question

This is a problem solving approach. It is a decision making framework which assists the nurse in determining what the needs of the patient are and how they can help care for the patient. This assists with providing appropriate, effective nursing care to the patient through thought, analysis and planning.

answer

THE NURSING PROCESS

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The Nursing Process is a _____ approach.

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Systemic

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The nursing process consists of 5 steps. What are the 5 steps?

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1.) Assessment 2.) Nursing Diagnosis 3.) Planning 4.) Implementation 5.) Evaluation

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Assessment and nursing diagnosis are the responsibilities of the:

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REGISTERED NURSE.

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In the nursing process, the LPN will participate directly in the steps of ___1___, ____2___ and ___3___. The LPN can CONTRIBUTE to the nursing __4___, however, the information they obtain must be shared and confirmed by the RN.

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1.) planning 2.) implementation 3.) evaluation 4.) diagnosis

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This is the 1st step in the nursing process:

answer

assessment

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Assessment is a ___1____, __2____ collection of data that helps in determining the __3__as well as the __4__ of the patient. This will help the nurse to decide what __5__ and ___6___ that the patient is using or has used. During step, it is a time where a nurse can form the ___7___. Assessment is performed by ___8___ the patient and by performing ___9___ assessment of the patient and it is a review of the lab and diagnostic testing.

answer

1.) deliberate 2.) systemic 3.) current and past health status 4.) functional health status 5.) coping mechanisms 6.) normal activities of daily living 7.) nurse-patient relationship 8.) interviewing 9.) head-to-toe

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Assessment consists of 5 steps. What are the 5 steps?

answer

1.) gathering of information aka data collection 2.) validating data 3.) organizing data 4.) Interpreting the data 5.) Documenting the data

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In the gathering of information aka data collection step, the information is gathered from many different sources in order to establish a database of information concerning the patient's __1__, __2__ and __3__ health. This will help us to identify __4__ behaviors and also either actual or potential __5__.

answer

1.) physical 2.) psychosocial 3.) emotional 4.) health promoting 5.) health problems

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In the validating data step of assessment, the data you collected must be __1__ and __2__ for the rest of the process will depend on the __3__. Your sources must be __4__ and there should not be any __5__. It is important to recheck __6__.

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1.) correct 2.) accurate 3.) data you collected 4.) reliable 5.) conflicting information 6.) abnormal findings

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In the organizing data step of assessment, it is important that the nurse makes the information available in an __1__ fashion so that the information will not only be useful for themselves, but for __2__. Related pieces of information need to __3__ in a __4__ way. This will help to focus on the __5__ of the correct patient problem.

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1.) orderly 2.) other health care professionals 3.) clustered together 4.) systemic 5.) indentification

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In the interpreting the data step of assessment, once the data is __1__, the nurse must be able to understand the __2__. Through __3__ and __4__. The nurse needs to be able to determine which of the data is __5__ and which is __6__. When interpreting the data, you need to know what the __7__ and __8__ are.

answer

1.) collected and organized 2.) meaning of the information 3.) reasoning 4.) judgment 5.) relevant 6.) irrelevant 7.) cause 8.) effect

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In the documenting the data step of the assessment, the information obtained, needs to be __1__, __2__ and __3__ recorded in order to communicate the information that was obtained through the assessment to the other health care members. By documenting the data, you are also providing a basis for planning and providing __4__ nursing care. The nurse also needs to decide which information needs to be __5__ immediately to others and determine which information needs to be __6__. Documentation is a __7__ and __8__ requirement that is found in the __9__.

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1.) accurately 2.) completely 3.) timely 4.) effective 5.) reported 6.) recorded 7.) legal 8.) professional 9.) Nurse Practice Acts

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The 3 types of assessments include:

answer

1.) comprehensive 2.) focused 3.) ongoing

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When a particular patient need, health concern or potential health risk is focused upon. These assessments have a limited scope and they are not nearly as detailed as your comprehensive assessments. You may use this type of assessment if the patient is going to have a short stay or if they are in a special area such as OB (obstetrics) or if they are in a mental health setting or if they are in a clinical setting. A.) comprehensive B.) focused C.) ongoing D.) physiological

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Answer: B

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This is an assessment that continues once the problems are identified and one needs to follow-up. With these assessments, it includes systematic monitoring and observation of the patient to validate the findings. This type of assessment will also help in determining problems that did not arise initially as well as responses to interventions that are aimed at problems. A.) comprehensive B.) focused C.) ongoing D.) physiological

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Answer: C

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This is an assessment that includes a complete health history and physical assessment along with the patient's current assessed needs. The purpose of a comprehensive assessment is to provide a baseline of information in which changes in the patient's health status can be measured against. The assessment is usually done upon admission to a health care facility. A.) comprehensive B.) focused C.) ongoing D.) physiological

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Answer: A

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Sources of data are considered __1__ or __2__.

answer

1.) subjective 2.) objective

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Subjective is also known as:

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symptom or covert data

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Objective is also known as:

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sign or overt data

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This is what the patient is feeling, thinking, perceiving or concerned about. With this data, only the patient knows for sure. 1 way to get this data from the patient is by interviewing them:

answer

subjective

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This is data which is observed or measured. One uses their senses to obtain the information. You can obtain this data via physical assessment and also by labs/diagnostic procedures:

answer

Objective

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Objective data will __1__ subjective data.

