Nursing Diagnosis and Care Planning
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Questions and Answers

What is a key aspect of the evaluation process in nursing?

  • Form clinical judgments based on client responses. (correct)
  • Determine the best practices globally.
  • Develop new nursing theories.
  • Assess only the physical symptoms of clients.

    • Which statement best describes critical thinking in nursing?

  • It is the same as making quick decisions with limited data.
  • It is a spontaneous action taken without reflection.
  • It only requires intuition and personal experience.
  • It involves a systematic process grounded in reason. (correct)

    • Which component is essential for nurses to develop critical thinking skills?

  • Avoiding discussions with peers.
  • Reflecting on experiences and ascertaining their meanings. (correct)
  • Focusing solely on theoretical knowledge.
  • Attending mandatory training only.

    • What does the process of inference involve in clinical decision-making?

    <p>Connecting various pieces of data to identify relationships.</p> Signup and view all the answers

    Reflecting on past nursing experiences should help a nurse to alleviate which of the following?

    <p>Confusion about the next steps in care.</p> Signup and view all the answers

    What is the primary focus of nursing diagnosis?

    <p>Identifying patient health status for independent action</p> Signup and view all the answers

    Which stage of planning occurs after the initial patient contact?

    <p>Ongoing Planning</p> Signup and view all the answers

    What does discharge planning primarily aim to achieve?

    <p>Facilitating self-care after leaving healthcare settings</p> Signup and view all the answers

    Which type of evaluation focuses on observable changes in the client's health status?

    <p>Outcomes Evaluation</p> Signup and view all the answers

    During the analysis phase, what is the primary task of a nurse?

    <p>Critically assessing patient data to identify health status</p> Signup and view all the answers

    What is the significance of the nursing care plan?

    <p>It provides a comprehensive guide tailored to each client's needs.</p> Signup and view all the answers

    Which evaluation method focuses solely on the activities performed in patient care?

    <p>Process Evaluation</p> Signup and view all the answers

    What factor is essential in the implementation phase of the nursing process?

    <p>Performing planned interventions based on the care plan</p> Signup and view all the answers

    Which of the following best describes initial planning in nursing care?

    <p>Development of the initial comprehensive care plan</p> Signup and view all the answers

    Critical thinking in the nursing process is primarily utilized during which step?

    <p>Planning</p> Signup and view all the answers

    Which type of sound is characterized as flat, very high, very soft, and very short?

    <p>Flat</p> Signup and view all the answers

    What is the main purpose of using a stethoscope during auscultation?

    <p>To enhance the sense of hearing</p> Signup and view all the answers

    What kind of auscultation method involves directly listening for sounds?

    <p>Direct auscultation</p> Signup and view all the answers

    Which type of auscultation is best suited for listening to high-pitch sounds?

    <p>Diaphragm of the stethoscope</p> Signup and view all the answers

    What does the 'S' in SOAPIE documentation represent?

    <p>Subjective data</p> Signup and view all the answers

    Which piece of equipment would be used to measure joint range of motion?

    <p>Goniometer</p> Signup and view all the answers

    Which of the following would best document objective data?

    <p>Blood pressure reading of 120/80 mmHg</p> Signup and view all the answers

    What does tympany sound like in terms of pitch and duration?

    <p>Medium and musical</p> Signup and view all the answers

    During a general survey, which aspect is NOT typically assessed?

    <p>Medical history</p> Signup and view all the answers

    If a patient does not appear to be their stated age, this should be noted during which assessment?

    <p>General survey</p> Signup and view all the answers

    What does the acronym A&O X3 represent in documentation?

    <p>Alert and Oriented to three places</p> Signup and view all the answers

    During which stage of the health interview do you gather detailed medical history?

    <p>Information gathering stage</p> Signup and view all the answers

    What type of questions should be used primarily to control the pace of the interview?

    <p>Nondirective questions</p> Signup and view all the answers

    Which of the following best defines the chief concern in health history?

    <p>A brief statement of the reason for seeking care</p> Signup and view all the answers

    Which of the following is NOT included in the review of systems?

    <p>Childhood illnesses</p> Signup and view all the answers

    What information does the 'Severity' component of the HPI assess?

    <p>How bad the pain is on a scale from 0 to 10</p> Signup and view all the answers

    Which aspect is primarily focused on human responses to health problems?

    <p>Nursing history</p> Signup and view all the answers

    What is the main purpose of the functional assessment in client evaluation?

    <p>To determine the client's ability to care for themselves</p> Signup and view all the answers

    Which psychosocial factor is considered when assessing a client's health practices?

    <p>Nutritional patterns</p> Signup and view all the answers

    During an interview, which type of question is best to introduce new sections?

