Fundamentals - Nursing Process Flashcards

Questions and Answers

What must the nurse ensure regarding the related factor for a nursing diagnosis?

It is a condition that responds to nursing interventions.

Which client is likely to have a health promotion nursing diagnosis?

The elderly client with dementia admitted to the healthcare facility.

The client with reduced cognitive ability while recovering from surgery.

The client who is willing to take a 30-minute walk daily. (correct)

The client with acute pain due to appendicitis.

What should the nurse do when the defining characteristics of assessment data for a client can apply to more than one diagnosis? (Select all that apply)

Reassess the client.

Review all defining characteristics. (correct)

Identify related factors. (correct)

Reject all diagnoses.

Gather more information. (correct)

What is the correct order of steps of the nursing diagnostic process?

Validate the data with other sources. Signup and view all the answers

Which features distinguish nursing diagnoses from medical diagnoses? (Select all that apply)

Nursing diagnoses involve the client when possible. Signup and view all the answers

Which step of the nursing process is directly affected if the nurse does not make a nursing diagnosis?

Planning Signup and view all the answers

A child being treated with cardiac drugs developed certain symptoms. Which drug toxicity is responsible for these symptoms?

Digoxin Signup and view all the answers

Which diagnosis made by the nurse is most helpful in providing the right nursing interventions for the client?

The nurse identifies that the client is not aware of perineal care and has impaired skin integrity. Signup and view all the answers

What benefits are associated with using standard formal nursing diagnostic statements? (Select all that apply)

Provides precise definition of the client's problem Signup and view all the answers

What is critical thinking?

A combination of reasoned thinking, openness to alternatives, ability to reflect, and a desire to seek truth. Signup and view all the answers

What is the nursing process?

A systematic problem-solving process that guides all nursing actions. Signup and view all the answers

What are the phases of the nursing process?

Diagnosis Signup and view all the answers

What is evaluating?

The final phase: judge whether your actions have successfully treated or prevented the client's health problems. Signup and view all the answers

What is full spectrum nursing?

A unique blend of thinking, doing, and caring for the purpose of affecting good outcomes from a patient situation. Signup and view all the answers

What are the types of nursing diagnoses?

Actual Signup and view all the answers

Which is the next step in the nursing process for a postsurgical client who becomes short of breath with little exertion?

Reevaluating and creating a new nursing diagnosis and outcome Signup and view all the answers

What is true about conducting nursing assessments? (Select all that apply)

Assessments must be completed within 24 hours of inpatient admission. Signup and view all the answers

Which information is considered primary data during a client's appointment at the women's clinic? (Select all that apply)

Heavy menstrual flow every 3 weeks with severe abdominal cramping Signup and view all the answers

Which is the best explanation of the difference between a medical diagnosis and a nursing diagnosis?

A medical diagnosis defines an illness or disease with a certain pathology, while a nursing diagnosis is geared toward the client's health status and how a nurse can help independently. Signup and view all the answers

Using Maslow's hierarchy of needs, place the nursing diagnoses in order of priority.

Ineffective airway clearance = 1 Ineffective breathing pattern = 2 Deficient fluid volume = 3 Risk for fall = 4 Wandering = 5 Impaired memory = 6 Signup and view all the answers

Which type of intervention has the nurse implemented when explaining the importance of using oxygen to the client with chronic obstructive pulmonary disease?

Interdependent Signup and view all the answers

What does the evaluative statement, 'Circulation status: 3,' mean according to the Nursing Outcome Classification (NOC)?

The client's circulation is moderately compromised. Signup and view all the answers

How can the nurse promote client participation and adherence to the nursing plan with a postoperative bariatric client? (Select all that apply)

Help the client set realistic goals. Signup and view all the answers

Which is the priority nursing diagnosis for a client experiencing increasing shortness of breath and labored breathing?

Ineffective breathing pattern Signup and view all the answers

During an assessment, if a nurse notes that the client has an elevated temperature, what type of data is this?

Objective Signup and view all the answers

According to Maslow's Hierarchy of Needs, what is the appropriate order of priority of the client needs?

Adequate hydration = 1 Falls prevention = 2 Support group = 3 Medication teaching = 4 A vase of flowers = 5 Signup and view all the answers

Which describes the central source of information needed to guide holistic, goal-oriented care?