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Validate

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An example of this type of data would be if the patient reports being nauseated. This would be something only the patient knows:

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Subjective Data

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An example of this type of data would be if a patient looked pale and their skin felt cool and moist:

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Objective Data

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The 2 sources of data are:

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1.) primary 2.) secondary

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With this source, the patient will be your main source of data. This data can be objective or subjective data that one obtains from the patient:

answer

Primary

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These are sources other than the patient which may include their family members, health care providers and health records. Therefore the information you are obtaining is second hand information:

answer

Secondary

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There are 3 methods of data collection. These include:

answer

1.) Interview 2.) Observation 3.) Physical Examination or Assessment of Patient

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This method of data collection is organized, purposeful, structured conversation with the patient to gather subjective information for the database. A.) Interview B.) Observation C.) Physical Examination or Assessment of Patient

answer

Answer: A

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This method of data collection includes using your senses to collect and interpret data about the patient and their environment. You should systematically observe the patient each time you are in contact with them. A.) Interview B.) Observation C.) Physical Examination or Assessment of Patient

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Answer: B

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This method of data collection has 4 techniques that are used to obtain OBJECTIVE data which will help in detecting signs and symptoms that will help in formulating the nursing diagnosis. A.) Interview B.) Observation C.) Physical Examination or Assessment of Patient

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Answer: C

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The 4 techniques of physical examination or assessment of patient include:

answer

1.) inspection 2.) palpation 3.) percussion 4.) auscultation

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This technique includes striking the surface of the body with the tip of your finger to produce different vibrations and sounds which depend upon what you are finding in the area you are tapping. These sounds can be caused by air, fluid or solid areas. These will all have differing sounds or vibrations when compared to each other. A.) inspection B.) palpation C.) percussion D.) auscultation

answer

Answer: C

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This technique consists of light touch using your hands to determine areas of tenderness, then you will progress to deeper touch, using the pads of your fingers to examine the organs. A.) inspection B.) palpation C.) percussion D.) auscultation

answer

Answer: B

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This technique consists of the visual examination of the patient for any normal or abnormal findings. A.) inspection B.) palpation C.) percussion D.) auscultation

answer

Answer: A

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This technique consists of listening for sounds that are made by the patient or using a stethoscope to listen for normal or abnormal sounds within the body. A.) inspection B.) palpation C.) percussion D.) auscultation

answer

Answer: D

question

While conducting an interview, introduce yourself and explain your __1__. Establish a rapport, a sense of caring and a ___2___ with the patient.

answer

1.) role 2.) therapeutic relationship

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While conducting an interview, we want to build a community sense of __1__ and __2__ with the patient.

answer

1.) trust 2.) community

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During interview we gather information about the patient's __1___. In order to do that, we need to obtain a health history from the patient and we need to use __2__ questions. These are the most effective questions. We can use closed ended questions if necessary. If we are getting this health history from the patient, we want to ensure we are using communication strategies, such as; listening, clarifying, etc. We need to encourage the patient to share any concerns or worries as well as what they expect from the health care system.

answer

1.) health status 2.) open-ended

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These are the most effective questions in the interview process:

answer

open-ended questions

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True or False In the interview process, once we have gathered our information, we want to let the patient know the interview is ending. Example: "I have just two more questions to ask."

answer

Answer: True

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Once you have conducted an interview, you need to ____ the information and inquire if they have any questions.

answer

Summarize

question

North American Nursing Diagnosis Association. Established in 1982:

answer

NANDA

question

"Nursing diagnosis is a clinical judgment about individual, family or community responses to actual or potential health problems/life processes. A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable." What is this quote?

answer

Answer: NANDA definition

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This is the 2nd step of the nursing process:

answer

Nursing Diagnosis

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In the nursing diagnosis step, you need to use ____ thinking skills.

answer

Answer: critical

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Nursing diagnosis is exclusively a _____ function.

answer

Answer: nursing

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In the nursing diagnosis step, you need to focus on the ________ unlike a medical diagnosis which mostly includes signs, symptoms and lab results to identify a disease or condition.

answer

Answer: Needs of the patient

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Nursing diagnosis classifies health problems by addressing __1__, __2__, __3__ and __4__ needs of the patient. This sounds like a "__5__ approach."

answer

1.) physical 2.) psychosocial 3.) spiritual 4.) environmental 5.) holistic

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Nursing diagnosis is the basis for planning ____-___ goals and interventions

answer

patient-centered

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When nursing diagnoses are formulated, it is the responsibility of the __1__, not the __2__, although the __3__ may help.

