The Nursing Process
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The Nursing Process

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Questions and Answers

Which one of these is NOT a part of the gastrointestinal assessment mentioned in the text?

  • Auscultating bowel sounds
  • Palpating masses
  • Assessing fluid intake (correct)
  • Observing for distention

    • Which one of these is NOT a part of the urinary assessment mentioned in the text?

  • Assessing urine amount
  • Evaluating urine odor
  • Measuring blood pressure (correct)
  • Checking urine color

    • Which one of these is NOT a part of the mobility assessment mentioned in the text?

  • Assessing activity level
  • Measuring blood pressure (correct)
  • Evaluating gait
  • Determining level of tolerance

    • Which one of these is NOT a purpose of vital signs assessment mentioned in the text?

    <p>Serving as a diagnostic tool</p> Signup and view all the answers

    Which one of these is a baseline measurement against which changes can be measured?

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

    Which one of these prefixes means 'slow'?

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

    Which one of these prefixes means 'fast'?

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

    Which one of these prefixes means 'without' or 'absence of'?

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

    Which one of these prefixes means 'below normal' or 'deficient'?

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

    Which one of these suffixes means 'abnormal condition of breathing'?

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

    Which of the following is NOT a component of the nursing process?

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

    Who is the primary source of client data in the nursing process?

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

    What is a nursing diagnosis?

    <p>A potential health problem</p> Signup and view all the answers

    How often is the NANDA-I diagnosis list updated?

    <p>Every 2 years</p> Signup and view all the answers

    Who is responsible for analyzing data and identifying health problems in the nursing process?

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

    Which of the following is an example of a nursing diagnosis?

    <p>Impaired Physical Mobility related to decreased muscle control</p> Signup and view all the answers

    What does a nurse do during the planning phase of the nursing process?

    <p>Write desired client goals</p> Signup and view all the answers

    What does ADPIE stand for in the nursing process?

    <p>Assessment, Diagnosis, Planning, Implementation, Evaluation</p> Signup and view all the answers

    What is the role of the LPN in the nursing process?

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

    What is the primary purpose of the nursing process?

    <p>To identify and address client's health problems</p> Signup and view all the answers

    Which category of goals takes into account the long-lasting impact of illness or disease?

    <p>Long-term goals</p> Signup and view all the answers

    When should a physical assessment be performed?

    <p>All of the above</p> Signup and view all the answers

    What is the role of an LPN in physical assessment?

    <p>Perform a focused assessment</p> Signup and view all the answers

    What are the two categories of goals?

    <p>Short-term goals and long-term goals</p> Signup and view all the answers

    What is the purpose of setting SMART goals?

    <p>To make goals specific and measurable</p> Signup and view all the answers

    What is the purpose of the nursing process implementation phase?

    <p>To put the established plan into action</p> Signup and view all the answers

    What indicates that a client has either met or not met the established goal?

    <p>Completion of a care plan</p> Signup and view all the answers

    What are the two types of data collection in a physical assessment?

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

    What are the interviewing techniques used in a physical assessment?

    <p>Inspection, auscultation, palpation, percussion, olfaction</p> Signup and view all the answers

    What should be monitored and noted in the respiratory assessment?

    <p>Crackles, rhonchi, wheezes, and pleural rub</p> Signup and view all the answers

    Which of the following is NOT a component of the nursing process?

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

    What is the purpose of the nursing process implementation phase?

    <p>To carry out the planned interventions</p> Signup and view all the answers

    Which one of these is NOT a part of the gastrointestinal assessment mentioned in the text?

    <p>Measuring blood pressure</p> Signup and view all the answers

    What are the interviewing techniques used in a physical assessment?

    <p>Open-ended and closed-ended questions</p> Signup and view all the answers

    What are the two types of data collection in a physical assessment?

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

    What does a nurse do during the planning phase of the nursing process?

    <p>Develops a nursing care plan</p> Signup and view all the answers

    What is a nursing diagnosis?

    <p>An actual health problem</p> Signup and view all the answers

    Which one of these is NOT a part of the urinary assessment mentioned in the text?

    <p>Assessing heart sounds</p> Signup and view all the answers

    What are the two categories of goals?

    <p>Short-term and long-term</p> Signup and view all the answers

    Who is responsible for analyzing data and identifying health problems in the nursing process?

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

    Which one of these is NOT a part of the respiratory assessment mentioned in the text?

    <p>Observing for distention</p> Signup and view all the answers

    Which one of these prefixes means 'normal' or 'good'?

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

    What should be monitored and noted in the cardiovascular assessment?

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

    Which one of these is the appropriate activity level for a client who is able to move freely without restrictions?

    <p>Up ad-lib</p> Signup and view all the answers

    Which one of these is the most accurate description of the purpose of vital signs assessment?

    <p>To provide data regarding the patient's overall condition</p> Signup and view all the answers

    Which one of these prefixes means 'above normal' or 'excessive'?

