75 Questions
Which of the following is NOT a component of the nursing process?
Treatment
Who is considered the primary source of client data in the nursing process?
Client
What is the purpose of nursing diagnosis?
To identify health problems
Which organization publishes the NANDA-I diagnosis list?
NANDA-I (North American Nursing Diagnosis Association International)
Who is responsible for analyzing data and identifying health problems in the nursing process?
Registered Nurse (RN)
Which of the following is an example of a nursing diagnosis?
Impaired Physical Mobility
What does the nurse do during the planning phase of the nursing process?
Write desired client goals
What is a goal in the context of the nursing process?
A statement that describes measurable, observable behavior
Which of the following is NOT a secondary source of client data in the nursing process?
Client physical assessment
What does ADPIE stand for in the nursing process?
Assessment, Diagnosis, Planning, Intervention, Evaluation
Which system does the term 'gastrointestinal' refer to?
Digestive system
Which term refers to the absence or lack of heart rate?
A-
Which term refers to excessive or above normal pressure or stretching?
-tension
What does the term 'urinary' refer to?
Urinary system
What does the prefix 'Hypo-' mean?
Below or less than normal
What does the suffix '-pnea' refer to?
Breathing/respiration
What does the term 'vital signs' provide data about?
Patient's overall condition
What does the prefix 'Tachy-' mean?
Fast heart
What does the term 'mobility' refer to?
Patient's mobility
What does the term 'baseline measurements' refer to?
Non-invasive measurements of life-sustaining functions
Which one of these is true about nursing goals?
Goals are used to determine when the plan is completed
Which one of these is an example of a short-term goal?
The client will remain free from skin breakdown for the duration of their hospitalization
Which one of these is an example of a long-term goal?
The client will achieve a full recovery within 6 months
Which one of these is not a characteristic of a SMART goal?
Realistic
During which phase of the nursing process are nursing interventions performed?
Implementation
When is a physical assessment typically performed?
On admission
What is the role of an LPN in physical assessment?
Collect and report patient data
What is the difference between signs and symptoms in a physical assessment?
Signs are directly observable or measurable, while symptoms are verbalized by the patient
Which technique is used to listen to body organs for abnormal sounds?
Auscultation
What is the purpose of a head-to-toe/system review in a physical assessment?
To assess the cardiovascular system
What is the primary source of client data in the nursing process?
Nursing physical assessment
What is the NANDA-I diagnosis list?
A list of nursing diagnoses
Who is responsible for analyzing data and identifying health problems in the nursing process?
The RN
What is an example of a nursing diagnosis?
Impaired Physical Mobility
What does the nurse do during the planning phase of the nursing process?
Writes desired client goals
What is the purpose of a nursing diagnosis?
To identify health problems
What does the term 'mobility' refer to?
Ability to move freely
Which organization publishes the NANDA-I diagnosis list?
The North American Nursing Diagnosis Association International
What does the term 'vital signs' provide data about?
Cardiovascular function
What is a goal in the context of the nursing process?
A statement that describes measurable, observable behavior that the client should demonstrate after nursing interventions
Which one of these is NOT a category that goals fall within?
Intermediate Goals
When is a physical assessment typically performed?
On admission
What does the term 'auscultation' refer to in a physical assessment?
Listening to body organs for abnormal sounds
What does the term 'palpation' refer to in a physical assessment?
Touching or feeling the torso and limbs
What does the term 'percussion' refer to in a physical assessment?
Using tapping movements to detect abnormalities of internal organs
What does the term 'olfaction' refer to in a physical assessment?
Using the sense of smell
What does the term 'level of consciousness' refer to in a neurological assessment?
All of the above
What does the term 'apical pulse' refer to in a cardiovascular assessment?
Strength and regularity of the pulse
What does the term 'tachypnea' refer to in respiratory assessment?
Rapid breathing
What does the term 'baseline measurements' refer to in a physical assessment?
Establishing a starting point for comparison
Which one of these is a component of the gastrointestinal assessment?
Observing for distention
What does the prefix 'Brady-' refer to?
Slow heart
What is the purpose of measuring vital signs?
Provide data regarding patient's overall condition
What does the term 'mobility' refer to?
Activity level
What does the suffix '-cardia' refer to?
Heart/heart related
What does the prefix 'Hyper-' mean?
Excessive or above normal
What does the term 'baseline measurements' refer to?
Measurements against which changes can be measured
What does the term 'urinary' refer to?
Urine amount, color, odor
What does the prefix 'A-' mean?
Absence or lack of
What does the term 'tachy-' mean?
Fast heart
Which of the following is NOT a component of the nursing process?
Intervention
What is the purpose of a nursing diagnosis?
To identify the client's health problems
What does the term 'apical pulse' refer to in a cardiovascular assessment?
Pulse felt over the heart
What does the term 'tachypnea' refer to in respiratory assessment?
Rapid breathing
When is a physical assessment typically performed?
All of the above
Which organization publishes the NANDA-I diagnosis list?
North American Nursing Diagnosis Association International
What is the purpose of measuring vital signs?
To provide data about the client's baseline measurements
What does the term 'tissue ischemia' refer to?
Reduced blood flow to tissues
What is the primary source of client data in the nursing process?
The client
What is an example of a nursing diagnosis?
Impaired Physical Mobility
Which one of these is an example of a gastrointestinal assessment?
Palpating masses and tenderness in the abdomen
What does the suffix '-pnea' refer to in a physical assessment?
Breathing/respiration
What does the prefix 'Hypo-' mean?
Below or less than normal
What does the term 'mobility' refer to in patient assessment?
Assessing the activity level and gait of the patient
What is the purpose of measuring vital signs?
To provide data about the patient's overall condition
Study Notes
Nursing Process - ADPIE
- The nursing process consists of five components: Assessment, Diagnosis, Planning, Implementation, and Evaluation (ADPIE).
- Assessment involves collecting data from the client as well as other sources such as physical assessments, history and physical from physicians, lab and diagnostic test results, and information from other health personnel.
- Nursing diagnosis is determined after analyzing the collected data and involves identifying actual or potential health problems that can be addressed through nursing interventions.
- Nursing diagnoses are not the same as medical diagnoses and are updated every two years based on evidence-based practices by the North American Nursing Diagnosis Association International (NANDA-I).
- An example of a nursing diagnosis is "Impaired Physical Mobility related to decreased muscle control as evidenced by inability to control lower extremities."
- Planning involves generating a care plan with desired client goals, which are measurable and observable behaviors that the client should demonstrate after nursing interventions.
- Care plans include short-term goals that can be achieved within hours, days, or weeks, and long-term goals that consider the long-lasting impact of illness or disease.
- Setting SMART goals (Specific, Measurable, Achievable, Realistic, Timely) is important in the planning phase.
- Implementation is the phase where the established care plan is put into action, and nursing interventions are performed, including physical interventions, counseling, education, 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 to address any unsuccessful components.
- Physical assessment is an important part of data collection, which includes a comprehensive assessment of the whole person and focused assessments of specific body systems.
Test your knowledge of the nursing process components with this quiz on assessment, diagnosis, planning, interventions, and evaluation. Learn about the different sources of client data and how to conduct a thorough nursing physical assessment.
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