answer

1.) registered nurse 2.) practical nurse 3.) practical nurse

question

There are 4 steps in nursing diagnosis. Name the 4 steps:

answer

1.) Analysis and Interpretation of the Data 2.) Problem Identification 3.) Formulation of Nursing Diagnosis 4.) Documentation of Nursing Diagnosis

question

In the "Analysis and Interpretation of the Data" step of nursing diagnosis, this would be to take data and use critical thinking to draw conclusions based upon your __1__ about your patient's health status. By doing so, you are able to narrow down your information to what is __2__. This will also give you the opportunity to determine if there is a need for new information or whether the patient needs to be __3__. You will need to engage in __4__ data which is a group of signs or symptoms that enable the nurse to discover a pattern, which leads them to the patient's problem.

answer

1.) assessment 2.) significant 3.) further assessed 4.) clustering

question

In the "Problem Identification" step of nursing diagnosis, the basis for this is identifying the defining characteristics that do not fall in the healthy ____.

answer

norm

question

In the "Formulation of Nursing Diagnosis" step of nursing diagnosis, to form the nursing diagnosis, you have to determine the problem by completing the previous steps and then select the __1__ from the approved __2__ list.

answer

1.) nursing diagnosis 2.) NANDA

question

In the "Documentation of Nursing Diagnosis" step of nursing diagnosis, in order to document your nursing diagnosis, you need to first __1__ the problems. This is often based on __2__. Once you have determined the first problem in the nursing diagnosis that envelopes that problem, then you will write a __3__

answer

1.) prioritize 2.) Maslow's Hierarchy of Needs 3.) nursing diagnosis

question

A group of signs or symptoms that enable the nurse to discover a pattern, which leads them to the patient's problem.

answer

clustering data

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Different factors that cause or contribute to the problem.

answer

etiology

question

Constipation...we know this is not in the healthy norm. We must be able to identify the problem's etiology in order to direct the nursing interventions. THIS IS AN EXAMPLE OF:

answer

problem identification

question

If problem is constipation, then the _____ may be that it is due to a lack of fiber.

answer

etiology

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This consists of both a problem and the etiology and possibly signs and symptoms. This is the name of the nursing diagnosis that is approved by NANDA. It is a word or a phrase representing a pattern of related data that describes a problem or a wellness response.

answer

problem statement or diagnostic label

question

In terms of nursing diagnosis, there are two types of statements. These 2 statements are:

answer

1.) two part statement 2.) three part statement

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In a two part statement, the first component is:

answer

the problem or diagnostic label describing the patient's response to an actual or potential health problem or wellness condition.

question

In a two-part statement, the second component is:

answer

the etiology of the problem or the different factors that cause or contribute to the problem.

question

In a three-part statement, the first two components are __1___ and ___2___.

answer

1.) diagnostic label 2.) etiology.

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In a three-part statement, the 3rd component is:

answer

defining characteristics, which are signs and symptoms aka clinical manifestations

question

The statement, "constipation related to lack of dietary fiber as evidenced by firm, hardened stool" is an example of what kind of statement?

answer

Three-part

question

Read the statement, "constipation related to lack of dietary fiber as evidenced by firm, hardened stool" In this statement: constipation = __1__ related to dietary fiber = __2__ firm, hardened stools = __3__

answer

1.) problem or diagnostic label 2.) etiology 3.) signs/symptoms

question

The statement, "constipation related to lack of dietary fiber" is an example of this kind of statement:

answer

two-part statement

question

In the statement, "constipation related to lack of dietary fiber": constipation = __1__ lack of dietary fiber = __2__

answer

1.) problem or diagnostic label 2.) etiology

question

The two part statement consists of __1__ components and the three part statement consists of __2__ components.

answer

1.) two 2.) three

question

There are 3 types of nursing diagnoses. These 3 include:

answer

1.) actual 2.) risk 3.) wellness

question

This is a nursing diagnosis in which there is a response to a health condition or life process may occur, but it hasn't happened yet. And so the problem doesn't exist at this particular time, but there are risk factors that are present. A.) actual B.) risk C.) wellness D.) problematic

answer

Answer: B

question

This diagnosis consists of patient response to levels of wellness is one to attain a higher level of wellness in some area of their functioning. A.) actual B.) risk C.) wellness D.) problematic

answer

Answer: C

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This is a type of nursing diagnosis in which an actual problem is occurring. A.) actual B.) risk C.) wellness D.) problematic

answer

Answer: A

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In an actual nursing diagnosis, there is _____ available to help you determine that the patient does have a problem.

