Professional practice final
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Questions and Answers

What does the 'E' in the nursing process ADPIE stand for?

  • Explain
  • Execute
  • Evaluate (correct)
  • Examine

    • Which step of the nursing process involves identifying the client's problem?

  • Plan
  • Implement
  • Assess
  • Diagnose (correct)

    • What is the primary purpose of the nursing process?

  • To identify, diagnose, and treat health problems (correct)
  • To provide medical treatment
  • To administer medications
  • To perform surgeries

    • Which of the following is NOT a step in the nursing process?

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

    What does the planning step of the nursing process entail?

    <p>Setting goals of care and desired outcomes</p> Signup and view all the answers

    Which type of assessment is performed upon a client's admission to establish a complete data base?

    <p>Initial assessment</p> Signup and view all the answers

    What is a key characteristic of the nursing process?

    <p>It is centered on the patient</p> Signup and view all the answers

    In the intervention step of ADPIE, what is the nurse primarily responsible for?

    <p>Performing the nursing actions identified in planning</p> Signup and view all the answers

    What type of data is defined as the patient's verbal descriptions of their health concerns?

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

    Which phase of the interview process focuses on gathering information from the patient?

    <p>Working phase</p> Signup and view all the answers

    Which of the following is a primary source of data in patient assessment?

    <p>Patient who is conscious and alert</p> Signup and view all the answers

    What is the first step in the nursing process?

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

    Which assessment technique involves listening for sounds produced by the body?

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

    An example of objective data includes which of the following?

    <p>Nurse observes a high temperature</p> Signup and view all the answers

    What is typically included in a nursing diagnosis?

    <p>A 2–3 part statement addressing the problem</p> Signup and view all the answers

    Which of the following data collection methods is used primarily to gather subjective data?

    <p>Patient interviews</p> Signup and view all the answers

    Which component of the nursing diagnosis identifies potential causes of a health issue?

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

    When conducting a focused assessment, what is the primary objective?

    <p>To prioritize life-threatening problems</p> Signup and view all the answers

    Which factor is NOT considered when selecting nursing interventions?

    <p>Patient insurance status</p> Signup and view all the answers

    What is the primary focus of the Nursing Outcomes Classification (NOC)?

    <p>To identify and classify nursing sensitive patient outcomes</p> Signup and view all the answers

    What should a nurse do if an order is unclear, incomplete, or inappropriate?

    <p>Contact the prescriber for clarification</p> Signup and view all the answers

    Which of the following is NOT a component of the evaluation process?

    <p>Initiating new medication orders</p> Signup and view all the answers

    A positive outcome in the evaluation process implies that:

    <p>The desired outcome has been met</p> Signup and view all the answers

    Which is the correct sequence of steps in interpreting and summarizing findings?

    <p>Examine outcome criteria, assess behavior, compare behaviors, judge agreement</p> Signup and view all the answers

    Which domain is considered the highest level within the Nursing Intervention Classification (NIC)?

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

    If a patient's pain level remains at 7/10 after 2.5 mg of IV morphine, this result is classified as what type of outcome?

    <p>Unmet outcome</p> Signup and view all the answers

    To enhance the condition of a patient, a nursing intervention is defined as:

    <p>Any treatment based on clinical judgment</p> Signup and view all the answers

    Which clinical category does not belong to the classes in Nursing Intervention Classification?

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

    What type of nursing diagnosis is represented by risk factors such as falls or dehydration?

    <p>Potential nursing diagnosis</p> Signup and view all the answers

    Which element is NOT part of a SMART goal statement?

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

    What distinguishes a nursing diagnosis from a medical diagnosis?

    <p>Nursing diagnoses are clinical judgments within nursing's domain.</p> Signup and view all the answers

    Which of the following represents a direct care intervention?

    <p>Conducting a patient education session</p> Signup and view all the answers

    Which of the following interventions is an example of a nurse-initiated intervention?

    <p>Instructing a patient on post-surgery care</p> Signup and view all the answers

    What is the primary focus of mutual goal setting in patient care?

    <p>To engage patients and families in care priorities</p> Signup and view all the answers

    Which phrase best defines an expected outcome in nursing care?

