyoftenyasyaypatient'syconditionyrequiresysuchyasse
ssment,yprioritizingyandyadaptingyassessmentyofyvitalysignsytoyaddressytheypatient'sy
uniqueysituationy-yCORRECTyANSWER-True

Whatyareytheyfactorsyaffectingybodyytemperaturey-yCORRECTyANSWER-Age
DiurnalyVariationsy(CircadianyRhythms)
Exercise
Hormones
Stressy
Environment
Underlyingydiseaseyoryconditionsy(infections/endocrineydisorders)

Whatyfactorsyincreaseymetabolism?y(4)y-yCORRECTyANSWER-
Hormones,ymuscle,ymovements,yexercise