answer

sufficient data

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An EXAMPLE of this type of diagnosis would be when a patient is responding to a life condition/process. A.) actual B.) risk C.) wellness D.) problematic

answer

Answer: A

question

An EXAMPLE of this type of diagnosis would be "deficient fluid volume related to nausea and vomiting as evidenced by dry skin and mucous membranes and decreased oral intake." A.) actual B.) risk C.) wellness D.) problematic

answer

Answer: A

question

An EXAMPLE of this type of diagnosis would be "readiness for enhanced knowledge as evidenced by an expression of interest in learning." A.) actual B.) risk C.) wellness D.) problematic

answer

Answer: C

question

An EXAMPLE of this type of diagnosis would be, "risk for aspiration related to impaired swallowing." A.) actual B.) risk C.) wellness D.) problematic

answer

Answer: B

question

In a risk diagnosis, we do not use, "as evidenced by" because:

answer

there is no diagnosis yet.

question

What type of statement is, "deficient fluid volume related to nausea and vomiting as evidenced by dry skin and mucous membranes and decreased oral intake."

answer

Three-part statement.

question

The 3rd step of the nursing process is:

answer

planning

question

Planning of nursing care, requires critical thinking. There are 3 PHASES of planning. These 3 PHASES are:

answer

1.) initial 2.) ongoing 3.) discharge

question

This is when we continuously update the patient's care plan with new information that is gathered and evaluated. A.) initial B.) ongoing C.) discharge D.) wellness

answer

Answer: B

question

This is when a preliminary plan of care is based on the admission assessment. A.) initial B.) ongoing C.) discharge D.) wellness

answer

Answer: A

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When we are planning for the needs of the patient after dismissal. A.) initial B.) ongoing C.) discharge D.) wellness

answer

Answer: C

question

There are 3 STEPS in the planning process. These 3 STEPS are:

answer

1.) Prioritizing nursing diagnosis 2.) Identifying outcomes 3.) Developing Nursing Interventions

question

With this, you will have goals. When you formulate a goal, it will usually be a broad statement. These goals need to be realistic and based on the needs of the patient. You should include the patient in setting the goals. This will ensure your nursing care is individualized and focused on that particular patient. A.) Prioritizing nursing diagnosis B.) Identifying outcomes C.) Developing Nursing Interventions

answer

Answer: B

question

With this, you will need to determine is which nursing diagnosis is most important and requires attention first. So these patients may not only have 1 problem, they may have several and you need to decide which ones need to be taken care of first via prioritization. A.) Prioritizing nursing diagnosis B.) Identifying outcomes C.) Developing Nursing Interventions

answer

Answer: A

question

These will be identified once the goals have been established. These are a detailed, specific and measurable statement. They will describe how the goal will be met. A.) goal B.) short-term goal C.) long-term goal D.) expected outcomes aka patient outcomes

answer

Answer: D

question

A desired achievement in resolving a nursing diagnosis over a longer period of time. This usually takes weeks to months. These often include prevention, rehabilitation, discharge and health education. A.) goal B.) short-term goal C.) long-term goal D.) expected outcomes aka patient outcomes

answer

Answer: C

question

Desired achievements that will occur within a few hours or days. They will provide direction for the immediate care of the patient. A.) goal B.) short-term goal C.) long-term goal D.) expected outcomes aka patient outcomes

answer

Answer: B

question

An intended or desired change in a patient's condition or behavior A.) goal B.) short-term goal C.) long-term goal D.) expected outcomes aka patient outcomes

answer

Answer: A

question

"Increase ambulation with assistance" is an example of this: A.) goal B.) short-term goal C.) long-term goal D.) expected outcomes aka patient outcomes

answer

Answer: B

question

"To understand the need for improving mobility long-term" would be an example of this: A.) goal B.) short-term goal C.) long-term goal D.) expected outcomes aka patient outcomes

answer

Answer: C

question

"The patient will ambulate to the doorway of the room with assistance of one person by tomorrow morning" is an example of: A.) goal B.) short-term goal C.) long-term goal D.) expected outcomes aka patient outcomes

answer

Answer: D

question

These are principles that are scientifically or research based that are used to select interventions. These include "why" questions. "Why are you doing these interventions."

answer

scientific principles and rationale

question

Scientific principles and rationale are part of the ___ step of planning.

answer

scientific principles and rationales

question

Nursing actions or interventions that are written to resolve the patient's problems. These are treatments or actions that are based on clinical judgment and knowledge to enhance the outcomes of the patient.

answer

Nursing Orders

question

Nursing orders/nursing interventions are __1__ and __2__ for that particular patient.

answer

1.) specific 2.) individualized

question

Writing the nursing care planning consists of organizing data into a __1__ statement. This includes the __2__ of the nursing process. This will include assessment, diagnosis, planning, etc. It is also a document that includes the patient and the nursing care to all members of the health care team. The purpose of the nursing care plan is that it __3__ clinical care.

answer

1.) formal 2.) components 3.) directs

question

It is important to ____ your care plans.

