Nursing Process and Diagnosis Quiz
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Questions and Answers

What is the highest priority in the establishment of nursing diagnoses?

  • Evaluation of care plans
  • Client preference
  • Maslow’s Hierarchy of human needs
  • Preservation of life (correct)
  • What is the primary focus of the evaluation step in the nursing process?

  • Reviewing the financial cost of patient care
  • Determining the client's health status and progress (correct)
  • Assessing the nursing staff's performance
  • Collecting data for future research
  • Which of the following is NOT a component of planning in nursing diagnosis?

  • Designating evaluation methods
  • Performing surgery (correct)
  • Establishing priority diagnoses
  • Prescribing nursing interventions
  • Which type of evaluation assesses the immediate effects of the nursing care plan?

    <p>Impact evaluation (C)</p> Signup and view all the answers

    What should be included when writing an evaluative statement?

    <p>Outcomes of the care plan and client’s outcomes (B)</p> Signup and view all the answers

    In a collaborative diagnosis, what role does the nurse play?

    <p>Coordinates care based on medical diagnoses (D)</p> Signup and view all the answers

    Which approach is essential when prioritizing nursing diagnoses according to Maslow's Hierarchy?

    <p>Safety and security are prioritized over self-actualization. (C)</p> Signup and view all the answers

    What aspect of a client's status is not generally evaluated in the nursing process?

    <p>Sensitive personal information (C)</p> Signup and view all the answers

    What should the evaluation methods in nursing care plans primarily focus on?

    <p>Standards or criteria for client progress (C)</p> Signup and view all the answers

    In conducting an evaluation, which of the following methods would be appropriate?

    <p>Asking the client to demonstrate skills learned (C)</p> Signup and view all the answers

    Which of the following represents a three-part nursing diagnostic statement?

    <p>Anxiety related to change in environment as evidenced by insomnia. (C)</p> Signup and view all the answers

    What is the primary focus of a risk nursing diagnosis?

    <p>Addressing potential issues related to risk factors. (A)</p> Signup and view all the answers

    Which of the following is an example of a one-part statement in nursing diagnosis?

    <p>Readiness for enhanced family processes. (D)</p> Signup and view all the answers

    In the PES format, what does 'E' represent?

    <p>Etiology. (A)</p> Signup and view all the answers

    What would be an appropriate related factor in the nursing diagnosis 'Impaired memory'?

    <p>Age-related changes. (C)</p> Signup and view all the answers

    Which of the following correctly identifies a defining characteristic for 'ineffective airway clearance'?

    <p>Decreased breath sounds. (A)</p> Signup and view all the answers

    What is the correct structure of a two-part risk nursing diagnosis statement?

    <p>Risk for problem related to existing disease. (A)</p> Signup and view all the answers

    Which is true about 'related factors' in a nursing diagnosis?

    <p>They can include both physiological and psychological components. (D)</p> Signup and view all the answers

    What is a key principle of ethical nursing intervention?

    <p>Patient autonomy (A)</p> Signup and view all the answers

    Which of the following is NOT a component of a well-written outcome statement?

    <p>General expectations (B)</p> Signup and view all the answers

    What action should follow an individualized and measurable outcome statement?

    <p>Providing health teaching (D)</p> Signup and view all the answers

    In writing outcome statements, which modifier is important to specify?

    <p>How and when the action will be performed (A)</p> Signup and view all the answers

    Which of the following is an essential characteristic of a measurable outcome?

    <p>Defined performance criteria (C)</p> Signup and view all the answers

    What should be included in a nursing assessment during implementation?

    <p>Assisting in activities for clients (B)</p> Signup and view all the answers

    Which verb could be used in an expected outcome statement?

    <p>Will list (B)</p> Signup and view all the answers

    What is the primary focus of the balance between cost and care in nursing interventions?

    <p>Strike a balance between effective treatments and financial responsibility (D)</p> Signup and view all the answers

    What is a characteristic of a nursing sensitive outcome?

    <p>It can be achieved or influenced by nursing interventions. (C)</p> Signup and view all the answers

    Which component is NOT part of the SMART criteria when setting expected outcomes?

    <p>Marginal (B)</p> Signup and view all the answers

    In the context of writing nursing orders, what is the correct structure of a nursing order?

    <p>Subject + Action Verb + Descriptive Phase + Time Frame (D)</p> Signup and view all the answers

    Which type of nursing intervention relies on the nurse's judgment and knowledge?

    <p>Independent intervention (A)</p> Signup and view all the answers

    What is the purpose of problem-focused nursing diagnoses?

    <p>To reduce or eliminate contributing factors or promote wellness. (A)</p> Signup and view all the answers

    Which type of goal is specifically measurable within a defined timeframe?

    <p>Short-term goal (B)</p> Signup and view all the answers

    What type of nursing diagnosis aims to prevent possible health problems?

