Nursing Process
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Questions and Answers

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

  • Assessment
  • Diagnosis
  • Planning
  • Treatment (correct)

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

  • Lab technician
  • Nurse
  • Physician
  • Client (correct)

    • What is the purpose of nursing diagnosis?

  • To prescribe medications
  • To identify health problems (correct)
  • To perform physical assessments
  • To determine medical conditions

    • Which organization publishes the NANDA-I diagnosis list?

    <p>NANDA-I (North American Nursing Diagnosis Association International)</p> Signup and view all the answers

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

    <p>Registered Nurse (RN)</p> Signup and view all the answers

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

    <p>Impaired Physical Mobility</p> Signup and view all the answers

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

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

    What is a goal in the context of the nursing process?

    <p>A statement that describes measurable, observable behavior</p> Signup and view all the answers

    Which of the following is NOT a secondary source of client data in the nursing process?

    <p>Client physical assessment</p> Signup and view all the answers

    What does ADPIE stand for in the nursing process?

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

    Which system does the term 'gastrointestinal' refer to?

    <p>Digestive system</p> Signup and view all the answers

    Which term refers to the absence or lack of heart rate?

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

    Which term refers to excessive or above normal pressure or stretching?

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

    What does the term 'urinary' refer to?

    <p>Urinary system</p> Signup and view all the answers

    What does the prefix 'Hypo-' mean?

    <p>Below or less than normal</p> Signup and view all the answers

    What does the suffix '-pnea' refer to?

    <p>Breathing/respiration</p> Signup and view all the answers

    What does the term 'vital signs' provide data about?

    <p>Patient's overall condition</p> Signup and view all the answers

    What does the prefix 'Tachy-' mean?

    <p>Fast heart</p> Signup and view all the answers

    What does the term 'mobility' refer to?

    <p>Patient's mobility</p> Signup and view all the answers

    What does the term 'baseline measurements' refer to?

    <p>Non-invasive measurements of life-sustaining functions</p> Signup and view all the answers

    Which one of these is true about nursing goals?

    <p>Goals are used to determine when the plan is completed</p> Signup and view all the answers

    Which one of these is an example of a short-term goal?

    <p>The client will remain free from skin breakdown for the duration of their hospitalization</p> Signup and view all the answers

    Which one of these is an example of a long-term goal?

    <p>The client will achieve a full recovery within 6 months</p> Signup and view all the answers

    Which one of these is not a characteristic of a SMART goal?

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

    During which phase of the nursing process are nursing interventions performed?

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

    When is a physical assessment typically performed?

    <p>On admission</p> Signup and view all the answers

    What is the role of an LPN in physical assessment?

    <p>Collect and report patient data</p> Signup and view all the answers

    What is the difference between signs and symptoms in a physical assessment?

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

    Which technique is used to listen to body organs for abnormal sounds?

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

    What is the purpose of a head-to-toe/system review in a physical assessment?

    <p>To assess the cardiovascular system</p> Signup and view all the answers

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

    <p>Nursing physical assessment</p> Signup and view all the answers

    What is the NANDA-I diagnosis list?

    <p>A list of nursing diagnoses</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

    What is an example of a nursing diagnosis?

    <p>Impaired Physical Mobility</p> Signup and view all the answers

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

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

    What is the purpose of a nursing diagnosis?

    <p>To identify health problems</p> Signup and view all the answers

    What does the term 'mobility' refer to?

    <p>Ability to move freely</p> Signup and view all the answers

    Which organization publishes the NANDA-I diagnosis list?

    <p>The North American Nursing Diagnosis Association International</p> Signup and view all the answers

    What does the term 'vital signs' provide data about?

    <p>Cardiovascular function</p> Signup and view all the answers

    What is a goal in the context of the nursing process?

    <p>A statement that describes measurable, observable behavior that the client should demonstrate after nursing interventions</p> Signup and view all the answers

    Which one of these is NOT a category that goals fall within?

    <p>Intermediate Goals</p> Signup and view all the answers

    When is a physical assessment typically performed?

    <p>On admission</p> Signup and view all the answers

    What does the term 'auscultation' refer to in a physical assessment?

    <p>Listening to body organs for abnormal sounds</p> Signup and view all the answers

    What does the term 'palpation' refer to in a physical assessment?

    <p>Touching or feeling the torso and limbs</p> Signup and view all the answers

    What does the term 'percussion' refer to in a physical assessment?

    <p>Using tapping movements to detect abnormalities of internal organs</p> Signup and view all the answers

    What does the term 'olfaction' refer to in a physical assessment?

    <p>Using the sense of smell</p> Signup and view all the answers

    What does the term 'level of consciousness' refer to in a neurological assessment?

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

    What does the term 'apical pulse' refer to in a cardiovascular assessment?

    <p>Strength and regularity of the pulse</p> Signup and view all the answers

    What does the term 'tachypnea' refer to in respiratory assessment?

    <p>Rapid breathing</p> Signup and view all the answers

    What does the term 'baseline measurements' refer to in a physical assessment?

    <p>Establishing a starting point for comparison</p> Signup and view all the answers

    Which one of these is a component of the gastrointestinal assessment?

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

    What does the prefix 'Brady-' refer to?

    <p>Slow heart</p> Signup and view all the answers

    What is the purpose of measuring vital signs?

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

    What does the term 'mobility' refer to?

    <p>Activity level</p> Signup and view all the answers

    What does the suffix '-cardia' refer to?

    <p>Heart/heart related</p> Signup and view all the answers

    What does the prefix 'Hyper-' mean?

    <p>Excessive or above normal</p> Signup and view all the answers

    What does the term 'baseline measurements' refer to?

    <p>Measurements against which changes can be measured</p> Signup and view all the answers

    What does the term 'urinary' refer to?

    <p>Urine amount, color, odor</p> Signup and view all the answers

    What does the prefix 'A-' mean?

    <p>Absence or lack of</p> Signup and view all the answers

    What does the term 'tachy-' mean?

    <p>Fast heart</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 purpose of a nursing diagnosis?

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

    What does the term 'apical pulse' refer to in a cardiovascular assessment?

    <p>Pulse felt over the heart</p> Signup and view all the answers

    What does the term 'tachypnea' refer to in respiratory assessment?

    <p>Rapid breathing</p> Signup and view all the answers

    When is a physical assessment typically performed?

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

    Which organization publishes the NANDA-I diagnosis list?

    <p>North American Nursing Diagnosis Association International</p> Signup and view all the answers

    What is the purpose of measuring vital signs?

    <p>To provide data about the client's baseline measurements</p> Signup and view all the answers

    What does the term 'tissue ischemia' refer to?

    <p>Reduced blood flow to tissues</p> Signup and view all the answers

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

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

    What is an example of a nursing diagnosis?

    <p>Impaired Physical Mobility</p> Signup and view all the answers

    Which one of these is an example of a gastrointestinal assessment?

    <p>Palpating masses and tenderness in the abdomen</p> Signup and view all the answers

    What does the suffix '-pnea' refer to in a physical assessment?

    <p>Breathing/respiration</p> Signup and view all the answers

    What does the prefix 'Hypo-' mean?

    <p>Below or less than normal</p> Signup and view all the answers

    What does the term 'mobility' refer to in patient assessment?

    <p>Assessing the activity level and gait of the patient</p> Signup and view all the answers

    What is the purpose of measuring vital signs?

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

    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.

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    Description

    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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