Sherpath Ch 16 Nursing Assessment WK1

Questions and Answers

Match the nursing process characteristic to its description.

Nurses evaluate patient results to determine effectiveness. = Collaborative The nursing process incorporates the interprofessional team. = Outcome oriented Nurses use critical thinking for each step of the nursing process. = Analytical The nursing process helps ensure that patient care is well planned. = Organized

Which component determines whether an assessment is primary or secondary?

Source of data (correct)

types of data

categories of data

objectivity of the data

Match the category of data with its description.

Obtained directly from patient = Primary Blood pressure reading and weight = Objective Direct quotes describing patient feelings = Subjective Obtained from other health care professionals or medical records = Secondary

Which examples reflect subjective data? Select all that apply.

feelings and perceptions Signup and view all the answers

Which nursing concept is defined as an actual or potential problem or response to a problem?

Diagnosis Signup and view all the answers

Which aspects do nurses make judgments about when determining initial nursing diagnoses? Select all that apply

Vulnerabilities Signup and view all the answers

Which action reflects a primary task in the analysis step of the nursing process?

Forming diagnostic conclusions Signup and view all the answers

Which term describes how the nursing process changes over time in response to patients’ individual needs?

Dynamic Signup and view all the answers

Which statement defines collaborative interventions?

Involve the expertise of health care team members Signup and view all the answers

Match the type of nursing intervention to the example.

<h1>Patient positioning = Independent Foley catheter insertion = Dependent Respiratory therapy consult = Interdependent</h1> Signup and view all the answers

Which function describes the primary purpose for documenting nursing interventions?

Facilitate communication. Signup and view all the answers

Which interventions reflect indirect nursing care?

Documenting medications administered Signup and view all the answers

During the implementation step of the nursing process, a nurse reviews and revises a patient’s plan of care. Place the steps of review and revision in the order in which each should occur.

Reassess the patient and Review and revise the existing plan of care. = 1 and 2 Anticipate and prevent complications. = 4 Organize resources and care delivery. = 3 Implement nursing interventions. = 5 Signup and view all the answers

Which aspect would the nurse consider as a component of the evaluation step of the nursing process?

The patient’s achievement of short- and long-term goals Signup and view all the answers

Which critical-thinking functions must the nurse perform to effectively evaluate patient goals during the final step of the nursing process?

Recognizing errors Signup and view all the answers

Which questions would the nurse ask when revising the plan of care because of unmet patient goals? Select all that apply

Were the original goals realistic? Signup and view all the answers

Which characteristics of the nursing process allow the nurse to effectively apply critical thinking to patient care? Select all that apply.

It is organized. Signup and view all the answers

Which organization defines standards of nursing practice and states that the nursing process forms the foundation for clinical decision making?

American Nurses Association Signup and view all the answers

Which step of the nursing process does the nurse use when obtaining the following patient information: blood pressure of 180/75, pulse of 90, and a complaint of chest pain?

Assessment Signup and view all the answers

Which type of data do the patient’s family members, friends, or other nurses provide?

Secondary Signup and view all the answers

Which type of patient assessment takes into account all factors, such as the patient’s physical, psychological, emotional, environmental, cultural, and spiritual health?

Holistic Signup and view all the answers

Which nursing action occurs during the analysis step of the nursing process?

Clustering patient data to identify patient problems Signup and view all the answers

During which step of the nursing process would the nurse establish long-term goals with the patient?

Planning Signup and view all the answers

Which part of the nursing process involves the nurse setting short-term goals for the patient?

Planning Signup and view all the answers

Which step of the nursing process involves carrying out nursing actions designed to meet a patient’s unique needs?

Implementation Signup and view all the answers

Which intervention reflects direct nursing care?

Giving an injection Signup and view all the answers

Which step of the nursing process considers the effectiveness of nursing care?

Evaluation Signup and view all the answers

Which step of the nursing process includes a decision point on whether to discontinue, continue, or revise the plan of care?

Evaluation Signup and view all the answers

Which questions are critical for the nurse to ask during each step in the nursing process? Select all that apply

Is collected data thorough and accurate? Signup and view all the answers

Which phrase describes the primary purpose of nursing analysis and diagnosis?

Communicates patient problems Signup and view all the answers

Which phrases describe the role of the International Classification for Nursing Practice (ICNP) in the nursing process? Select all that apply

Identifies common labels for nursing diagnoses Signup and view all the answers

During which step of the nursing process would the nurse prioritize nursing diagnoses?