    <p>Nondirective questions</p> Signup and view all the answers

    Which component of the HPI describes what makes the pain feel better or worse?

    <p>Palliative/Provocation</p> Signup and view all the answers

    What information is included when documenting a client’s vital signs?

    <p>Pain level and temperature</p> Signup and view all the answers

    Which element is considered in the 'Sleep/rest patterns' of psychosocial history?

    <p>Quality and duration of sleep</p> Signup and view all the answers

    What is the normal adult range for pulse beats per minute at rest?

    <p>60-100 beats per minute</p> Signup and view all the answers

    When measuring blood pressure, how should the cuff be positioned?

    <p>1 inch above the antecubital area</p> Signup and view all the answers

    Which position should a patient be in for a rectal temperature measurement?

    <p>Sim’s position with the right leg flexed</p> Signup and view all the answers

    What indicates bradycardia in a patient?

    <p>Pulse under 60 beats per minute</p> Signup and view all the answers

    What is the expected range for respiratory rate in adults?

    <p>12-20 breaths per minute</p> Signup and view all the answers

    Which device is used to measure oxygen saturation levels?

    <p>Pulse oximeter</p> Signup and view all the answers

    What is the effect of using a blood pressure cuff that is too large?

    <p>Falsely low reading</p> Signup and view all the answers

    Which pulse point is located at the wrist?

    <p>Radial</p> Signup and view all the answers

    Which range indicates normal blood pressure classification?

    <p>less than 120 systolic and less than 80 diastolic</p> Signup and view all the answers

    What is the expected response for pulse strength of 3+?

    <p>Brisk, expected</p> Signup and view all the answers

    What is bradypnea?

    <p>Slow breathing</p> Signup and view all the answers

    What is the minimum effective oxygen saturation for clients with chronic lung disease?

    <p>80-85%</p> Signup and view all the answers

    What is the best method for assessing a client’s pain level?

    <p>Client’s self-report</p> Signup and view all the answers

    What should be avoided when taking a pulse oximetry reading?

    <p>Nail polish or gel</p> Signup and view all the answers

    Which method is used to assess strength and quality of a pulse?

    <p>Feeling for regularity of pulsations</p> Signup and view all the answers

    Which factor is NOT recognized as influencing respiratory rate?

    <p>Skin elasticity</p> Signup and view all the answers

    What is the primary purpose of conducting a review of systems during a patient evaluation?

    <p>To evaluate overall health and identify unexpected manifestations</p> Signup and view all the answers

    Which tool is generally NOT used for measuring blood pressure?

    <p>A pulse oximeter</p> Signup and view all the answers

    In the health interview process, which component is NOT part of the 'PLEASE' acronym?

    <p>Physical examination findings</p> Signup and view all the answers

    Which thermometer type is least likely to provide an accurate measurement due to its location?

    <p>Axillary thermometer</p> Signup and view all the answers

    What should be considered when interpreting oxygen saturation readings?

    <p>Skin pigmentation and thickness</p> Signup and view all the answers

    Which respiratory assessment technique is essential for determining the respiratory rate accurately?

    <p>Observing chest rise and fall</p> Signup and view all the answers

    Which of the following is a factor affecting blood pressure measurements?

    <p>Volume of circulating blood</p> Signup and view all the answers

    Which technique is primarily used to assess areas of swelling or pain during a skin assessment?

    <p>Palpation</p> Signup and view all the answers

    What is the primary method used to evaluate respiratory abnormalities during a physical examination?

    <p>Auscultation</p> Signup and view all the answers

    Which of the following tools is considered essential for accurately measuring blood pressure?

    <p>Sphygmomanometer</p> Signup and view all the answers

    During the health interview, which component primarily gathers information about current health concerns?

    <p>Chief complaint</p> Signup and view all the answers

    What is the primary purpose of the review of systems in assessing a client's health?

    <p>To identify any additional health issues</p> Signup and view all the answers

    What is the primary technique used to examine the skin for abnormalities?

    <p>Inspection</p> Signup and view all the answers

    Which of the following is a key method used in assessing the respiratory system?

    <p>Listening through a stethoscope</p> Signup and view all the answers

    What is the purpose of utilizing an appropriate blood pressure cuff size during measurement?

    <p>To ensure accurate readings</p> Signup and view all the answers

    Which component of the health interview mainly focuses on the patient's past medical history and current health?

    <p>Health history</p> Signup and view all the answers

    What is the primary purpose of conducting a review of systems?

    <p>To identify potential health issues across different body systems</p> Signup and view all the answers

    When palpating a patient's abdomen, what is the primary goal?

    <p>To identify masses or areas of pain</p> Signup and view all the answers

    Which factor is NOT considered when examining the respiratory system?