answer

individualize

question

There are 6 different types of nursing care plans. These 6 types include:

answer

1.) student-oriented 2.) standardized 3.) institutional 4.) computerized 5.) critical pathways 6.) concept map

question

A care plan which demonstrates an inner relationship between concepts. A.) student-oriented B.) standardized C.) institutional D.) computerized E.) critical pathways F.) concept map

answer

Answer: F

question

This is a care plan that is developed in which all disciplines in the care of the patient will be used. It provides for a continuity of care and also a monitoring of the patient's total progress. A.) student-oriented B.) standardized C.) institutional D.) computerized E.) critical pathways F.) concept map

answer

Answer: E

question

These are pre-planned, pre-printed guides for a group of patients who have common needs. A.) student-oriented B.) standardized C.) institutional D.) computerized E.) critical pathways F.) concept map

answer

Answer: B

question

A document that becomes the part of the medical record. A.) student-oriented B.) standardized C.) institutional D.) computerized E.) critical pathways F.) concept map

answer

Answer: C

question

This assists in learning problem solving skills, the nursing process, communication skills and organizational skills. It teaches planning and it includes scientific rationales for the interventions. A.) student-oriented B.) standardized C.) institutional D.) computerized E.) critical pathways F.) concept map

answer

Answer: A

question

This is when the nurse can select appropriate diagnoses from a computer which in turn may list interventions or goals. A.) student-oriented B.) standardized C.) institutional D.) computerized E.) critical pathways F.) concept map

answer

Answer: D

question

EXAMPLE: A cardex, which tells many things you need to know about your patient, but may not contain all components of the nursing process. This is an example of this type of care plan: A.) student-oriented B.) standardized C.) institutional D.) computerized E.) critical pathways F.) concept map

answer

Answer: C

question

The purpose of a nursing order is to provide all caregivers with ____ of the patient's care

answer

direction

question

There are three different types of nursing interventions. These three are:

answer

1.) independent 2.) interdependent 3.) dependent

question

This is a collaborative intervention, meaning that it is carried in collaboration with other team members. A.) independent B.) interdependent C.) dependent

answer

Answer: B

question

This requires a physician order to carry out the intervention. A.) independent B.) interdependent C.) dependent

answer

Answer: C

question

This is initiated by the nurse, based on the nurse's knowledge and skills. These do not have to have a physician's order to conduct. Nurses are accountable for these interventions. A.) independent B.) interdependent C.) dependent

answer

Answer: A

question

EXAMPLE: Teaching a patient about their medications. A.) independent B.) interdependent C.) dependent

answer

Answer: A

question

EXAMPLE: To assist the patient to perform an exercise taught to the patient by the physical therapist. So in collaboration with the physical therapist, you would carry out the care of the patient. A.) independent B.) interdependent C.) dependent

answer

Answer: B

question

EXAMPLE: "One tab, once per day." A.) independent B.) interdependent C.) dependent

answer

Answer: C

question

This is the 4th step in the nursing process.

answer

implementation

question

Implementation is the __1__ phase. You will perform the actions. Interventions that are performed to enhance the outcomes are based upon the nurse's __2__ and __3__. This is when action is carried out which are derived from __4__. This involves delegation of planned interventions for which the nurse will still remain __5__.

answer

1.) action 2.) judgment 3.) knowledge 4.) previous steps 5.) accountable

question

Actions or interventions that are performed by the nurse while interacting directly with the patient. EXAMPLE: Bathing the patient.

answer

Direct care

question

Actions or interventions that are performed by the nurse without the patient being present. EXAMPLE: Documenting patient care.

answer

indirect care

question

You must reassess a patient __1__ and __2__ implementing action. This will tell you if the patient has had a __3__ or a __4__ response to the action. And it will provide feedback as to whether there is a need for __5__ in the intervention.

answer

1.) during 2.) after 3.) negative 4.) positive 5.) change

question

There are 3 types of nursing skills. These are:

answer

1.) cognitive 2.) interpersonal aka affective 3.) psychomotor

question

Skills that are used to assist with safely and effectively carrying out interventions A.) cognitive B.) interpersonal aka affective C.) psychomotor

answer

Answer: C

question

Skills that are used to interact with the patient and their family to collect data, provide patient teaching and to provide comfort. These will use therapeutic communication skills and also assists in developing a nurse-patient relationship. A.) cognitive B.) interpersonal aka affective C.) psychomotor

answer

Answer: B

question

They assist the nurse to understand, analyze, observe ask appropriate questions, make judgments and decisions. Critical thinking is important with this type of skill. A.) cognitive B.) interpersonal aka affective C.) psychomotor

answer

Answer: A

question

EXAMPLE: Taking a patient's history. A.) cognitive B.) interpersonal aka affective C.) psychomotor

answer

Answer: B

question

EXAMPLE: Giving an injection. A.) cognitive B.) interpersonal aka affective C.) psychomotor

answer

Answer: C

question

EXAMPLE: Understanding why the patient needs oxygen when they are short of breath. A.) cognitive B.) interpersonal aka affective C.) psychomotor

answer

Answer: A

question

This is part of the nursing care plan and the permanent medical record.

