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Questions and Answers
Which phase comes after interventions in the nursing process?
Which phase comes after interventions in the nursing process?
What is the primary focus of physical assessment in nursing?
What is the primary focus of physical assessment in nursing?
Which of the following describes dependent nursing interventions?
Which of the following describes dependent nursing interventions?
What is required for a nurse to become proficient in physical assessment skills?
What is required for a nurse to become proficient in physical assessment skills?
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In the planning phase, what should a nurse do if outcomes are not met?
In the planning phase, what should a nurse do if outcomes are not met?
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Which assessment technique involves observing the client for physical characteristics?
Which assessment technique involves observing the client for physical characteristics?
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What is the primary purpose of documenting nursing actions?
What is the primary purpose of documenting nursing actions?
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Which type of intervention is considered indirect?
Which type of intervention is considered indirect?
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What is the primary purpose of health assessment in nursing?
What is the primary purpose of health assessment in nursing?
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Which phase of the assessment process involves explaining the purpose of the interview to the client?
Which phase of the assessment process involves explaining the purpose of the interview to the client?
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What is a crucial role of the nurse during the health assessment?
What is a crucial role of the nurse during the health assessment?
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How can effective interviewing skills impact health assessment?
How can effective interviewing skills impact health assessment?
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Which of the following activities is least relevant during the preparatory phase of the health assessment?
Which of the following activities is least relevant during the preparatory phase of the health assessment?
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What is one of the main benefits of preparing both the client and the environment for a health assessment?
What is one of the main benefits of preparing both the client and the environment for a health assessment?
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What component is essential in establishing trust during the introductory phase of the interview?
What component is essential in establishing trust during the introductory phase of the interview?
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What is one aspect that should NOT be neglected during the health assessment process?
What is one aspect that should NOT be neglected during the health assessment process?
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What is the primary purpose of focused assessment in nursing?
What is the primary purpose of focused assessment in nursing?
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Which assessment technique is primarily concerned with listening to body sounds?
Which assessment technique is primarily concerned with listening to body sounds?
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Which of the following is NOT an objective of the nursing process?
Which of the following is NOT an objective of the nursing process?
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During the time lapsed assessment, what is primarily evaluated?
During the time lapsed assessment, what is primarily evaluated?
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Which of the following phases in the nursing process comes after diagnosis?
Which of the following phases in the nursing process comes after diagnosis?
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What does clustering data during a nursing assessment help to achieve?
What does clustering data during a nursing assessment help to achieve?
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Which assessment skill involves the physical examination technique of applying pressure to identify abnormalities?
Which assessment skill involves the physical examination technique of applying pressure to identify abnormalities?
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What is the goal of implementation in the nursing process?
What is the goal of implementation in the nursing process?
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Study Notes
Nursing Process Review
- It's a systematic, rational method for planning and delivering individualized nursing care.
- Objectives include identifying patient needs, prioritizing care, maximizing strengths, resolving problems (actual or potential), and promoting health.
- Phases: Assessment, Diagnosis, Outcome Identification, Planning, Implementation, Evaluation.
Assessment
- Systematic and continuous collection, validation, and communication of patient data.
- Data base includes all patient information collected by healthcare professionals to enable effective care planning.
- Primary source is the patient. Secondary sources include: family, friends, medical history, physical examination, lab tests, and other professionals.
- Types: Initial (shortly after admission), Emergency (for physiological/psychological crisis), Time-lapsed (comparing current status to baseline).
Assessment Skills
- Observation
- Interviewing (direct and non-directive)
- Physical Examination Techniques (Inspection, Palpation, Percussion, Auscultation)
Assessment Activities
- Identify priorities based on assessment purpose and patient condition.
- Organize data for systematic collection.
- Establish data using nursing history, records, literature.
- Continuously update, validate, and communicate data.
Nursing Diagnosis
- Second step in the nursing process.
- Clinical judgment about individual, family, or community response to actual or potential health problems.
- Basis for developing nursing interventions.
- Activities: interpret and analyze patient data.
- Types: Actual, Risk, Possible, Wellness, Syndrome.
Types of Nursing Diagnoses
- Actual: Problem already validated by characteristics (e.g., Impaired physical mobility).
- Risk: Vulnerable to developing a problem (e.g., Risk for deficient fluid volume).
- Possible: Suspected problem (e.g., Chronic low self-esteem).
- Wellness: Transition to a higher level of wellness (e.g., Readiness for enhanced self-esteem).
- Syndrome: Cluster of actual or risk diagnoses (e.g., suspected to be present according to certain events).
Differentiating Nursing vs Medical Diagnoses
- Nursing diagnoses focus on unhealthy responses to health and illness, with treatments based on independent nurse practice.
- Medical diagnoses identify diseases, with treatments directed by physicians.
Nursing Planning
- Third step in the nursing process.
- Formulates guidelines for nursing actions to resolve diagnoses and develop a client care plan.
- Activities include establishing priorities, identifying expected outcomes, selecting evidence-based interventions, and communicating the care plan.
- Stages: Initial and Ongoing (to keep plan current by analyzing data).
Implementation
- Carrying out nursing interventions.
- Types: Dependent, Independent, Collaborative.
- Direct: Interaction with clients
- Indirect: Away from client (or behalf of).
Evaluation
- Last phase of the nursing process.
- Assessing the effectiveness of interventions by evaluating whether client goals are met.
- Outcome measures include whether the client achieved desired outcomes, and if interventions need modification.
Discharge Planning
- Best carried out by the nurse who worked most closely with the patient and family.
- Includes four critical elements: established priorities, goals, nursing intervention, documentation.
Physical Assessment
- Collection of objective data directly observed or elicited through examination techniques.
- Includes types and operations of equipment, preparation for examination, and performance of assessment techniques (inspection, palpation, percussion, auscultation).
- Equipment preparation, and preparing oneself and the client for an examination are also part of physical assessment.
Interviewing
- Four phases: Preparatory, Introductory, Maintenance, and Concluding.
- Preparatory involves preparing client and environment, introductory involves establishing rapport and discussing purpose, maintenance focuses on collecting and processing, and concluding confirms understanding and validates plans.
- Techniques include being non-judgmental, maintaining a professional distance, adopting appropriate appearance, observing and managing facial expressions, employing appropriate silence where necessary.
Listening
- The most important skill in gathering valid data.
- Maintain good eye contact, display appropriate facial expression, and an open posture to encourage participation.
- Avoid distracting behaviors and engage in silence to allow clients to reflect and accurately process information.
Communication
- Two main types are nonverbal and verbal.
- Nonverbal includes: appearance, demeanor, facial expression.
- Verbal includes: open-ended (How...), closed-ended (When..), and well-placed phrases.
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Description
Test your understanding of the nursing process, including its phases and assessment techniques. This quiz covers essential skills for effective patient care, focusing on systematic methods for planning and delivering individualized nursing interventions. Evaluate your knowledge on patient data collection and assessment strategies.