    <p>Skin integrity</p> Signup and view all the answers

    What is the importance of assessing both internal and external factors during a functional assessment?

    <p>To understand the patient's complete health picture</p> Signup and view all the answers

    Which communication technique is most effective for gathering sensitive information during a health interview?

    <p>Open-ended questions</p> Signup and view all the answers

    During the review of systems, which component would be evaluated last?

    <p>Whole-body systems</p> Signup and view all the answers

    Which assessment technique is most effective for evaluating skin hydration?

    <p>Turgor test</p> Signup and view all the answers

    What is the primary purpose of a respiratory assessment in a health evaluation?

    <p>To identify both structural and functional abnormalities</p> Signup and view all the answers

    Which blood pressure measurement tool offers the highest level of accuracy in a clinical setting?

    <p>Aneroid sphygmomanometer</p> Signup and view all the answers

    During a health interview, which component is crucial to establishing rapport with the patient?

    <p>Engaging in small talk before delving into health concerns</p> Signup and view all the answers

    What is the primary function of the review of systems in a comprehensive health assessment?

    <p>To identify symptoms related to different body systems</p> Signup and view all the answers

    In assessing skin color variations in a health assessment, which observation would most likely indicate cyanosis?

    <p>Bluish tint observed in the lips and fingertips</p> Signup and view all the answers

    During respiratory assessment, which method is most beneficial for assessing breath sounds?

    <p>Auscultation with a stethoscope</p> Signup and view all the answers

    When measuring blood pressure, what is the most critical factor to ensure accurate readings?

    <p>Using a cuff size appropriate for the patient's arm</p> Signup and view all the answers

    Which of the following is least likely included in the health interview component when assessing a patient?

    <p>Providing a full physical examination</p> Signup and view all the answers

    Which symptom would most likely warrant further investigation during a review of systems?

    <p>Persistent shortness of breath</p> Signup and view all the answers

    What aspect of skin assessment pertains to the examination of color and texture?

    <p>Color and texture inspection</p> Signup and view all the answers

    Which method is best suited for evaluating respiratory function in a clinical setting?

    <p>Use of a stethoscope for auscultation</p> Signup and view all the answers

    When measuring blood pressure, which tool is critical for obtaining accurate readings?

    <p>Sphygmomanometer</p> Signup and view all the answers

    What is primarily documented during the health interview component focused on client history?

    <p>All previous hospitalizations</p> Signup and view all the answers

    The purpose of the review of systems (ROS) is to:

    <p>Identify potential health issues by assessing various body systems</p> Signup and view all the answers

    Which of the following factors is NOT typically assessed when evaluating skin condition?

    <p>Weight appropriate for height</p> Signup and view all the answers

    When conducting a respiratory assessment, which of the following findings is a red flag?

    <p>Wheezing or crackles</p> Signup and view all the answers

    In which situation is it critical to re-evaluate the client's blood pressure readings?

    <p>After any cardiovascular symptoms arise</p> Signup and view all the answers

    Which component of the health interview is essential for tailoring care plans?

    <p>Previous health care experiences</p> Signup and view all the answers

    Which element is crucial when assessing overall behavior during the general survey?

    <p>Posture and movement stability</p> Signup and view all the answers

    Study Notes

    Nursing and Medical Diagnoses

    • Nursing diagnosis defines patient health that nurses can manage independently, focusing on prevention and treatment.
    • Medical diagnosis specifies diseases or injuries, aiming to identify pathologies for appropriate treatment.

    Planning Stages

    • Initial Planning involves developing a comprehensive care plan upon first patient contact.
    • Ongoing Planning updates care plans based on patient progress and prioritization of issues.
    • Discharge Planning promotes self-care and continuity of care post-discharge, enhancing health management and reducing readmissions.

    Nursing Care Plan

    • Serves as a holistic guide for individualized, goal-oriented nursing care.
    • Details dependent, interdependent, and independent nursing actions necessary for patient care.

    Implementation and Evaluation

    • Implementation entails executing interventions and adhering to the care plan.
    • Evaluation assesses patient progress, care effectiveness, and overall nursing quality using practical judgment.

    Evaluation Types

    • Structure Evaluation assesses the care setting.
    • Process Evaluation reviews the activities performed.
    • Outcomes Evaluation measures observable health changes from care delivered.

    Critical Thinking in Nursing

    • Critical thinking involves systematic collection and analysis of patient data to identify needs and guide care.
    • Nurses establish care priorities based on measurable outcomes and selected interventions.
    • Reflection is vital for assessing care effectiveness and improving future nursing judgments.

    Assessment Techniques

    • Auscultation techniques include direct listening and indirect methods using a stethoscope for various body sounds.
    • Documentation methods like SOAPIE, DAR, and PIE help structure patient records accurately and legally.

