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?

Connecting various pieces of data to identify relationships. Signup and view all the answers

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

Confusion about the next steps in care. Signup and view all the answers

What is the primary focus of nursing diagnosis?

Identifying patient health status for independent action Signup and view all the answers

Which stage of planning occurs after the initial patient contact?

Ongoing Planning Signup and view all the answers

What does discharge planning primarily aim to achieve?

Facilitating self-care after leaving healthcare settings Signup and view all the answers

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

Outcomes Evaluation Signup and view all the answers

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

Critically assessing patient data to identify health status Signup and view all the answers

What is the significance of the nursing care plan?

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

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

Process Evaluation Signup and view all the answers

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

Performing planned interventions based on the care plan Signup and view all the answers

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

Development of the initial comprehensive care plan Signup and view all the answers

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

Planning Signup and view all the answers

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

Flat Signup and view all the answers

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

To enhance the sense of hearing Signup and view all the answers

What kind of auscultation method involves directly listening for sounds?

Direct auscultation Signup and view all the answers

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

Diaphragm of the stethoscope Signup and view all the answers

What does the 'S' in SOAPIE documentation represent?

Subjective data Signup and view all the answers

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

Goniometer Signup and view all the answers

Which of the following would best document objective data?

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

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

Medium and musical Signup and view all the answers

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

Medical history Signup and view all the answers

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

General survey Signup and view all the answers

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

Alert and Oriented to three places Signup and view all the answers

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

Information gathering stage Signup and view all the answers

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

Nondirective questions Signup and view all the answers

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

A brief statement of the reason for seeking care Signup and view all the answers

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

Childhood illnesses Signup and view all the answers

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

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

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

Nursing history Signup and view all the answers

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

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

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

Nutritional patterns Signup and view all the answers

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

Nondirective questions Signup and view all the answers

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

Palliative/Provocation Signup and view all the answers

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

Pain level and temperature Signup and view all the answers

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

Quality and duration of sleep Signup and view all the answers

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

60-100 beats per minute Signup and view all the answers

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

1 inch above the antecubital area Signup and view all the answers

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

Sim’s position with the right leg flexed Signup and view all the answers

What indicates bradycardia in a patient?

Pulse under 60 beats per minute Signup and view all the answers

What is the expected range for respiratory rate in adults?

12-20 breaths per minute Signup and view all the answers

Which device is used to measure oxygen saturation levels?

Pulse oximeter Signup and view all the answers

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

Falsely low reading Signup and view all the answers

Which pulse point is located at the wrist?

Radial Signup and view all the answers

Which range indicates normal blood pressure classification?

less than 120 systolic and less than 80 diastolic Signup and view all the answers

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

Brisk, expected Signup and view all the answers

What is bradypnea?

Slow breathing Signup and view all the answers

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

80-85% Signup and view all the answers

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

Client’s self-report Signup and view all the answers

What should be avoided when taking a pulse oximetry reading?

Nail polish or gel Signup and view all the answers

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

Feeling for regularity of pulsations Signup and view all the answers

Which factor is NOT recognized as influencing respiratory rate?

Skin elasticity Signup and view all the answers

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

To evaluate overall health and identify unexpected manifestations Signup and view all the answers

Which tool is generally NOT used for measuring blood pressure?

A pulse oximeter Signup and view all the answers

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

Physical examination findings Signup and view all the answers

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

Axillary thermometer Signup and view all the answers

What should be considered when interpreting oxygen saturation readings?

Skin pigmentation and thickness Signup and view all the answers

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

Observing chest rise and fall Signup and view all the answers

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

Volume of circulating blood Signup and view all the answers

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

Palpation Signup and view all the answers

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

Auscultation Signup and view all the answers

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

Sphygmomanometer Signup and view all the answers

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

Chief complaint Signup and view all the answers

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

To identify any additional health issues Signup and view all the answers

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

Inspection Signup and view all the answers

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

Listening through a stethoscope Signup and view all the answers

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

To ensure accurate readings Signup and view all the answers

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

Health history Signup and view all the answers

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

To identify potential health issues across different body systems Signup and view all the answers

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

To identify masses or areas of pain Signup and view all the answers

Which factor is NOT considered when examining the respiratory system?

Skin integrity Signup and view all the answers

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

To understand the patient's complete health picture Signup and view all the answers

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

Open-ended questions Signup and view all the answers

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

Whole-body systems Signup and view all the answers

Which assessment technique is most effective for evaluating skin hydration?

Turgor test Signup and view all the answers

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

To identify both structural and functional abnormalities Signup and view all the answers

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

Aneroid sphygmomanometer Signup and view all the answers

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

Engaging in small talk before delving into health concerns Signup and view all the answers

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

To identify symptoms related to different body systems Signup and view all the answers

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

Bluish tint observed in the lips and fingertips Signup and view all the answers

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

Auscultation with a stethoscope Signup and view all the answers

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

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

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

Providing a full physical examination Signup and view all the answers

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

Persistent shortness of breath Signup and view all the answers

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

Color and texture inspection Signup and view all the answers

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

Use of a stethoscope for auscultation Signup and view all the answers

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

Sphygmomanometer Signup and view all the answers

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

All previous hospitalizations Signup and view all the answers

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

Identify potential health issues by assessing various body systems Signup and view all the answers

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

Weight appropriate for height Signup and view all the answers

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

Wheezing or crackles Signup and view all the answers

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

After any cardiovascular symptoms arise Signup and view all the answers

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

Previous health care experiences Signup and view all the answers

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

Posture and movement stability 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.