    <p>A projected measurable change in the patient’s condition</p> Signup and view all the answers

    What type of intervention requires an order or directive from a physician?

    <p>Dependent nursing intervention</p> Signup and view all the answers

    What characterizes a collaborative problem in nursing?

    <p>It requires collaboration with other healthcare disciplines.</p> Signup and view all the answers

    Which statement accurately describes a potential nursing diagnosis?

    <p>It signifies a risk factor for a future problem.</p> Signup and view all the answers

    Which source of data is primarily obtained from caregivers or a patient's medical record?

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

    A nursing diagnosis focuses only on the actual health problems, not potential ones.

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

    The primary source of data is the ________, who is conscious, safe, alert, and able to provide accurate information.

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

    Match the types of data sources with their descriptions:

    <p>Primary = Data obtained directly from the patient. Secondary = Data collected from caregivers or medical records. Tertiary = Information based on nurses' experiences or external sources.</p> Signup and view all the answers

    Which of the following is NOT a component of the evaluation process?

    <p>Educating the patient on their diagnosis</p> Signup and view all the answers

    Nurse-initiated interventions require a physician's order.

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

    Match the following types of nursing interventions with their definitions:

    <p>Nurse Initiated = Actions performed independently by nurses Dependent = Actions requiring physician's orders Collaborative = Interventions that involve multiple healthcare professionals Evaluation = Process of determining the effectiveness of a care plan</p> Signup and view all the answers

    Which Nursing intervention is an interdependent one

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

    Which action would a nurse take during the commitment level in critical thinking

    <p>Anticipate the need to make choices without assistance from other professional</p> Signup and view all the answers

    which indication is served by seeing a time frame for outcomes of care

    <p>When the patient is expected to respond in the desired manner</p> Signup and view all the answers

    Which action would the newly hired nurse take when asked to perform a procedure they have not previously performed. Select all that may apply

    <p>Learn about the procedure and gather knowledge</p> Signup and view all the answers

    What components makes up a nursing diagonsis

    <p>Diagnostic label</p> Signup and view all the answers

    Which term describes the process of thinking about patient issues, making inference, and deciding on the actions to be implemented in a particular situation

    <p>clinical reasoning</p> Signup and view all the answers

    Which action would the nurse take when unable to successfully perform a complex intervention for a patient

    <p>Ask for assistance from a senior nurse</p> Signup and view all the answers

    Study Notes

    Nursing Process Overview

    • The nursing process is a cognitive framework for identifying, diagnosing, and treating health issues using a holistic approach.
    • It is patient-centered, systematic, universally applicable, and guides clinical judgment, decision-making, and reflective practice.
    • The process involves five steps: Assessment, Diagnosis, Planning, Implementation, and Evaluation (ADPIE).

    Steps of the Nursing Process

    • Assessment: Gather comprehensive information about the client's condition.
    • Diagnosis: Identify the client’s health problems based on assessment data.
    • Planning: Establish care goals, desired outcomes, and appropriate nursing actions.
    • Implementation: Execute the nursing interventions identified during planning.
    • Evaluation: Assess if goals were met and outcomes achieved.

    Types of Assessments

    • Initial Assessment: Conducted at admission to establish a baseline data set.
    • Focused Assessment: Frequent evaluations on specific issues, depending on patient's status.
    • Emergency Assessment: Prioritization of life-threatening issues before completing a full assessment.

    Types of Data in Assessment

    • Subjective Data: Patient's verbal expressions of health concerns, such as feelings or self-reported symptoms.
    • Objective Data: Measurable or observable data, such as vital signs and physical examinations.

    Sources of Data

    • Primary: Directly from the patient when they are alert and able to provide accurate information.
    • Secondary: From caregivers or the patient's medical record, including shift reports and lab results.
    • Tertiary: From external sources such as textbooks and the nurse's experience with similar cases.

    Data Collection Methods

    • Interviews: Collect subjective information through structured phases:
      • Orientation: Explain purpose and confidentiality.
      • Working: Gather detailed information using open and closed questions.
      • Termination: Summarize and clinically conclude the interview with the patient.

    Nursing Diagnosis

    • A clinical judgment identifying actual or potential health issues within nursing's domain.
    • Nursing diagnoses follow a 2–3 part format: problem statement, etiology (cause), and defining characteristics.

