32 Questions
What is the main purpose of the nursing process?
To plan and provide individualized nursing care
Who can be the recipient of care in the nursing process?
Individuals, families, communities, or groups
What is a key characteristic of the nursing process?
Client-centered
How does the nursing process approach decision making?
By identifying possible solutions and choosing the best one
What kind of data from each phase of the nursing process influences the next phase?
Data from each phase provides input to the next phase
What is the purpose of nurses validating assessment data?
To confirm that data is complete, factual, and accurate
Why is it important for nurses to be aware of their own biases, values, and beliefs?
To build an accurate database
What should nurses do if they encounter ambiguous or vague statements during assessments?
Clarify the statements to ensure understanding
In validating assessment data, what should nurses check if the data are extremely abnormal?
Double check the abnormal data
Why is it important for nurses to use cues rather than inferences in their data collection?
Cues help in building an accurate database
What is the purpose of direct percussion?
Detect possible tenderness
Which type of percussion involves using one hand flat on the body surface and striking with the fist of the other hand?
Blunt percussion
What is the key movement involved in direct percussion?
Movement from the wrist
In indirect percussion, what produces a sound or tone that varies with the density of underlying structures?
Tapping done with specific fingers
What should be done immediately after delivering two quick taps in direct percussion?
Flex your wrist
Which type of percussion is used to detect tenderness over the sinuses?
Direct percussion
Which position is primarily used to assess the hip joint?
Prone
In which position is the weight of the body supported by the chest and knees?
Knee-chest
Which position is used to examine the female genitalia, reproductive tracts, and the rectum?
Lithotomy
What is the main purpose of the standing position during a physical examination?
Assessing posture, balance, and gait
Which position allows full expansion of the lungs during examination?
Sitting
For which clients would the knee-chest position be embarrassing and uncomfortable?
Clients with cardiac and respiratory problems, elderly clients, and those examining rectal areas
What is the purpose of collecting, organizing, validating, and documenting client data in nursing practice?
To establish a database about the client's response to health concerns
What is the purpose of diagnosing in nursing practice?
To identify client's strengths and health problems
What does implementing in nursing practice involve?
Reassessing the client to update the database
When is an emergency assessment typically performed in nursing?
During any physiological or psychological crisis of the client
What is the purpose of an initial assessment in nursing practice?
To establish a complete database for future comparison
In the nursing process, what does evaluating entail?
Measuring the degree to which goals/outcomes have been achieved
What is the main role of a nurse in health assessment?
Obtaining patient's health history
What is the primary purpose of planning in nursing practice?
To develop an individualized care plan specifying client goals and related nursing interventions
What activity is involved in diagnosing in nursing practice?
Interpreting and analyzing data
When is a time-lapsed assessment usually done?
Several months after initial assessment
Learn about the importance of validating assessment data in nursing, including techniques to compare subjective and objective data. Understand the significance of separating facts from inferences, interpretations, and assumptions, and the role of nurses in building an accurate client database.
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