    <p>Risk nursing diagnosis (A)</p> Signup and view all the answers

    Which of the following is a goal related to the nursing intervention of reducing acute pain?

    <p>The client will identify three non-pharmacological pain-relieving methods. (C)</p> Signup and view all the answers

    What indicates that an outcome is partially achieved?

    <p>The plan of care needs revisions due to reduced problems. (D)</p> Signup and view all the answers

    Which of the following is NOT a cue when formulating accurate nursing diagnostic statements?

    <p>Using medical diagnosis as etiology. (B)</p> Signup and view all the answers

    When evaluating the client's understanding of hospital routines, which response indicates the outcome was achieved?

    <p>The client states an understanding of routines and treatments. (A)</p> Signup and view all the answers

    Which nursing diagnostic statement correctly differentiates etiology and symptoms?

    <p>Constipation related to lack of dietary fiber, evidenced by hard faeces. (A)</p> Signup and view all the answers

    If a problem still exists post-evaluation, what should be the next step?

    <p>Re-examine the entire plan of care. (C)</p> Signup and view all the answers

    Which statement is an example of a legally inadvisable nursing diagnosis statement?

    <p>Client is non-compliant with care instructions. (C)</p> Signup and view all the answers

    Which of these is an example of an achieved outcome in the context of nursing evaluation?

    <p>The client demonstrates improved coping strategies. (D)</p> Signup and view all the answers

    What should a nurse do if desired outcomes have not been achieved?

    <p>Revise the care plan based on new assessments. (A)</p> Signup and view all the answers

    Flashcards

    SOAP/SOAPIER

    A structured method for organizing client information and care plans in nursing.

    Evaluation in Nursing

    The assessment of a client's health status and effectiveness of the nursing care plan.

    Types of Evaluation

    Includes process, impact, and outcome evaluations to assess care effectiveness.

    Area of Evaluation

    Focus areas in nursing evaluations include cognitive, psychomotor, affective, and body function.

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    Evaluative Statement

    A summary of evaluation results comparing desired outcomes with client outcomes.

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    SMART goals

    A framework for setting specific, measurable, achievable, realistic, and timely goals.

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    Nursing sensitive outcomes

    Outcomes that can be influenced by nursing interventions.

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    Short-term goal

    A goal to be achieved within a short time frame, usually days to weeks.

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    Long-term goal

    A goal intended to be achieved over an extended period, usually months to years.

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    Independent interventions

    Nursing actions that the nurse can initiate without a physician's order.

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    Dependent interventions

    Nursing actions that require a physician's orders to implement.

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    Collaborative problems

    Nursing diagnoses that require input from multiple healthcare team members.

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    Components of nursing orders

    Details that specify the nurse's actions, including subject, action verb, descriptive phase, and time frame.

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    Nursing Diagnosis

    A clinical judgment about an individual's response to health conditions.

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    P.E.S. Format

    A three-part statement for writing diagnostic statements: Problem, Etiology, Symptoms.

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    Risk Nursing Diagnosis

    Two-part statement indicating potential problems due to risk factors.

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    Health-Promotion Nursing Diagnosis

    A one-part statement focusing on health enhancement readiness.

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    Defining Characteristics

    Signs and symptoms that support a nursing diagnosis.

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    Related Factors

    Conditions or situations related to the nursing diagnosis.

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    Diagnostic Label

    A term used to describe a nursing diagnosis based on clinical findings.

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    Example Diagnostic Statement

    A statement like 'Anxiety related to change in environment as evidenced by insomnia.'

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    Complications of Haemorrhage

    Potential adverse effects arising from excessive bleeding.

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    Priority Diagnosis

    The process of determining which health issues need immediate attention.

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    Maslow's Hierarchy

    A framework prioritizing human needs from basic to advanced.

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    Goal Setting in Nursing

    Establishing standards to evaluate patient outcomes and progress.

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    Autonomy

    The right of patients to make their own healthcare decisions.

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    Accountable

    Being responsible for one’s actions and outcomes in nursing.

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    Outcome Statements

    Statements that define expected results of nursing interventions.

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    Components of Outcome Statements

    Includes Subject, Action Verb, Conditions, Criteria, and Time.

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    Implementation in Nursing

    The process of carrying out nursing interventions and plans.

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    Health Teaching

    Educational activities to inform patients about their health and treatment.

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    Referral

    The process of directing a patient to another healthcare provider.

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    Outcome Achieved

    The actual problem has been resolved, and there are no new problems.

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    Outcome Partially Achieved

    The problem has been reduced, but there is a need for revisions or more time to achieve full resolution.

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    Outcome Not Achieved

    The problem still exists, requiring re-evaluation and potential revision of the care plan.

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    Desired Outcomes

    Goals set for the client, like feeling less anxious or understanding hospital routines.

