75 Questions
Which one of these is NOT a part of the gastrointestinal assessment mentioned in the text?
Assessing fluid intake
Which one of these is NOT a part of the urinary assessment mentioned in the text?
Measuring blood pressure
Which one of these is NOT a part of the mobility assessment mentioned in the text?
Measuring blood pressure
Which one of these is NOT a purpose of vital signs assessment mentioned in the text?
Serving as a diagnostic tool
Which one of these is a baseline measurement against which changes can be measured?
Vital signs
Which one of these prefixes means 'slow'?
Brady-
Which one of these prefixes means 'fast'?
Tachy-
Which one of these prefixes means 'without' or 'absence of'?
A-
Which one of these prefixes means 'below normal' or 'deficient'?
Hypo-
Which one of these suffixes means 'abnormal condition of breathing'?
-pnea
Which of the following is NOT a component of the nursing process?
Evaluation
Who is the primary source of client data in the nursing process?
The client
What is a nursing diagnosis?
A potential health problem
How often is the NANDA-I diagnosis list updated?
Every 2 years
Who is responsible for analyzing data and identifying health problems in the nursing process?
RN
Which of the following is an example of a nursing diagnosis?
Impaired Physical Mobility related to decreased muscle control
What does a nurse do during the planning phase of the nursing process?
Write desired client goals
What does ADPIE stand for in the nursing process?
Assessment, Diagnosis, Planning, Implementation, Evaluation
What is the role of the LPN in the nursing process?
Collecting data
What is the primary purpose of the nursing process?
To identify and address client's health problems
Which category of goals takes into account the long-lasting impact of illness or disease?
Long-term goals
When should a physical assessment be performed?
All of the above
What is the role of an LPN in physical assessment?
Perform a focused assessment
What are the two categories of goals?
Short-term goals and long-term goals
What is the purpose of setting SMART goals?
To make goals specific and measurable
What is the purpose of the nursing process implementation phase?
To put the established plan into action
What indicates that a client has either met or not met the established goal?
Completion of a care plan
What are the two types of data collection in a physical assessment?
Comprehensive assessment and focused assessment
What are the interviewing techniques used in a physical assessment?
Inspection, auscultation, palpation, percussion, olfaction
What should be monitored and noted in the respiratory assessment?
Crackles, rhonchi, wheezes, and pleural rub
Which of the following is NOT a component of the nursing process?
Treatment
What is the purpose of the nursing process implementation phase?
To carry out the planned interventions
Which one of these is NOT a part of the gastrointestinal assessment mentioned in the text?
Measuring blood pressure
What are the interviewing techniques used in a physical assessment?
Open-ended and closed-ended questions
What are the two types of data collection in a physical assessment?
Objective and subjective
What does a nurse do during the planning phase of the nursing process?
Develops a nursing care plan
What is a nursing diagnosis?
An actual health problem
Which one of these is NOT a part of the urinary assessment mentioned in the text?
Assessing heart sounds
What are the two categories of goals?
Short-term and long-term
Who is responsible for analyzing data and identifying health problems in the nursing process?
The RN
Which one of these is NOT a part of the respiratory assessment mentioned in the text?
Observing for distention
Which one of these prefixes means 'normal' or 'good'?
Eu-
What should be monitored and noted in the cardiovascular assessment?
Blood pressure
Which one of these is the appropriate activity level for a client who is able to move freely without restrictions?
Up ad-lib
Which one of these is the most accurate description of the purpose of vital signs assessment?
To provide data regarding the patient's overall condition
Which one of these prefixes means 'above normal' or 'excessive'?
Hyper-
What is the appropriate method to assess the presence of bowel sounds?
Auscultation
What is the appropriate method to assess the color and odor of urine?
Observation
What is the appropriate method to assess the presence of catheters?
Observation
What is the appropriate method to assess the activity level of a client?
Observation
What are the two categories of goals in nursing care planning?
Short-term and long-term goals
When should a physical assessment be performed?
On admission, at the beginning of each shift, when client condition changes, and when evaluating effectiveness of nursing care
What are the interviewing techniques used in a physical assessment?
Inspection, auscultation, palpation, percussion, and olfaction
What are the signs and symptoms used in a physical assessment?
Signs are objective and directly observable or measurable, while symptoms are subjective and verbalized by the patient
What is the role of the LPN in physical assessment?
Performs a focused assessment, collects and reports patient data, and performs indirect patient care based on data and MD orders
What is the purpose of setting SMART goals in nursing care planning?
To ensure that goals are specific, measurable, achievable, realistic, and timely
What is the primary purpose of the nursing process evaluation phase?
To determine the client's progress toward goal achievement and the effectiveness of nursing care
What are the two types of data collection in a physical assessment?
Comprehensive assessment and focused assessment
What is the primary source of client data in the nursing process?
The client/patient
What should be monitored and noted in the respiratory assessment?
Posterior and anterior lung sounds, respiration characteristics, and signs of abnormal breathing
Which one of these is NOT a part of the gastrointestinal assessment mentioned in the text?
Diet, appetite, fluid intake
What should be monitored and noted in the urinary assessment?
All of the above
What is the appropriate method to assess the activity level of a client?
All of the above
What is the appropriate method to assess the presence of bowel sounds?
Auscultating presence of bowel sounds x4
What is the purpose of the nursing process implementation phase?
To implement planned interventions
What is the purpose of the nursing process evaluation phase?
To determine the client's progress toward goal achievement and effectiveness of the nursing care plan
What is the appropriate method to assess the presence of bowel sounds?
Auscultation
What is the appropriate method to assess the color and odor of urine?
Olfaction
What is the primary source of client data in the nursing process?
Patient's self-report
Which one of these prefixes means 'without' or 'absence of'?
A-
Which of the following is NOT a component of the nursing process?
Intervention
What is the role of an LPN in physical assessment?
Collecting data
What is the appropriate method to assess the presence of bowel sounds?
Listening
What is the purpose of setting SMART goals in nursing care planning?
To ensure goals are specific, measurable, achievable, relevant, and time-bound
What does a nurse do during the evaluation phase of the nursing process?
Determine if goals were met
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.
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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