    Health Assessment Tools

    • Various tools, such as nasoscope and transilluminator, assist in examining different body parts and functions.
    • Goniometer, calipers, and scales measure joint range, body fat, and weight respectively.

    Vital Signs and Measurements

    • Normal temperature ranges from 96.8 to 100.4°F, with methods including oral, rectal, axillary, temporal, and tympanic.
    • Adult pulse ranges from 60-100 bpm; tachycardia indicates a faster pulse, while bradycardia indicates a slower rate.
    • Respiratory rate is expected to be 12-20 breaths per minute, while blood pressure classifications range from normal to hypertension.

    Pain Assessment

    • Self-reported pain assessment is most reliable, utilizing a scale from 0 to 10 to evaluate intensity and impact.

    Client Interview Process

    • The interview gathers subjective data and progresses through three stages: opening, information gathering, and closing.
    • It uses nondirective (open-ended) and directive (closed-ended) questions to facilitate structured conversations.

    Health Histories

    • Medical History focuses on illnesses and treatments, while Nursing History emphasizes responses to health problems.
    • Current Health History entails chief concerns, symptoms analysis, medication use, and substance use.
    • Past Health History includes childhood illnesses, surgeries, and significant medical events.

    Family and Psychosocial History

    • Family history records health details of relatives, aiding in genetic risk assessment.
    • Psychosocial Background includes lifestyle, exercise patterns, stress coping mechanisms, and social support systems.

    Review of Systems

    • Evaluates overall health through targeted questions about symptoms across bodily systems, including respiratory, cardiovascular, and gastrointestinal.

    Functional Assessment

    • Assesses a client's ability to perform daily activities and manage self-care during non-acute illness phases, covering emotional and physical well-being.

    Overview of Vital Signs

    • Temperature Measurement: Skills include using different types of thermometers: oral, rectal, axillary, tympanic, and temporal.
    • Pulse Assessment: Palpation techniques to evaluate pulse quality, strength, rate, and rhythm at various sites including temporal, carotid, radial, and more.
    • Pulse Oximetry: Tools for measuring oxygen saturation; awareness of factors affecting readings, including circulation, skin type, and tobacco use.
    • Respiratory Assessment: Techniques for obtaining respiratory rate and recognizing influences on respiratory patterns.
    • Blood Pressure: Identification of assessment tools and knowledge of influences such as cardiac output and blood viscosity.
    • Pain Assessment: Differentiation of pain sources and validation of subjective through objective data.

    Health and Interviewing Overview

    • Health Interview Elements (PLEASE): Key components include past medical history, last oral intake, events leading to illness, allergies, symptoms, and medications.
    • Therapeutic Communication: Importance of prior learning; understanding health history and interview stages including opening, information gathering, and closing.
    • Past Health History: Recognition of components including family history.

    Review of Systems

    • Purpose: Evaluates overall health and identifies unexpected symptoms.
    • Conduct Order: Systematic evaluation from skin to whole-body systems.

    Functional Assessment

    • Purpose: Assesses self-care ability during non-acute illness periods, considering internal (self-concept, health literacy) and external factors (occupational health, environment).
    • Functional Assessment Questions: Identify areas to address regarding patient capabilities.

    Client Interview and Communication Techniques

    • Communication Styles: Differentiate between open-ended and direct questions; strategize for difficult inquiries.
    • Health History Components: Understand subjective vs. objective data along with psychosocial and cultural influences.

    Physical Assessment Techniques

    • Inspection: Visual assessment of the patient’s appearance and demeanor.
    • Palpation: Use of touch to assess swelling, masses, and pain, including light and deep techniques.
    • Auscultation: Listening to body sounds to detect potential health issues.

    Ethical and Safety Considerations

    • Ethical Principles: Key concepts include nonmaleficence, beneficence, autonomy, justice, and confidentiality.
    • Patient Privacy: Maintaining privacy through appropriate draping and awareness of individual preferences.
    • Mandatory Reporting Situations: Recognize instances such as neglect, abuse, and safety concerns requiring reporting.

    Assessment Techniques

    • Critical Thinking in Assessments: Involves evaluating health conditions based on observed data, medications, and treatments.
    • Measurement Techniques: Understanding techniques for height, weight, and BMI calculation.

    Communication Skills in Nursing

    • Therapeutic Communication Factors: Key elements include active listening, use of silence, and focus questions for effective data collection.

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    Description

    This quiz explores the concepts of nursing and medical diagnosis, as well as the planning involved in creating a nursing care plan. Understand the differences between diagnosing health status and disease, and the importance of creating effective care strategies. Test your knowledge on initial planning and intervention selection.

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