NCHP- Exam 1 Study Questions with Answers

The nursing process - ADPIE Assessment Diagnosis Planning Implementation Evaluation assessment -symptoms (subjective data) described by patient (ex: pain, fatigue, nausea, "i feel sad") -direct quotes from patient/SO/caregiver -significant data that pertains to the specific patient problem being addressed objective data -Signs (e.g., fever, height, weight, dx test, labs) -Relevant physical assessment findings 1) If you observe something and I can observe the same thing, it is _____. 2) If you can't physically observe the data, it is _____. 1)OBJECTIVE (example: redness, vomiting) 2)SUBJECTIVE (pain, nausea) •A nurse's _____ _____ about an individual's response to actual or potential health problems and life processes. clinical judgment clinical judgement the process by which the nurse decides on data to be collected about a client, makes an interpretation of the data, arrives at a nursing diagnosis, and identifies appropriate nursing actions; this involves problem solving, decision making, and critical thinking. Problem/Diagnosis -stated in terms approved by NANDA what is NANDA's mission? to "facilitate the development, refinement, dissemination and use of standardized nursing diagnostic terminology" with the vision to "improve the health care of all people" -taxonomy with 13 domains: as health promotion, nutrition, elimination and exchange, self-perception -diagnoses are retired if it becomes evident that their usefulness is limited or outdated planning/outcomes -must be realistic, specific, measurable, have specific time frame -Person, family or caregiver centered: Facilitate them to be involved in his/her own care