Planning Signup and view all the answers

Which statements reflect the nurse’s role during the implementation step of the nursing process? Select all that apply

Be accountable for safe practice. Signup and view all the answers

Which questions would the nurse ask to evaluate the effectiveness of nursing interventions? Select all that apply

Should the plan of care be discontinued? Signup and view all the answers

Which characteristics describe the purpose of clinical judgment in nursing practice? Select all that apply.

Affects patient outcomes Signup and view all the answers

Which rationale supports the significance of recognizing patient cues as soon as the nurse enters the room?

The nurse is less likely to miss key information if listening to the patient and observing the environment. Signup and view all the answers

Which sources would the nurse use to collect objective patient cues during the assessment? Select all that apply.

Laboratory test results and physical examination Signup and view all the answers

Which priority outcome would the nurse associate with the ability to recognize subtle cues?

Prevention of complications Signup and view all the answers

Match the category for organizing patient cues to the appropriate description.

<h1>Significance of collected patient cues = Importance Findings that demand immediate attention = Degree of concern Degree to which cue is connected to a patient issue = Relevance</h1> Signup and view all the answers

Which patient cues would the nurse categorize as “important”?

Cues identified as the most significant patient data collected Signup and view all the answers

To effectively recognize patient cues, which concepts would the nurse need to understand? Select all that apply.

The first few minutes of the patient encounter are critical. Signup and view all the answers

Which factors can hinder the nurse’s ability to recognize patient cues?

The patient is 3 years old. Signup and view all the answers

Which examples are objective patient cues collected from the electronic health record?

Potassium level is 3.5 mmol/L and Blood pressure is 118/70 mm Hg. Signup and view all the answers

Which factor can influence the nurse’s ability to recognize and categorize patient cues?

Experience with other patients Signup and view all the answers

The answer to which question would help the nurse categorize patient cues according to the degree of concern?

Which cues demand immediate attention? Signup and view all the answers

Which patient cue would the nurse categorize as “urgent” for a patient diagnosed with pneumonia?

Shortness of breath Signup and view all the answers

Which patient cue would the nurse categorize as “important” for a patient diagnosed with a femur fracture?

Temperature of 102.4°F (39°C) Signup and view all the answers

Study Notes

Nursing Process Overview

The nursing process comprises assessment, diagnosis, planning, implementation, and evaluation phases, forming a systematic approach to patient care.
Critical thinking is essential throughout the process, enabling nurses to respond to patients' unique needs dynamically.

Assessment

Primary assessments involve direct patient data, while secondary assessments derive from other sources.
Subjective data is based on patient perceptions, experiences, and feelings, such as complaints of pain or emotional distress.
Objective data includes measurable information like vital signs or test results, often provided by family or healthcare professionals.
Comprehensive patient assessments account for physical, psychological, emotional, environmental, cultural, and spiritual factors.

Diagnosis

Nursing diagnoses identify actual or potential problems related to patient care.
The analysis step determines the need for long-term goals and prioritizes nursing diagnoses based on patient data.

Planning and Goal Setting

Long-term goals are set during the planning phase, while short-term goals are established to address immediate needs.
Review and revision of care plans include evaluating patient progress and adjusting goals accordingly.

Implementation

Direct nursing care involves actions such as administering medications or performing procedures.
Indirect nursing interventions include tasks like delegating responsibilities or coordinating care with other health professionals.
During the implementation phase, nurses must prioritize tasks and carry out actions tailored to the patient’s specific needs.

Evaluation

The evaluation step assesses the effectiveness of nursing interventions and the patient's progress toward goals.
It includes determining whether to continue, modify, or discontinue the care plan.
Critical questions revolve around the achievement of patient goals and the utilization of assessment findings for future modifications.

Clinical Judgment

Clinical judgment relates to interpreting patient cues, ensuring prompt recognition for effective response.
Understanding patient cues helps nurses prioritize interventions based on urgency and significance.
Objectives for recognizing patient cues include grasping comprehensive clinical information and environmental factors.

Factors Influencing Care

Factors hindering cue recognition include environmental distractions, lack of experience, and incomplete patient data.
Sources for objective cues include electronic health records, nursing observations, and vital sign documentation.

Questions for Evaluation

Evaluative questions focus on determining care effectiveness, such as assessing symptom improvement and patient feedback.
Engaging patients in assessments promotes active participation in their care planning and goal setting.