answer

Documenting and Reporting Interventions

question

In terms of documenting and reporting interventions, you need to write the __1__ and the __2__ of the intervention and this will demonstrate that the procedure was __3__.

answer

1.) time 2.) details 3.) completed

question

In terms of documenting and reporting interventions, items that would be included would be the patient's condition __1__ to the intervention, the intervention that was __2__ and the __3__ and the __4__ of the interventions.

answer

1.) prior 2.) performed 3.) response 4.) outcomes

question

Documentation also provides the necessary data that will enable __1__ for the services that were provided. Reporting interventions will take place at __2__ between the nurses as the responsibility of care changes from one nurse to the next. __3__ communication about current changes and actions is important between health care providers. Communication, whether it be __4__ or __5__ should be __6__, __7__ and __8__. It should not contain opinions, but rather __9__.

answer

1.) reimbursement 2.) shift-change 3.) verbal 4.) verbal 5.) written 6.) complete 7.) objective 8.) descriptive 9.) observations

question

- This is the last step in the nurse process.

answer

EVALUATION

question

We want to assist the patient in the outcomes and evaluation is going to tell you if that has happened. This helps determine __1___ or __2__ of outcomes.

answer

1.) improvement 2.) achievement

question

If you know your outcome was met, you know your interventions were successful and the nursing activities may be ceased or continued to maintain the patient's status.

answer

Goal/Outcome Achievment

question

If the goals or outcomes are partially met or not met, then the nurse will need to __1__ or __2__ the plan of care that may be needed. Evaluation must be __3__ in order for the nursing process to be implemented appropriately.

answer

1.) reassess 2.) revise 3.) ongoing

question

This is important in the nursing process. It is the use of words, clear and understandable phrases and has the same meaning to all users.

answer

Standardized Language

question

Examples of standardized language:

answer

1.) NIC- 1982 2.) NOC- 1997

question

NIC and NOC were developed by the center for nursing classification and clinical effectiveness at the university of ___ College of Nursing

answer

Iowa

question

This is grouped into domains, classes and interventions. Each class has interventions that consist of a label (is in standardized language), definition (explains meaning of label) and a variety of activities from the nurse to choose from.

answer

NIC

question

NIC is ____ oriented and assists with documenting nursing care.

answer

practice

question

The purpose of this is to identify, label, validate and classify nursing-sensitive patient outcomes.

answer

NOC

question

1982

answer

NIC

question

1997

answer

NOC

question

This tests and validates classification of nurse sensitive patient outcomes and defines the test/measurements.

answer

NOC

question

NOC uses __1__ and a __2__.

answer

1.) brief phrases 2.) measurement scale

question

When using outcomes, NOC uses the acronym, "smart." What does each letter of the word, "smart" stand for?

answer

S- specific M- measurable A- attainable R- realistic T- timed

question

The Paul 1988 definition of critical thinking is "The art of thinking about your while you are __1__ in order to make your thinking __2__, more __3__, more __4__ or more __5__."

answer

1.) thinking 2.) better 3.) clear 4.) accurate 5.) defensible

question

(Wilkinson, Van Leauven 2007) Definition of critical thinking: "A combination of __1__ thinking, openness to __2__, an ability to __3__ and a desire to seek the __4__."

answer

1.) reasoned 2.) alternatives 3.) reflect 4.) truth

question

(Paul, Ennis, Norris 1996) Definition of Critical Thinking: "The disciplined intellectual process of applying skillful reasoning as a guide to __1__ or __2__."

answer

1.) belief 2.) action

question

(assessment technologies incorporated 1998) Definition of Critical Thinking: "A __1__, __2__, __3__ process that results in reasoned decisions and judgments."

answer

1.) dynamic 2.) purposeful 3.) analytic

question

(Heaslip 1992) Definition of Critical Thinking: The ability to think in a __1__ and __2__ manner, with openness to __3__ and reflect on reasoning process used to ensure __4__ nursing practice and __5__ care.

answer

1.) systematic 2.) logical 3.) question 4.) safe 5.) quality

question

(Wilkinson 2001) Definition of Critical Thinking: Disciplined, self-directed, rational thinking that supports what we __1__ and makes clear what we __2__.

answer

1.) know 2.) don't know

question

Critical thinking is a _____ concept.

answer

complex

question

Critical thinking is used to problem-solve decisions and assists the nurse to not jump to any __1__ about the patients or patient care, but it rather assists the nurse to make decisions by __2__ the data they have obtained. This helps the nurse to determine if their actions are appropriate and will assist them in providing the __3__ for their patient.

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1.) conclusions 2.) validating 3.) best care

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6 skills that are needed for critical thinking:

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1.) Cognitive skills- 2.) asking questions 3.) being well informed 4.) being honest to face any personal bias 5.) being willing to reconsider and think clearly about the data, problems, judgments and decisions 6.) Being able to communicate well with the patient, improving your nurse-patient relationship.

