Nursing Process Overview Quiz
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Questions and Answers

What is the first step in the nursing process?

  • Implementing
  • Assessing (correct)
  • Evaluating
  • Diagnosing
  • Which of the following types of assessments is aimed at identifying immediate health issues?

  • Time-lapsed reassessment
  • Problem-focused assessment
  • Emergency assessment (correct)
  • Initial assessment
  • Which action is part of the implementing phase of the nursing process?

  • Analyze data
  • Reassess the client (correct)
  • Prioritize problems
  • Document data
  • What is the main focus of nursing assessments?

    <p>Client's responses to health problems</p> Signup and view all the answers

    What role does validation play in the assessing phase?

    <p>To ensure collected data is trustworthy</p> Signup and view all the answers

    What is the main purpose of an initial assessment?

    <p>To establish a complete database for problem identification</p> Signup and view all the answers

    When is a problem-focused assessment performed?

    <p>Ongoing process integrated with nursing care</p> Signup and view all the answers

    What does an emergency assessment primarily aim to identify?

    <p>Life-threatening problems</p> Signup and view all the answers

    What is meant by a time-lapsed reassessment?

    <p>Several months after the initial assessment</p> Signup and view all the answers

    Which step is NOT involved in the assessment process?

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

    What does data clustering help the nurse to determine?

    <p>Whether patterns exist in the data</p> Signup and view all the answers

    Why is data collection considered systematic and continuous?

    <p>To prevent omission of significant data</p> Signup and view all the answers

    What does the collecting data step in assessment refer to?

    <p>Gathering information about a client's health status</p> Signup and view all the answers

    After clustering data, what is the next step for the nurse and client?

    <p>Identify problems and strengths</p> Signup and view all the answers

    How can strengths of a client be identified?

    <p>Through the health assessment record</p> Signup and view all the answers

    During which type of assessment is fluid intake and urinary output monitored?

    <p>Problem-focused assessment</p> Signup and view all the answers

    What is indicated when some data suggests a possible problem that disappears upon further clustering?

    <p>The potential problem may not exist</p> Signup and view all the answers

    Which aspect of assessment can provide insight into a client's strengths?

    <p>Their work and social life</p> Signup and view all the answers

    What is one critical component of a basic two-part nursing diagnosis?

    <p>A statement of the client's response</p> Signup and view all the answers

    What type of problems can a nurse identify after analyzing clustered data?

    <p>Nursing diagnoses, medical diagnoses, or collaborative problems</p> Signup and view all the answers

    What might be considered a strength in a client's health assessment?

    <p>Absence of allergies and being a nonsmoker</p> Signup and view all the answers

    What are cues in nursing practice?

    <p>Subjective or objective data that can be observed</p> Signup and view all the answers

    When should a nurse validate data?

    <p>When there is a discrepancy between subjective and objective data</p> Signup and view all the answers

    What is the correct way to document a client's breakfast intake?

    <p>Coffee 240 mL, juice 120 mL, 1 egg, and 1 slice of toast</p> Signup and view all the answers

    Why is it important to record subjective data in the client's own words?

    <p>To avoid misinterpretation of what the client means</p> Signup and view all the answers

    What should a nurse watch for when assessing a child recovering from surgery with anxious parents?

    <p>Potential problems with the child's condition</p> Signup and view all the answers

    What does making an inference involve in nursing assessments?

    <p>Drawing conclusions based on observed cues</p> Signup and view all the answers

    Which type of data does not require validation?

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

    What is a potential problem when restating clients' statements in nursing documentation?

    <p>It can change the original meaning</p> Signup and view all the answers

    What skills does a nurse utilize when giving injections?

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

    What is involved in the evaluation step of the nursing process?

    <p>Determining if client goals have been met</p> Signup and view all the answers

    Which of the following might indicate ineffective airway clearance?

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

    When a goal is not met, what is the nurse's next step?

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

    What might be a reason for goals not being met?

    <p>Inappropriate nursing interventions</p> Signup and view all the answers

    What is a desired outcome for ineffective airway clearance?

    <p>Demonstrate behaviors to achieve airway clearance</p> Signup and view all the answers

    Which skill is essential for determining the appropriate intervention for a nursing diagnosis?

    <p>Critical thinking skills</p> Signup and view all the answers

    What aspect does a nurse document during the implementation step?

    <p>Specific interventions performed</p> Signup and view all the answers

    Study Notes

    Assessing

    • Assessing is continuous collection, organization, validation, and documentation of data in nursing.
    • Completeness of assessment impacts the accuracy of subsequent nursing steps.
    • Four types of assessments include:
      • Initial assessment: Establishes a complete baseline after admission.
      • Problem-focused assessment: Ongoing, evaluates specific health issues.
      • Emergency assessment: Conducted during crises to identify life-threatening problems.
      • Time-lapsed reassessment: Compares current status to previous baseline after some months.

    Assessment Steps

    • Steps consist of collecting diverse data, validating information, organizing findings, and identifying patterns.
    • Inferences are interpretations by the nurse based on objective and subjective cues observed.
    • Validating data is essential when discrepancies between subjective and objective information arise.

    Documenting Data

    • Accurate documentation of client data is crucial and should avoid personal interpretations.
    • Documentation should be factual; subjective reports must be recorded verbatim to maintain accuracy.
    • Example: Instead of stating "appetite good," record actual food intake to avoid subjective bias.

    Identifying Health Problems, Risks, and Strengths

    • After data analysis, strengths and problems are collaboratively identified by the nurse and client.
    • The nurse evaluates whether a problem is nursing, medical, or collaborative.
    • Strengths may include resources and coping abilities relevant to health.

    Formulating Diagnostic Statements

    • Nursing diagnoses typically comprise two or three part statements addressing client responses and related factors.
    • Basic two-part statement includes:
      • Problem (P): Client’s response (NANDA label).
      • Etiology: Related factors influencing the problem.

    Implementing

    • Implementation involves reassessing the client and determining nursing interventions required.
    • Nurses must document outcomes, interventions performed, and client responses.

    Evaluating

    • Evaluation determines whether client goals are met, partially met, or unmet.
    • Reasons for unmet goals may include incomplete initial data, unrealistic goals, or inappropriate interventions.
    • Evaluation is an ongoing process throughout nursing care, guiding future actions and modifications.

    Example Nursing Diagnosis: Ineffective Airway Clearance

    • Related to:
      • Tracheal bronchial inflammation, edema formation, increased sputum production, pleuritic pain, and decreased energy.
    • Evidenced by:
      • Abnormal respiratory rate and depth, abnormal breath sounds, dyspnea, cyanosis, and ineffective cough.
    • Desired outcome:
      • Display patent airway, effective breath sounds, and absence of dyspnea or cyanosis.

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    Related Documents

    Nursing Process PDF

    Description

    Test your knowledge on the nursing process by assessing your understanding of data collection, diagnosing health problems, planning interventions, and implementing care. This quiz covers key steps in the nursing process that are essential for delivering quality patient care.

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