Roles of Nursing Standards

The International Classification for Nursing Practice (ICNP) aids in standardizing terminology and supports accurate nursing documentation and diagnosis.
Institutions define nursing practice standards that guide nurse's actions and responsibilities through systematic frameworks like the nursing process.

Studying That Suits You

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Description

Test your knowledge on the nursing process by matching its characteristics to their correct descriptions. This quiz will help reinforce your understanding of key concepts crucial for nursing practice.

Sherpath Ch 16 Nursing Assessment WK1

Questions and Answers

Match the nursing process characteristic to its description.

Which component determines whether an assessment is primary or secondary?

Match the category of data with its description.

Which examples reflect subjective data? Select all that apply.

Which nursing concept is defined as an actual or potential problem or response to a problem?

Which aspects do nurses make judgments about when determining initial nursing diagnoses? Select all that apply

Which action reflects a primary task in the analysis step of the nursing process?

Which term describes how the nursing process changes over time in response to patients’ individual needs?

Which statement defines collaborative interventions?

Match the type of nursing intervention to the example.

Which function describes the primary purpose for documenting nursing interventions?

Which interventions reflect indirect nursing care?

During the implementation step of the nursing process, a nurse reviews and revises a patient’s plan of care. Place the steps of review and revision in the order in which each should occur.

Which aspect would the nurse consider as a component of the evaluation step of the nursing process?

Which critical-thinking functions must the nurse perform to effectively evaluate patient goals during the final step of the nursing process?

Which questions would the nurse ask when revising the plan of care because of unmet patient goals? Select all that apply

Which characteristics of the nursing process allow the nurse to effectively apply critical thinking to patient care? Select all that apply.

Which organization defines standards of nursing practice and states that the nursing process forms the foundation for clinical decision making?

Which step of the nursing process does the nurse use when obtaining the following patient information: blood pressure of 180/75, pulse of 90, and a complaint of chest pain?

Which type of data do the patient’s family members, friends, or other nurses provide?

Which type of patient assessment takes into account all factors, such as the patient’s physical, psychological, emotional, environmental, cultural, and spiritual health?

Which nursing action occurs during the analysis step of the nursing process?

During which step of the nursing process would the nurse establish long-term goals with the patient?

Which part of the nursing process involves the nurse setting short-term goals for the patient?

Which step of the nursing process involves carrying out nursing actions designed to meet a patient’s unique needs?

Which intervention reflects direct nursing care?

Which step of the nursing process considers the effectiveness of nursing care?

Which step of the nursing process includes a decision point on whether to discontinue, continue, or revise the plan of care?

Which questions are critical for the nurse to ask during each step in the nursing process? Select all that apply

Which phrase describes the primary purpose of nursing analysis and diagnosis?

Which phrases describe the role of the International Classification for Nursing Practice (ICNP) in the nursing process? Select all that apply

During which step of the nursing process would the nurse prioritize nursing diagnoses?

Which statements reflect the nurse’s role during the implementation step of the nursing process? Select all that apply

Which questions would the nurse ask to evaluate the effectiveness of nursing interventions? Select all that apply

Which characteristics describe the purpose of clinical judgment in nursing practice? Select all that apply.

Which rationale supports the significance of recognizing patient cues as soon as the nurse enters the room?

Which sources would the nurse use to collect objective patient cues during the assessment? Select all that apply.

Which priority outcome would the nurse associate with the ability to recognize subtle cues?

Match the category for organizing patient cues to the appropriate description.

Which patient cues would the nurse categorize as “important”?

To effectively recognize patient cues, which concepts would the nurse need to understand? Select all that apply.

Which factors can hinder the nurse’s ability to recognize patient cues?

Which examples are objective patient cues collected from the electronic health record?

Which factor can influence the nurse’s ability to recognize and categorize patient cues?

The answer to which question would help the nurse categorize patient cues according to the degree of concern?

Which patient cue would the nurse categorize as “urgent” for a patient diagnosed with pneumonia?

Which patient cue would the nurse categorize as “important” for a patient diagnosed with a femur fracture?

Study Notes

Nursing Process Overview

Assessment

Diagnosis

Planning and Goal Setting

Implementation

Evaluation

Clinical Judgment

Factors Influencing Care

Questions for Evaluation

Roles of Nursing Standards

Studying That Suits You

Description

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