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There are 5 different components to critical thinking, which include:

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1.) knowledge base 2.) experience 3.) competence 4.) attitude 5.) standards

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This is how the nurse approaches a patient's problem. These would include; confidence, thinking independently, fairness, responsibility and accountability, risk-taking, discipline, perseverance, creativity, curiosity, integrity and humility. A.) knowledge base B.) experience C.) competence D.) attitude E.) standards

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Answer: D

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Information or theory that the nurse has learned from their educational experience A.) knowledge base B.) experience C.) competence D.) attitude E.) standards

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Answer: A

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Knowing what to do and demonstrating that you can provide the best care. A.) knowledge base B.) experience C.) competence D.) attitude E.) standards

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Answer: C

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when one has had the opportunity to practice and make decisions about patient care. This will include observing, talking with families of patients and reflecting on those experiences. A.) knowledge base B.) experience C.) competence D.) attitude E.) standards

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Answer: B

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Intellectual standards such as; precisement, accuracy and consistency are used in order to make sound decisions. Professional standards such as ethics, professional responsibilities and scientific based criteria are used to be certain that the highest level of care is given. A.) knowledge base B.) experience C.) competence D.) attitude E.) standards

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Answer: E

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One should not allow their thinking to become __1__ or __2__. There is always a need for new information. Each patient is unique and the nurse needs to be able to think critically in order to care for that particular patient.

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1.) routine 2.) standardized

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In terms of the use of critical thinking in the nursing process, the nursing process involves includes __1__ and __2__.

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1.) thinking 2.) doing

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In terms of the use of critical thinking in the nursing process, the nursing process assists in providing goal-directed, _____ care.

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patient-centered

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In terms of the use of critical thinking in the nursing process, in the nursing process, decisions must be made by the _____ in each step of the nursing process.

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nurse

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In terms of the use of critical thinking in the nursing process, in the nursing process, the decisions result from critical thinking and problem-solving strategies. It is your critical thinking and decision-making skills that will help you to ______ your patient's needs.

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prioritize

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Recording information by charting or making a written notation about a patient's status or care.

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DOCUMENTATION

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Documentation must be accurate, concise, comprehensive and systematic.

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1.) accurate 2.) concise 3.) comprehensive 4.) systematic

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A patient's chart or medical record is a __1__ document. Therefore, it needs to provide proof of patient care that we give in case there is a __2__ that takes place. So we always want to protect ourselves by ensuring our documentation is accurate, concise, comprehensive and systematic.

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1.) legal 2.) malpractice

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* Charting needs to be __1__ and __2__.

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1.) legible 2.) neat

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While documenting, you need to use proper __1__ and __2__.

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1.) spelling 2.) grammar

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While documenting, you need to use _____ abbreviations only.

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acceptable

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While documenting, you need to make sure that what you write is __1__ and __2__.

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1.) factual 2.) time-sequenced

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GENERAL GUIDELINES OF DOCUMENTATION: You need to make sure you have the correct patient's record. The patient's __1__ and __2__ should be on __3__.

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1.) name 2.) identifying information 3.) each page

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GENERAL GUIDELINES OF DOCUMENTATION: You need to document according to the _____ guidelines.

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institution's

question

GENERAL GUIDELINES OF DOCUMENTATION: You need to make sure that you document at the __1__ of the shift and as soon as a patient encounter or patient care has __2__. It is important to do it this way so you can document the information accurately.

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1.) beginning 2.) concluded

question

GENERAL GUIDELINES OF DOCUMENTATION: Each entry needs to have a __1__ and __2__.

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1.) date 2.) time

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GENERAL GUIDELINES OF DOCUMENTATION: Each entry must be signed with your __1__ and your __2__.

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1.) full legal name 2.) professional credentials

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GENERAL GUIDELINES OF DOCUMENTATION: You should not leave any _____ between entries because someone could write something in between that you may have done.

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spaces

question

GENERAL GUIDELINES OF DOCUMENTATION: If there is an error made during documentation, you will need to use a __1__ to cross out the error and __2__, __3__ and __4__ the correction.

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1.) single line 2.) date 3.) time 4.) sign

question

GENERAL GUIDELINES OF DOCUMENTATION: Never change another person's entry even if it is _____.

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incorrect

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GENERAL GUIDELINES OF DOCUMENTATION: You should use _______ if you are documenting a patient's response.

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quotation marks

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GENERAL GUIDELINES OF DOCUMENTATION: You need to document in ____ order.

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chronological

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GENERAL GUIDELINES OF DOCUMENTATION: You need to make sure you write legibly and if you are not using a computer, you need to make sure you are using permanent ink, preferably ____ ink.

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black

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GENERAL GUIDELINES OF DOCUMENTATION: It is important to document completely and concisely, using phrases and appropriate abbreviations, so when we chart, we do not use complete sentences and refrain from using ________.