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    Actual Outcomes

    What really happens versus the desired outcomes; evidence of care effectiveness.

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    Etiology in Nursing

    The cause or contributing factors of a health-related issue, vital for proper nursing diagnosis.

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    Signs vs. Symptoms

    Signs are observable indications of a problem, while symptoms are reported by the client.

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    Study Notes

    Nursing Process Overview

    • The nursing process is a systematic problem-solving approach for identifying and managing client health problems.
    • It employs a five-phase cyclical process: assessment, diagnosis, planning, implementation, and evaluation.
    • The process is client-centered, continuous, and evidence-based.
    • A holistic approach is emphasized, incorporating client perspectives and incorporating research-based knowledge and skills, caring, communication, and ethical principles

    Learning Outcomes

    • Students will be able to describe the five phases of the nursing process.
    • Students will understand the differences between nursing diagnoses and collaborative problems.
    • Students will comprehend the importance of nursing diagnoses and the nursing process in informing nursing care.
    • Students will be proficient in formulating appropriate nursing diagnostic statements.
    • Students will know how to apply the nursing process to develop a nursing care plan.
    • Students will be familiar with recent research on nursing diagnoses and care plans, and their applications.

    Nursing Process: Five Phases

    • Assessment: Collecting data (including subjective and objective information).
    • Diagnosis: Identifying patterns in collected data.
      • Includes significant cues, data gaps, conclusions on health status, etiologies, verifying and labeling diagnoses.
    • Planning : Establishing priorities, creating goals, expected outcomes, and interventions.
    • Implementation : Putting the plan into action.
    • Evaluation: Evaluating if goals were met and making necessary adjustments.

    Assessment: Details

    • Assessment is the initial step where nurses gather comprehensive data on patients.

    • Phases of assessment: initial comprehensive assessment, and ongoing assessment

    • Data Sources: nursing history/interview, physical exam, patient observation, medical records, and information from colleagues.

    • Data Collection Methods: Interviews, physical assessment (head-to-toe), inspection, auscultation, percussion, palpation, vital signs, observation, diagnostic test results, and clinical records.

    • Data Types:

      • Subjective data (symptoms, patient experience).
      • Objective data (observable/measurable signs).
      • Primary data (collected directly from patient).
      • Secondary data (information from other sources like records).
    • Types of Assessment

      • Initial/baseline/screening: pre-determined data collection & initial problem identification (e.g., Gordon's Functional Health Patterns).

      • Ongoing: continuous, dynamic assessment to evaluate changes in condition.

    • Focus assessment: addressing specific issues

    Data organization

    • Organize data using models and frameworks like Gordon's Functional Health Patterns, body systems examination, and Maslow's Hierarchy of Needs.
    • Avoid vague language, ensuring clear and detailed documentation.

    Cues VS Inferences

    • Cues are specific factual data.
    • Inferences are conclusions based on data.
    • Accurate documentation differentiates between cues and inferences.

    Types of Nursing Diagnoses

    • Problem-focused diagnosis: addressing actual or potential health problems
    • Risk diagnosis: identifying vulnerabilities to developing problems.
    • Health promotion diagnosis: identifying strengths and promoting wellness.
    • Syndrome diagnosis: identifying a pattern of diagnoses.

    Writing Diagnostic Statements

    • Use the P.E.S. (Problem, Etiology, Signs/Symptoms) format: (Problem r/t Etiology a.e.b. Signs/Symptoms]

    • Examples for diagnoses are provided for clarity.

    Nursing Interventions Classification (NIC)

    • Classifies nursing interventions to guide interventions for each diagnosis.

    Planning Interventions

    • Adapting the care plan based on the client's condition is crucial and the plan to meet evolving needs is critical.

    Writing Nursing Orders

    • Subject, action verb, descriptive phase, time frame (e.g., q4h).
    • Nurses must abide by ethical and legal standards in their interventions, ensuring patient autonomy, their accountability, and balancing the cost and care implications.

    Writing Outcome Statements

    • Outcome statements should be Specific, Measurable, Achievable, Relevant, and Time-bound (SMART). They should be individualized, relevant to the client’s specific needs.

    Evaluation

    • Evaluating the client's health status according to the goals and the nursing care plan.
    • Assessing the effectiveness of the nursing care plan.
    • Methods of evaluation: Asking the client to verbalize their factors for wound healing, Asking the client to perform deep breathing techniques.
      • Determine whether the outcome was achieved or not.
    • Areas of assessment: Cognitive, psychomotor, affective, observing body functions and appearance; using the outcome statement.

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    Description

    Test your knowledge on the nursing process, including diagnosis, planning, and evaluation. This quiz covers key concepts like Maslow's Hierarchy, nursing diagnostic statements, and effective evaluation methods. Perfect for nursing students aiming to reinforce their understanding of the nursing care plan.

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