ULL Nursing 204 - Exam 2 Questions
And Answers
The five steps (phases) of the nursing process - CORRECT ANSWER-1. assessment
2. diagnosis
3. planning
4. implementation
5. evaluation
Evaluation - CORRECT ANSWER-evaluate goal achievement, modify as needed
Step 1: assessment process - CORRECT ANSWER-Begins: initial meeting b/t nurse
and client/ family
Next step: obtain info about the client's current and past problems
assessment history - CORRECT ANSWER-past records and tests
other health care team members
family history
assessment physical - CORRECT ANSWER-observation
current tests, measurements
assessment - CORRECT ANSWER-as new info becomes available, you must refine
and update the original assessment.
,assessment data collection - CORRECT ANSWER-1. subjective
objective
Assessment - CORRECT ANSWER-collect data/ info, analysis and verification of
information
Diagnosis - CORRECT ANSWER-identify health care needs/ problems
Planning - CORRECT ANSWER-identify and develop expected outcomes
Implementation - CORRECT ANSWER-take agreed-on action to achieve outcomes
subjective - CORRECT ANSWER-(stated)
clients perception of data and what client or family says about the data
document: patient states, "..."
objective - CORRECT ANSWER-(observed)
data directly observed or verified through physical exam or tests
document specific, measurable terms
assessment: analyzed data - CORRECT ANSWER-organize cluster behaviors and
make inferences on subjective and objective
assessment: verify data - CORRECT ANSWER-validate data and inferences with client
step 2: diagnosis - CORRECT ANSWER-analyze information received and identify gaps
,compare against normal health standards
look for functional vs. dysfunctional patterns
nursing diagnosis - CORRECT ANSWER-A comprehensive biopsychosocial statement
that captures the essence of the client's health care needs/problems
Developed & prioritized based on the client's most immediate needs in the current
health care situation.
Describes the client's human responses to health issues & medical diagnoses.
types of nursing diagnosis (ND) - CORRECT ANSWER-Problem-Focused
Risk & High-Risk
Possible
Health-Promotion
Syndrome
Collaborative Problem
Risk for Complications
problem focused ND - CORRECT ANSWER-Human response to health conditions/life
processes that can exist in an individual, family, or community.
Supported by defining characteristics that cluster in patterns of related cues or
inferences.
, problem-focused ND Major: - CORRECT ANSWER-Major: must be present (must have
it, pain must be present/ happening right now)
problem-focused ND Minor: - CORRECT ANSWER-Minor: provide support, but may or
may not be present (sudden onset, increased heart rate, blood pressure: some people
may be in pain but may not be present at the time)
Risk and high risk ND - CORRECT ANSWER-Human response to health conditions/life
processes that may develop in a vulnerable individual, family, or community.
Doesn't have problem yet, but may develop one
Supported by risk factors that contribute to increased vulnerability.
Risk ND - CORRECT ANSWER-expected or predictive diagnoses for all individuals who
are undergoing some situation
During an operation you may be at risk for something but not as much as if you already
had a risk, such as: heart disease
High-risk - CORRECT ANSWER-High-risk: for people with additional risk factors that
may be more vulnerable for the problem to occur.
Depressed immune system, cancer w/ chemotherapy: all factors that can lead to having
a high risk for an operation.
Possible ND - CORRECT ANSWER-Describe a suspected problem requiring additional
data to confirm or rule out (r/o).
And Answers
The five steps (phases) of the nursing process - CORRECT ANSWER-1. assessment
2. diagnosis
3. planning
4. implementation
5. evaluation
Evaluation - CORRECT ANSWER-evaluate goal achievement, modify as needed
Step 1: assessment process - CORRECT ANSWER-Begins: initial meeting b/t nurse
and client/ family
Next step: obtain info about the client's current and past problems
assessment history - CORRECT ANSWER-past records and tests
other health care team members
family history
assessment physical - CORRECT ANSWER-observation
current tests, measurements
assessment - CORRECT ANSWER-as new info becomes available, you must refine
and update the original assessment.
,assessment data collection - CORRECT ANSWER-1. subjective
objective
Assessment - CORRECT ANSWER-collect data/ info, analysis and verification of
information
Diagnosis - CORRECT ANSWER-identify health care needs/ problems
Planning - CORRECT ANSWER-identify and develop expected outcomes
Implementation - CORRECT ANSWER-take agreed-on action to achieve outcomes
subjective - CORRECT ANSWER-(stated)
clients perception of data and what client or family says about the data
document: patient states, "..."
objective - CORRECT ANSWER-(observed)
data directly observed or verified through physical exam or tests
document specific, measurable terms
assessment: analyzed data - CORRECT ANSWER-organize cluster behaviors and
make inferences on subjective and objective
assessment: verify data - CORRECT ANSWER-validate data and inferences with client
step 2: diagnosis - CORRECT ANSWER-analyze information received and identify gaps
,compare against normal health standards
look for functional vs. dysfunctional patterns
nursing diagnosis - CORRECT ANSWER-A comprehensive biopsychosocial statement
that captures the essence of the client's health care needs/problems
Developed & prioritized based on the client's most immediate needs in the current
health care situation.
Describes the client's human responses to health issues & medical diagnoses.
types of nursing diagnosis (ND) - CORRECT ANSWER-Problem-Focused
Risk & High-Risk
Possible
Health-Promotion
Syndrome
Collaborative Problem
Risk for Complications
problem focused ND - CORRECT ANSWER-Human response to health conditions/life
processes that can exist in an individual, family, or community.
Supported by defining characteristics that cluster in patterns of related cues or
inferences.
, problem-focused ND Major: - CORRECT ANSWER-Major: must be present (must have
it, pain must be present/ happening right now)
problem-focused ND Minor: - CORRECT ANSWER-Minor: provide support, but may or
may not be present (sudden onset, increased heart rate, blood pressure: some people
may be in pain but may not be present at the time)
Risk and high risk ND - CORRECT ANSWER-Human response to health conditions/life
processes that may develop in a vulnerable individual, family, or community.
Doesn't have problem yet, but may develop one
Supported by risk factors that contribute to increased vulnerability.
Risk ND - CORRECT ANSWER-expected or predictive diagnoses for all individuals who
are undergoing some situation
During an operation you may be at risk for something but not as much as if you already
had a risk, such as: heart disease
High-risk - CORRECT ANSWER-High-risk: for people with additional risk factors that
may be more vulnerable for the problem to occur.
Depressed immune system, cancer w/ chemotherapy: all factors that can lead to having
a high risk for an operation.
Possible ND - CORRECT ANSWER-Describe a suspected problem requiring additional
data to confirm or rule out (r/o).