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

    What is the appropriate method to assess the presence of bowel sounds?

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

    What is the appropriate method to assess the color and odor of urine?

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

    What is the appropriate method to assess the presence of catheters?

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

    What is the appropriate method to assess the activity level of a client?

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

    What are the two categories of goals in nursing care planning?

    <p>Short-term and long-term goals</p> Signup and view all the answers

    When should a physical assessment be performed?

    <p>On admission, at the beginning of each shift, when client condition changes, and when evaluating effectiveness of nursing care</p> Signup and view all the answers

    What are the interviewing techniques used in a physical assessment?

    <p>Inspection, auscultation, palpation, percussion, and olfaction</p> Signup and view all the answers

    What are the signs and symptoms used in a physical assessment?

    <p>Signs are objective and directly observable or measurable, while symptoms are subjective and verbalized by the patient</p> Signup and view all the answers

    What is the role of the LPN in physical assessment?

    <p>Performs a focused assessment, collects and reports patient data, and performs indirect patient care based on data and MD orders</p> Signup and view all the answers

    What is the purpose of setting SMART goals in nursing care planning?

    <p>To ensure that goals are specific, measurable, achievable, realistic, and timely</p> Signup and view all the answers

    What is the primary purpose of the nursing process evaluation phase?

    <p>To determine the client's progress toward goal achievement and the effectiveness of nursing care</p> Signup and view all the answers

    What are the two types of data collection in a physical assessment?

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

    What is the primary source of client data in the nursing process?

    <p>The client/patient</p> Signup and view all the answers

    What should be monitored and noted in the respiratory assessment?

    <p>Posterior and anterior lung sounds, respiration characteristics, and signs of abnormal breathing</p> Signup and view all the answers

    Which one of these is NOT a part of the gastrointestinal assessment mentioned in the text?

    <p>Diet, appetite, fluid intake</p> Signup and view all the answers

    What should be monitored and noted in the urinary assessment?

    <p>All of the above</p> Signup and view all the answers

    What is the appropriate method to assess the activity level of a client?

    <p>All of the above</p> Signup and view all the answers

    What is the appropriate method to assess the presence of bowel sounds?

    <p>Auscultating presence of bowel sounds x4</p> Signup and view all the answers

    What is the purpose of the nursing process implementation phase?

    <p>To implement planned interventions</p> Signup and view all the answers

    What is the purpose of the nursing process evaluation phase?

    <p>To determine the client's progress toward goal achievement and effectiveness of the nursing care plan</p> Signup and view all the answers

    What is the appropriate method to assess the presence of bowel sounds?

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

    What is the appropriate method to assess the color and odor of urine?

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

    What is the primary source of client data in the nursing process?

    <p>Patient's self-report</p> Signup and view all the answers

    Which one of these prefixes means 'without' or 'absence of'?

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

    Which of the following is NOT a component of the nursing process?

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

    What is the role of an LPN in physical assessment?

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

    What is the appropriate method to assess the presence of bowel sounds?

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

    What is the purpose of setting SMART goals in nursing care planning?

    <p>To ensure goals are specific, measurable, achievable, relevant, and time-bound</p> Signup and view all the answers

    What does a nurse do during the evaluation phase of the nursing process?

    <p>Determine if goals were met</p> Signup and view all the answers

    Study Notes

    Overview of the Nursing Process

    • The nursing process consists of five components: Assessment, Diagnosis, Planning, Implementation, and Evaluation (ADPIE).
    • Assessment involves collecting data from the client, including physical assessments, medical history, lab results, and information from other healthcare professionals.
    • Nursing diagnoses are determined after analyzing the collected data and identifying actual or potential health problems that can be addressed through nursing interventions.
    • The NANDA-I diagnosis list, updated every two years, is used to guide nursing diagnoses based on evidence-based practices.
    • The RN is responsible for analyzing data and identifying health problems, while the LPN assists by collecting data.
    • Planning involves setting goals for the client and creating a care plan that includes nursing interventions to achieve those goals.
    • Goals can be short-term (achievable within hours, days, or weeks) or long-term (lasting impact of illness or disease).
    • SMART goals are specific, measurable, achievable, realistic, and timely.
    • Implementation is the phase where the established care plan is put into action, with nursing interventions performed and documented.
    • Nursing interventions can be independent (nursing orders) or dependent (prescribed orders generated by a healthcare provider).
    • Direct care interventions include physical interventions, counseling, and education, while indirect care involves delegation and supervision.
    • Evaluation involves determining the client's progress towards goal achievement and the effectiveness of the nursing care plan. If a goal is not met, a new care plan must be generated.

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    Description

    Test your knowledge of the nursing process with this quiz! Explore the components of ADPIE - assessment, diagnosis, planning, intervention, and evaluation - and learn about the primary and secondary sources of client data. Perfect for nursing students and professionals.

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