Sherpath Ch 16 Nursing Assessment WK1
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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.

    <p>feelings and perceptions</p> Signup and view all the answers

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

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

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

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

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

    <p>Forming diagnostic conclusions</p> Signup and view all the answers

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

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

    Which statement defines collaborative interventions?

    <p>Involve the expertise of health care team members</p> 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?

    <p>Facilitate communication.</p> Signup and view all the answers

    Which interventions reflect indirect nursing care?

    <p>Documenting medications administered</p> 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.

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

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

    <p>The patient’s achievement of short- and long-term goals</p> 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?

    <p>Recognizing errors</p> 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

    <p>Were the original goals realistic?</p> 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.

    <p>It is organized.</p> 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?

    <p>American Nurses Association</p> 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?

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

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

    <p>Secondary</p> 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?

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

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

    <p>Clustering patient data to identify patient problems</p> Signup and view all the answers

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

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

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

    <p>Planning</p> 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?

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

    Which intervention reflects direct nursing care?

    <p>Giving an injection</p> Signup and view all the answers

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

    <p>Evaluation</p> 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?

    <p>Evaluation</p> 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

    <p>Is collected data thorough and accurate?</p> Signup and view all the answers

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

    <p>Communicates patient problems</p> 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

    <p>Identifies common labels for nursing diagnoses</p> Signup and view all the answers

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

    <p>Planning</p> 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

    <p>Be accountable for safe practice.</p> Signup and view all the answers

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

    <p>Should the plan of care be discontinued?</p> Signup and view all the answers

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

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

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

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

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

    <p>Laboratory test results and physical examination</p> Signup and view all the answers

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

    <p>Prevention of complications</p> 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”?

    <p>Cues identified as the most significant patient data collected</p> Signup and view all the answers

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

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

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

    <p>The patient is 3 years old.</p> Signup and view all the answers

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

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

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

    <p>Experience with other patients</p> Signup and view all the answers

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

    <p>Which cues demand immediate attention?</p> Signup and view all the answers

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

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

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

    <p>Temperature of 102.4°F (39°C)</p> 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.

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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.

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