Comprehensive nursing care plan Signup and view all the answers

What action should the nurse take when a client is unable to ambulate due to obesity and pain?

Request assistance with ambulating the client. Signup and view all the answers

Which is an example of a nurse using subjective data to clarify objective data?

The nurse notes the client has a rash and asks if the rash is itching. Signup and view all the answers

Which is an important consideration for discharge planning for a client using a walker after hip surgery?

The safety and physical layout of the home environment. Signup and view all the answers

Which is a valid goal statement for measuring and managing pain?

The client will report pain greater than level 4 to the nurse. Signup and view all the answers

Which describes the correct way to state a nursing diagnosis?

A problem and an etiology linked by a connecting phrase. Signup and view all the answers

When creating a care plan, which outcomes can be influenced by nursing interventions?

Nurse-sensitive outcomes. Signup and view all the answers

What is the appropriate action if a nurse considers 'anxiety' as a nursing diagnosis but lacks sufficient information?

Ask the client if there is anything specific he or she is anxious about. Signup and view all the answers

Who has accountability for the actions performed and the outcome when a task is delegated to a nursing assistant?

The nurse who delegated the task. Signup and view all the answers

Which scenario is an example of a lifestyle factor that influences sleep?

A client working irregular rotating overnight shifts complains of difficulty sleeping. Signup and view all the answers

With prolonged use, which medication may cause yellow discoloration of a child's teeth?

Tetracycline Signup and view all the answers

What condition may a client have if they report pain in the nose and difficulty breathing after a fall while playing football?

Fracture of the nose Signup and view all the answers

Which assessment activity enabled the nurse to derive the conclusion of a related factor as first time surgery?

The nurse asks the client to explain the surgery. Signup and view all the answers

How should the nurse document the nursing diagnosis according to NANDA-I?

NANDA-I label, related factor, and defining characteristics. Signup and view all the answers

Which related factor is appropriate for a nursing diagnosis?

Trauma of incision Signup and view all the answers

Study Notes

Nursing Process and Assessments

Reevaluating and creating a new nursing diagnosis based on client findings allows for updated interventions and goals.
Nursing assessments must be completed within 24 hours of inpatient admission and cannot be delegated.
All clients should be assessed for pain, nutritional status, and fall risk as per The Joint Commission standards.

Data Collection and Nursing Diagnoses

Primary data includes subjective and objective information from the client, such as heavy menstrual flow and its connection to anemia.
A medical diagnosis identifies illness and pathology, while a nursing diagnosis focuses on the client's health status and nursing interventions.
The priority of nursing diagnoses based on Maslow's hierarchy: airway clearance takes precedence over breathing patterns, fluid volume, fall risk, wandering, and memory impairment.

Interventions and Outcomes

Interdependent interventions indicate collaboration with healthcare team members, such as respiratory therapists for oxygen usage.
The Nursing Outcome Classification scale classifies circulation status; a rating of 3 indicates moderate compromise.
Promoting client participation in a nursing plan includes ensuring comfort in questions, simplicity in instructions, alignment of goals, and setting realistic expectations.

Specific Nursing Considerations

Ineffective breathing patterns are a priority nursing diagnosis when a client exhibits increasing shortness of breath.
Objective data, such as an elevated temperature, is measurable and used to inform nursing diagnoses.
Comprehensive nursing care plans are crucial for addressing unique client needs holistically.

Client Education and Discharge Planning

To facilitate care while helping a client with ambulation, seeking assistance is crucial if the client is unable to move independently.
Valid pain management goals should be specific and measurable, such as reporting pain levels.
A nursing diagnosis must convey a problem, related factor, and connecting phrase, adhering to NANDA-I standards.

Lifestyle Factors and Health Promotion

Lifestyle factors can greatly affect sleep patterns, as seen in clients with irregular work shifts who struggle with fatigue.
Tetracycline is known to cause yellowing of teeth in children with prolonged use.
Clients expressing a desire to improve health behaviors, such as walking daily, may be given a health promotion nursing diagnosis.