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unnecessary words

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GENERAL GUIDELINES OF DOCUMENTATION: If you receive a phone call, it is important to _____ that it occurred.

answer

document

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This is the traditional method of documentation. It is "story like" charting. It describes information that is specific to the patient's condition and describes nursing care such as activities, treatments, problems, complaints and patient responses. You chart in chronological order, so there is a timeline. This method of charting is time consuming, for you need to provide more detailed. The charts need to be well organized in this method of charting.

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narrative charting

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This particular type of documentation consists of different disciplines Each discipline will be present on a different record in a different section of the chart.

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source-oriented

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The disadvantage to source-oriented charting is that you will have to look in _____ to find the information you need.

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different sections

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The advantage of source-oriented charts is that the teams can easily ____ the section with the information because the sections will be labeled.

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find

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This type of documentation is organized according to the patient's problems.

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problem-oriented

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There are 4 components to problem oriented charts, including:

answer

1.) database 2.) problem list 3.) nursing care plan 4.) progress notes

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This will include the physician orders and the nursing care plan. If there are disciplines that are involved in the care of a patient, they can go ahead and contribute to the plan. A.) database B.) problem list C.) nursing care plan D.) progress notes

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Answer: C

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The monitoring and the reporting of the patient's process by the health care members. A.) database B.) problem list C.) nursing care plan D.) progress notes

answer

Answer: D

question

All identified problems that have been identified (can be acute, chronic, active or inactive problems) and arranged in chronological order. New problems will be added as they've been identified and the list will be updated if the problem is resolved or if there is a change in the problem. A.) database B.) problem list C.) nursing care plan D.) progress notes

answer

Answer: B

question

all available assessment information: A.) database B.) problem list C.) nursing care plan D.) progress notes

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Answer: A

question

Problem Oriented documentation has 3 types of methods. These are:

answer

1.) SOAP or SOAPIE 2.) PIE 3.) Focus Charting

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This is a problem oriented type of charting with a nursing origin. This type of documentation is nurse-centered. It is not a multi-disciplinary approach. This approach unifies the care plan in the progress notes. It does not include assessment information. Instead that assessment information will be kept on a flow sheet. Any problems the patient may have had that are now resolved, will be dropped from the daily documentation. Only your ongoing problems are documented. A.) SOAP or SOAPIE B.) PIE C.) Focus Charting

answer

Answer: B

question

Structured, logical, format with medical origin. It is an interdisciplinary approach. A.) SOAP or SOAPIE B.) PIE C.) Focus Charting

answer

Answer: A

question

This is in a column format that highlights the patient's concerns, problems or strengths. This helps to track the patient's condition and progress. A.) SOAP or SOAPIE B.) PIE C.) Focus Charting

answer

Answer: C

question

Acronym for what SOAPIE chart consists of:

answer

S- subjective data O- objective data A- assessment P- plan I- intervention E- evaluation.

question

Acronym for PIE

answer

P- problem I- intervention E- evaluation

question

Acronym for Focus Charting:

answer

D- Data (assessment) A- Action (planning and implementation phase) R- Response (evaluation of effectiveness)

question

What this does is eliminates redundancy and reduces the amount of time it takes to chart, which makes your chart streamlined.

answer

Charting by exception aka CBE

question

In charting by exception, we use flow sheets to document standardized care. If standardized care is not met, you will chart by exception, which means you would document only the _1__ or __2__.

answer

1.) significant findings 2.) exceptions

question

The biggest problem with charting by exceptions would be:

answer

inadvertent omissions

question

This documentation uses a computer. It collects, stores, retrieves, displays and communicates timely documentation. By using this method, your documentation time is decreased. Legibility and accuracy is increased. It uses standardized language. It can provide statistical analysis of the data. It provides implementation of the nursing process by an individualized plan of care. It provides quick access for the data that is needed. It is also useful for disciplinary networking.

answer

computerized documentation

question

Do not leave patient data displayed on a computer in plain sight due to _________ concerns.

answer

HIPPA and confidentiality

question

Once you have left the computer, you should not leave the computer terminal, for this may provide others with access to ______ information or may enable them to use it under your name.

answer

confidential

question

Do not give your password or computer signature to other people because anything that is charted will be _________.

answer

your responsibility

question

These are used to provide documentation for assessments or care that are performed frequently. These include activities and patient assessment parameters. This provides quick documentation and reference.

answer

Flow Sheets

question

True or false: You need to ensure that you fill flow sheets out completely and not leave any blank spaces

answer

True

question

If there is a blank space in a flow sheet, it will indicate that the intervention has not been __1__, not been __2__ or not been __3__.

answer

1.) completed 2.) attempted 3.) recognized

question

Flow sheets are often what we use as a supplement to ________.

answer

other types of charting

question

Desired patient outcomes should be __1__ and ___2__.

answer

1.) specific 2.) measurable

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