Exam 1 nur 152 Questions With Complete Solutions
Characteristics of the nursing process
- SYSTEMATIC = Ordered sequence of activities
- DYNAMIC = great interaction and overlapping amoung the 5
steps
- INTERPERSONAL = always about the pt
- OUTCOME ORIENTED= nurses and pt work together on
goals
- UNIVERSALLY APPLICABLE = A frame work for all
nursing activities
Steps in Concept Mapping
1. Collect pt problems and concerns on a list
2. connect and analyze the relationships
3. create a diagram
4. Keep in mind key concepts = the nursing process, safety and
advocacy
Reflection IN action
Happens in the here and now of activity. AKA "Thinking on
your feet"
Reflection ON action
,Occurs after the fact and involves thinking through a situation
that has occurred in the past
Reflection FOR action
Helps the person to think about how FUTURE actions might
change as a result of the reflection.
Standards for critical thinking
clear, precise, specific, accurate, relevant, plausible, consistent,
logical, deep, broad, complete, significant, adequate (for the
purpose), and fair
Physician roles
- Informed consent
- Determine course of treatment
- Prescriptions
- Order procedures
PLANNING INTERVENTIONS
1. Include subject (understood the subject is the nurse do not
state) – action verb–times & targets
2. Include “action” interventions & “monitoring” interventions
IMPLEMENTATION
1. "Doing" or "delegating" nursing intervention
2. Documenting
,3. Nursing, provider, collaborative team
§ Holistic, life span considerations
EVALUATION
1. Evaluate patient goal / outcome achievement.
2. Alter the plan as needed and restart the process
If you dont reach goal REVISION time or
TERMINATION!!!!
The Pt's vital signs were taken every 4 hours?
Intervention
The nurse turned Mrs. Jones from side to side at least everyone
2 hours?
Intervention
When asked by the nurse, Jonah rated his level of pain as a "4"
on a scale of 1 - 10.
Assessment
Mrs. Michaels developed a pressure sore on her coccyx in spite
of the nurses interventions, goal not met.
Evaluation
Risk for infection R/T decreased body defense system.
Diagnosis
Will perform passive range of motion (PROM) of 10 reps to her
right arm every shift.
Planning
, Will have an intake of 3,000 mL of fluid over a 24-hour period.
Planning
The nursing staff offered Anita 240 mL of water and/or her
favorite juices every hour while she was awake.
Intervention
Within 30-60 minutes of receiving analgesic medication, will
state that pain is < 4 on a scale of 1-10.
planning
Conducting a client interview.
Assessment
Choosing appropriate nursing interventions.
planning
Measuring the patient's intake and output at the end of the shift.
intervention
The nurse will administer the antibiotic as scheduled.
Intervention
Consist of the client's problem and its cause.
Diagnosis
Autocratic (authoritarian) Leadership
A leader is in control of everything, and you have to do what
that leader says. otherwise there are consequences and you will
be held accountable
Characteristics of the nursing process
- SYSTEMATIC = Ordered sequence of activities
- DYNAMIC = great interaction and overlapping amoung the 5
steps
- INTERPERSONAL = always about the pt
- OUTCOME ORIENTED= nurses and pt work together on
goals
- UNIVERSALLY APPLICABLE = A frame work for all
nursing activities
Steps in Concept Mapping
1. Collect pt problems and concerns on a list
2. connect and analyze the relationships
3. create a diagram
4. Keep in mind key concepts = the nursing process, safety and
advocacy
Reflection IN action
Happens in the here and now of activity. AKA "Thinking on
your feet"
Reflection ON action
,Occurs after the fact and involves thinking through a situation
that has occurred in the past
Reflection FOR action
Helps the person to think about how FUTURE actions might
change as a result of the reflection.
Standards for critical thinking
clear, precise, specific, accurate, relevant, plausible, consistent,
logical, deep, broad, complete, significant, adequate (for the
purpose), and fair
Physician roles
- Informed consent
- Determine course of treatment
- Prescriptions
- Order procedures
PLANNING INTERVENTIONS
1. Include subject (understood the subject is the nurse do not
state) – action verb–times & targets
2. Include “action” interventions & “monitoring” interventions
IMPLEMENTATION
1. "Doing" or "delegating" nursing intervention
2. Documenting
,3. Nursing, provider, collaborative team
§ Holistic, life span considerations
EVALUATION
1. Evaluate patient goal / outcome achievement.
2. Alter the plan as needed and restart the process
If you dont reach goal REVISION time or
TERMINATION!!!!
The Pt's vital signs were taken every 4 hours?
Intervention
The nurse turned Mrs. Jones from side to side at least everyone
2 hours?
Intervention
When asked by the nurse, Jonah rated his level of pain as a "4"
on a scale of 1 - 10.
Assessment
Mrs. Michaels developed a pressure sore on her coccyx in spite
of the nurses interventions, goal not met.
Evaluation
Risk for infection R/T decreased body defense system.
Diagnosis
Will perform passive range of motion (PROM) of 10 reps to her
right arm every shift.
Planning
, Will have an intake of 3,000 mL of fluid over a 24-hour period.
Planning
The nursing staff offered Anita 240 mL of water and/or her
favorite juices every hour while she was awake.
Intervention
Within 30-60 minutes of receiving analgesic medication, will
state that pain is < 4 on a scale of 1-10.
planning
Conducting a client interview.
Assessment
Choosing appropriate nursing interventions.
planning
Measuring the patient's intake and output at the end of the shift.
intervention
The nurse will administer the antibiotic as scheduled.
Intervention
Consist of the client's problem and its cause.
Diagnosis
Autocratic (authoritarian) Leadership
A leader is in control of everything, and you have to do what
that leader says. otherwise there are consequences and you will
be held accountable