Assessment Challenges

When assessment data applies to multiple diagnoses, further information must be gathered, related factors identified, and defining characteristics reviewed to clarify the situation.### Nursing Diagnostic Process
Correct interpretation of information enables accurate selection of nursing diagnoses.
Related factors provide context for defining client characteristics.
Individualizing nursing diagnoses requires identification of related factors.
Review and confirm relevant defining characteristics while eliminating irrelevant ones.
Data clusters form after thorough reassessment and validation of assessment data.
Not all diagnoses need rejection; review supports relevant diagnosis confirmation.

Steps of the Nursing Diagnostic Process

First, assess the client's health status through data gathering.
Validate collected data with other sources to ensure accuracy.
Interpret the meaning of the validated data for understanding client needs.
Cluster data to identify relationships between findings.
Look for defining characteristics that indicate the client's health issues.
Identify client’s needs based on the diagnostic information.
Formulate nursing diagnoses based on identified health problems.

Differences Between Nursing and Medical Diagnoses

Nursing diagnoses actively involve the client in the assessment and care process.
Medical diagnoses focus on disease conditions identified via diagnostic tests.
Nursing diagnoses classify health issues to be treated within the nursing domain and reflect clinical judgment of client responses.

Importance of Nursing Diagnosis

Planning phase of the nursing process relies heavily on established nursing diagnoses.
A clear and accurate diagnosis is essential for appropriate planning and intervention.

Symptoms of Digoxin Toxicity

The digoxin toxicity is indicated by symptoms such as vomiting, bradycardia, and dysrhythmias.
Digoxin improves heart efficiency, but overdose can lead to serious complications.

Diagnostic Labels

Diagnostic labels encapsulate the essence of a client's response to health conditions.
Labels are concise representations of nursing diagnoses, approved by NANDA-I.

Characteristics of Risk Nursing Diagnoses

Risk diagnoses lack defined related factors since they indicate potential responses not yet manifested.
These diagnoses focus on preventive measures for vulnerable individuals and populations.

Benefits of Standard Nursing Diagnostic Statements

Foster the development of nursing knowledge and clinical understanding.
Provide precise definitions of client problems, aiding clear communication.
Distinguish nursing roles from other healthcare providers, emphasizing nurses' responsibilities.

Critical Thinking in Nursing

Critical thinking is purposeful, analytical, and results in informed decision-making.
Essential for holistic care, combining various knowledge fields and skills in fast-paced environments.

Phases of the Nursing Process

Assessment: Initial data gathering about the client's health.
Diagnosis: Identification of client health needs based on assessment.
Planning: Establishing goals and interventions to be implemented.
Implementation: Executing planned interventions to support client care.
Evaluation: Assessing the effectiveness of interventions and overall client outcomes.

Types of Nursing Knowledge

Theoretical knowledge rooted in evidence and theory.
Practical knowledge gained through hands-on experience.
Self-knowledge reflecting on personal beliefs and practices.
Ethical knowledge guiding moral and ethical decision-making.

Types of Nursing Diagnoses

Actual diagnoses indicate current health issues.
Risk diagnoses suggest potential health risks.
Possible diagnoses identify areas needing further assessment.
Wellness diagnoses promote optimal health states.
Syndrome diagnoses encapsulate collective health responses.

Delegation

Nurses must not delegate interventions requiring specialized knowledge or judgment.
The "Five Rights of Delegation" ensure safe and effective delegation to appropriate personnel.

Cultural Concepts in Nursing

Bicultural individuals identify with and integrate multiple cultures.
Multiculturalism refers to diverse cultural groups.
Ethnocentrism is the belief in the superiority of one's own culture.
Vulnerable populations include groups at higher risk for health issues due to socioeconomic factors.

Safety and Developmental Factors

Safety varies across developmental stages:
- Infants and toddlers lack danger recognition.
- Preschoolers are adventurous but need supervision.
- School-age children face risks from unfamiliar environments.
- Adolescents engage in risky behavior due to a sense of invincibility.
- Adults may face workplace injuries and health decline with age.
- Older adults often experience physiological changes that impact safety.

Health Problems

Defined as conditions requiring intervention to prevent or resolve disease and support wellness.

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Description

Explore essential nursing process concepts through flashcards covering LP 4, 5, and 6. This quiz focuses on the next steps in care for postsurgical clients, emphasizing assessment and decision-making skills. Perfect for nursing students preparing for practical applications.