NURS 356 EXAM 1! || 100% ACCURATE ANSWERS.
Identify the steps of the nursing process (ADPIE). correct answers Assessment
Diagnosis (nursing)
Planning
Implementation
Evaluation
Assessment correct answers To begin the nursing process the nurse must first perform a nursing
assessment to gather information about the patient/client/resident. This may include both
subjective and objective assessment data.
Identify yourself, then gather necessary information
-Obtain an accurate health history: listen INTENTLY to the "story". What the person tells you is
the subjective info.
-Give verbal and non-verbal cues to show that you are focused and paying attention
-Review medical records and diagnostic tests
-Collaborate with the entire health care team and person's family, if appropriate
-Perform a physical assessment. What you see, observe, hear, touch, and smell is objective
-Be organized throughout the assessment phase
-One organizational approach is Gordon's Functional Health Patterns
-Remember that family, community, national, and global assessments of health, wellness, and
disease are done as well
Diagnosis (nursing) correct answers Three part system (PES):
P — Choose the label
Nursing Dx
,E — Write an r/t phrase
Etiology
S — Write the defining characteristics
Signs and symptoms
Problem-- (label from NANDA list). NANDA is the North American Diagnosis Association
Etiology (cause)--"related to" factor (What is contributing to the nursing diagnosis?)
Relationship to nursing Dx, cannot use medical diagnosis, but may be secondary
Symptom--"as evidenced by" (signs and symptoms, or as NANDA describes them, defining
characteristics, taken from assessment information)
How to make a nursing diagnosis: Look for common patterns in the assessment. Cluster or group
common patterns (verify defining characteristics). Identify possible nursing Dx using critical
thinking skills (These may be actual or potential problems, or wellness goals. Ask: Is it important
to the client? which is client centered care)
Nursing Diagnosis Example correct answers Ineffective airway clearance RELATED TO pooling
of secretions, secondary to COPD
AS EVIDENCE BY dyspnea, production of large amount of sputum and cough
Planning correct answers Prioritizing nursing Dx
Maslow's hierarchy
-General goal to improve health problem
-Outcomes
-Interventions based on evidence
, SMART correct answers Specific
Measurable
Achievable
Realistic
Timely
Implementation correct answers The implementation phase includes the "carrying out" of the
specific, individualized, jointly agreed upon interventions in the plan of care. Often, the
interventions implemented are focused on symptom management, which is alleviating
symptoms. Typically, nursing care does not involve "curing" the medical condition causing the
symptom. Rather, nursing care focuses on caring for the client/family so they can function at
their highest level.
Evaluation correct answers Continuous process
Constant evaluation of outcomes : Attainable, correct nursing Dx?, intervention changes
needed?, time frame appropriate?, APPROPRIATE FOR THE PERSON OR SYSTEM?
Constant evaluation of evidence
Nursing process critical thinking summary correct answers A-Assessment:
What/how/why/where/when to assess
D-Diagnosis: What will you base your diagnosis on?
P-Plan: What is your plan in relation to your diagnosis? What are your goals and what SMART
outcomes are you trying to achieve?
I-Implementation: How are you going to achieve your goals and meet your plan? Is what you are
implementing going to truly help you achieve your outcomes?
Identify the steps of the nursing process (ADPIE). correct answers Assessment
Diagnosis (nursing)
Planning
Implementation
Evaluation
Assessment correct answers To begin the nursing process the nurse must first perform a nursing
assessment to gather information about the patient/client/resident. This may include both
subjective and objective assessment data.
Identify yourself, then gather necessary information
-Obtain an accurate health history: listen INTENTLY to the "story". What the person tells you is
the subjective info.
-Give verbal and non-verbal cues to show that you are focused and paying attention
-Review medical records and diagnostic tests
-Collaborate with the entire health care team and person's family, if appropriate
-Perform a physical assessment. What you see, observe, hear, touch, and smell is objective
-Be organized throughout the assessment phase
-One organizational approach is Gordon's Functional Health Patterns
-Remember that family, community, national, and global assessments of health, wellness, and
disease are done as well
Diagnosis (nursing) correct answers Three part system (PES):
P — Choose the label
Nursing Dx
,E — Write an r/t phrase
Etiology
S — Write the defining characteristics
Signs and symptoms
Problem-- (label from NANDA list). NANDA is the North American Diagnosis Association
Etiology (cause)--"related to" factor (What is contributing to the nursing diagnosis?)
Relationship to nursing Dx, cannot use medical diagnosis, but may be secondary
Symptom--"as evidenced by" (signs and symptoms, or as NANDA describes them, defining
characteristics, taken from assessment information)
How to make a nursing diagnosis: Look for common patterns in the assessment. Cluster or group
common patterns (verify defining characteristics). Identify possible nursing Dx using critical
thinking skills (These may be actual or potential problems, or wellness goals. Ask: Is it important
to the client? which is client centered care)
Nursing Diagnosis Example correct answers Ineffective airway clearance RELATED TO pooling
of secretions, secondary to COPD
AS EVIDENCE BY dyspnea, production of large amount of sputum and cough
Planning correct answers Prioritizing nursing Dx
Maslow's hierarchy
-General goal to improve health problem
-Outcomes
-Interventions based on evidence
, SMART correct answers Specific
Measurable
Achievable
Realistic
Timely
Implementation correct answers The implementation phase includes the "carrying out" of the
specific, individualized, jointly agreed upon interventions in the plan of care. Often, the
interventions implemented are focused on symptom management, which is alleviating
symptoms. Typically, nursing care does not involve "curing" the medical condition causing the
symptom. Rather, nursing care focuses on caring for the client/family so they can function at
their highest level.
Evaluation correct answers Continuous process
Constant evaluation of outcomes : Attainable, correct nursing Dx?, intervention changes
needed?, time frame appropriate?, APPROPRIATE FOR THE PERSON OR SYSTEM?
Constant evaluation of evidence
Nursing process critical thinking summary correct answers A-Assessment:
What/how/why/where/when to assess
D-Diagnosis: What will you base your diagnosis on?
P-Plan: What is your plan in relation to your diagnosis? What are your goals and what SMART
outcomes are you trying to achieve?
I-Implementation: How are you going to achieve your goals and meet your plan? Is what you are
implementing going to truly help you achieve your outcomes?
