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Questions and Answers
What is the first step in the nursing process?
Which of the following types of assessments is aimed at identifying immediate health issues?
Which action is part of the implementing phase of the nursing process?
What is the main focus of nursing assessments?
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What role does validation play in the assessing phase?
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What is the main purpose of an initial assessment?
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When is a problem-focused assessment performed?
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What does an emergency assessment primarily aim to identify?
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What is meant by a time-lapsed reassessment?
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Which step is NOT involved in the assessment process?
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What does data clustering help the nurse to determine?
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Why is data collection considered systematic and continuous?
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What does the collecting data step in assessment refer to?
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After clustering data, what is the next step for the nurse and client?
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How can strengths of a client be identified?
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During which type of assessment is fluid intake and urinary output monitored?
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What is indicated when some data suggests a possible problem that disappears upon further clustering?
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Which aspect of assessment can provide insight into a client's strengths?
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What is one critical component of a basic two-part nursing diagnosis?
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What type of problems can a nurse identify after analyzing clustered data?
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What might be considered a strength in a client's health assessment?
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What are cues in nursing practice?
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When should a nurse validate data?
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What is the correct way to document a client's breakfast intake?
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Why is it important to record subjective data in the client's own words?
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What should a nurse watch for when assessing a child recovering from surgery with anxious parents?
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What does making an inference involve in nursing assessments?
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Which type of data does not require validation?
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What is a potential problem when restating clients' statements in nursing documentation?
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What skills does a nurse utilize when giving injections?
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What is involved in the evaluation step of the nursing process?
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Which of the following might indicate ineffective airway clearance?
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When a goal is not met, what is the nurse's next step?
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What might be a reason for goals not being met?
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What is a desired outcome for ineffective airway clearance?
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Which skill is essential for determining the appropriate intervention for a nursing diagnosis?
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What aspect does a nurse document during the implementation step?
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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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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.