    Differences in Diagnosis Types

    • Nursing Diagnosis: Focuses on health problems needing nursing intervention.
    • Medical Diagnosis: Identifies disease conditions based on specific evaluations.
    • Actual Nursing Diagnosis: Identifies present health issues.
    • Potential Nursing Diagnosis: Identifies risks for developing health issues.

    Goal Setting and Expected Outcomes

    • Goals are specific patient behaviors or physiological responses aimed for resolution of health problems.
    • SMART Criteria: Goals should be Specific, Measurable, Achievable, Relevant, and Timed.

    Implementation Strategies

    • Implementation includes executing planned nursing actions, managing care, and delegating tasks when necessary.
    • Direct Care Interventions: Direct interaction with patients (e.g., administering medications).
    • Indirect Care Interventions: Actions taken on behalf of patients (e.g., delegating nursing tasks).

    Nursing Intervention Classification (NIC)

    • Nursing interventions are categorized into domains and classes, helping in selecting appropriate actions based on patients' diagnoses.

    Evaluation Process

    • Final step assessing whether goal criteria and expected outcomes are met.
    • Evaluates through five elements: establishing criteria, data collection, findings interpretation, documentation, and care plan revision.
    • Positive outcomes indicate successful care interventions; unmet outcomes signal the need for adjustments.

    Nursing Outcomes Classification (NOC)

    • Developed to classify and label sensitive patient outcomes, aiding in evaluating nursing effectiveness.

    Evaluating Findings

    • To assess success, compare actual patient behaviors against established outcome criteria and investigate barriers to agreement when outcomes are not met.

    Evaluation in Nursing Process

    • Final step of the nursing process; assesses patient outcomes and effectiveness of care.
    • Involves examining a condition/situation and making judgments on whether change has occurred.
    • If nursing care is unsuccessful, the nursing process restarts to enhance patient well-being.

    Elements of the Evaluation Process

    • Identify evaluation criteria and standards to measure outcomes.
    • Collect data to assess whether set criteria or standards are met.
    • Interpret and summarize findings for understanding care effectiveness.
    • Document findings and clinical judgments for continuity and accountability.
    • Decide whether to terminate, continue, or revise the care plan based on evaluation.

    Factors for Selecting Interventions

    • Nursing diagnosis determines appropriate care strategies.
    • Establish clear goals and expected outcomes for the patient.
    • Interventions should be backed by evidence-based research.
    • Consider feasibility of interventions in the patient's context.
    • Ensure acceptability of interventions to the patient.
    • Assess the competence of the nursing staff involved in the interventions.

    Categories of Nursing Interventions

    • Nurse-Initiated Interventions:

      • Independent actions that do not require orders from other healthcare providers.
      • Grounded in evidence-informed decision-making.
      • Examples include assessing edema, educating patients about medication side effects, or instructing splinting during coughing.

    • Physician-Initiated Interventions:

      • Dependent actions needing orders from physicians.
      • Focuses on treating or managing specific medical diagnoses.
      • Nurse practitioners (NPs) can provide these orders.
      • Nurses must understand drug classifications, dosages, and potential adverse effects when administering medications.

    • Collaborative Interventions:

      • Require teamwork and combined expertise of multiple healthcare professionals.
      • Important to clarify unclear orders and maintain professional communication.
      • Nurses are accountable for their actions and should document any concerns professionally.

    Nursing Diagnosis

    • Determines health problems within nursing's scope.
    • A clinical judgment related to actual or potential health issues, guided by NANDA.
    • Distinguishes nursing roles from other healthcare providers, centering on nursing practice.

    Sources of Data for Evaluation

    • Primary Data: Obtained directly from the patient who is alert, safe, and able to provide reliable information.
    • Secondary Data: Collected from caregivers, medical records, and shift reports among nurses communicating essential patient information.
    • Tertiary Data: Information gathered from external sources, such as textbooks, prior nursing experiences, or patterns observed in similar patient cases.

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    Description

    Explore the nursing process and its significance in providing effective nursing care. This quiz delves into the historical development of the nursing process and its structured approach, highlighting its patient-centered focus and cognitive framework. Understand how the nursing process can be used to address health problems holistically.

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