Unit 3 – Nursing Process Practice Quiz – Flashcards

=Scientific rationales An aspect of a nursing care plan that is usually included in the student's care plan, but not in the client's record, is scientific rationales. Client outcomes are included in both student care plans and the client's record. Nursing diagnoses are included in both student care plans and the client's record. Nursing interventions are a component of both student care plans and a nursing care plan in the client's record.

=Assess the patient and place on NPO status Feeding a patient is a delegatable task that a CNA can perform. However, once it is reported to the registered nurse that the patient is having difficulty swallowing, this becomes a safety issue that the registered nurse must address. This circumstance is then no longer delegatable for any CNA regardless of experience. The first action by the nurse is to assess the patient and place the patient on NPO status until a primary provider is notified for further orders.

="When I give my patient his pain medication, I will have time to ask questions." A patient should be comfortable when interviewing. The pain medication should have time to work before the nurse would consider interviewing the patient, so asking questions when giving the medication is not a good idea. It is appropriate to interview patients without family/friends around. In nearly every culture, calling a patient Mr. or Mrs. shows respect and is, therefore, correct. Reading the patient's health record is appropriate preparation for an interview.

=Nausea A nursing diagnosis (or nursing problem) is a human response to a disease, injury, or other stressor that nurses can identify, prevent, or treat independently. Nausea is the only problem that meets that criterion; all others are medical or collaborative problems.

=Nurses care for clients who have multiple health problems. Critical thinking is essential for client care, particularly when the care is complex, involving numerous health issues. Following policies and procedures does not necessarily require critical thinking; working with others or being flexible and working different schedules do not necessarily require critical thinking

=Deficient knowledge related to understanding of need for cardiac catheterization The third example is a nursing diagnosis that is written correctly. It defines a problem and its etiology. In this case the problem is the client's response to a diagnostic test. A medical diagnosis should not be recorded as the etiology because nursing interventions cannot change the medical diagnosis. It would be appropriate to state acute pain related to impaired skin integrity secondary to mastectomy incision. This nursing diagnosis is written incorrectly because it uses supportive data of the problem as the etiology. This nursing diagnosis does not identify the problem and etiology. It identifies the client's goal rather than the problem. It could be reworded as imbalanced nutrition: less than body requirements related to inadequate protein intake.

="My patient was really quiet and didn't say much, so I charted that he acted depressed." When charting data, chart only what was observed, not what it meant. Inferences should not be made about a patient's behavior during data collection ("he acted depressed"), so that response reflects the student's lack of knowledge and need for teaching. (Instead, the student would chart something like "The patient would not make eye contact and remained facing the window. Answered with only I don't know to all questions.) Chart specific data, not vague phrases; the student is acknowledging the importance of this. There are no universally accepted phrases, just agency-approved abbreviations; the student is acknowledging the need to use agency-approved abbreviations. The student is correct that charting should be completed as soon after data collection as possible.

=Determining the client's main concerns about his diabetes Determining the client's main concerns promotes cooperation with the treatment regimen. For example, if the client is concerned about paying for diabetic monitoring equipment, he may disregard any teaching about the procedure. Although it is often important for a diabetic client to exercise and lose weight to control blood sugar levels, the client must want to do both. He will not exercise or lose weight simply because he is told to do so. The nurse must assess the client's support systems and resources, not merely tell him he must come to the diabetic clinic weekly. Some clients do not have access to transportation and, therefore, could not come to the clinic without social service intervention. Remember that knowledge does not necessarily change behavior.

=Determine the effectiveness of the nursing care provided The evaluation process determines the effectiveness of nursing care. The remaining options are all examples of evaluation but do not reflect the primary purpose of nursing evaluation.

=Describes the client's problem and needs for nursing care The benefits to nurses and nursing are that nursing diagnoses differentiate the nurse's role, they identify a unique body of nursing knowledge, and some think they help nursing to develop a more professional image. However, the primary goal of nursing is to serve the good of the patient. Therefore, the most important use of a diagnosis is to specifically identify the client's needs for quality nursing care.

="After assessing the client, compare their symptoms carefully to the defining characteristic of the nursing diagnosis in order to support or eliminate it as applicable." After assessing the client, always examine the defining characteristics in your database carefully to support or eliminate a nursing diagnosis. Although the other options are correct, they do not provide as concise an explanation as "after assessing the client, compare their symptoms carefully to the defining characteristic of the nursing diagnosis in order to support or eliminate it as applicable."

=seek assistance If a nurse does not know how to perform a procedure, he or she should seek assistance. Information about the procedure is obtained from the literature and the agency's procedure book. All equipment necessary for the procedure is collected. Finally, another nurse who has completed the procedure correctly and safely provides assistance and guidance. Reassessing the client is a partial assessment that may focus on one dimension of the client or on one system. Interpersonal skills are used to develop a trusting relationship, express a level of caring, and communicate clearly with the client, family, and health care team. Critical decision making is used when the nurse implements the care plan using the knowledge bases necessary for care planning and then completing the planned interventions most effectively.

=Clustering data Clustering data means the nurse organizes the information obtained into meaningful clusters. A cluster is a set of signs or symptoms grouped together in a logical order. When clustering data, the nurse identifies relationships between factors and symptoms. Validating data means to compare the data obtained with another source to ensure its accuracy. Peer review is the evaluation of the quality of the work effort of an individual by his or her peers. After validating data and clustering data, the nurse may formulate a problem statement, usually in the form of a nursing diagnosis.

=Risk for impaired parenting "Frequent urination" is a symptom, not a NANDA International nursing diagnosis label. "Coughing and dyspnea" are symptoms, not a NANDA International nursing diagnosis label. "Risk for impaired parenting" is a NANDA International nursing diagnosis label. "Abnormal hygienic care practices" is not a NANDA International nursing diagnosis label. It incorrectly implies a nurse's prejudicial judgment.

=Diarrhea related to food intolerance Diarrhea related to food intolerance is a correctly written nursing diagnosis. It consists of a problem related to an etiology, and it is a condition that nursing interventions can treat or manage. Alteration in comfort related to pain is not written correctly because it is a circular statement. It would be appropriate to state ineffective breathing pattern related to incisional pain. Risk for impaired skin integrity related to poor hygiene habits is not written correctly because it uses a nurse's prejudicial judgment. It would be more appropriate and professional to state risk for impaired skin integrity related to knowledge about perineal care. Potential complications related to insufficient vascular access is not written appropriately because it identifies a nursing problem, not a client's problem. It would be appropriate to state risk for infection related to presence of invasive lines.

=Each time the nurse interacts with the patient The nurse should make observations about the patient each time she enters the room or interacts with the patient to gain ongoing data about the patient.

="What do you think has been causing your current depression?" An open-ended question prompts the client to describe a situation in more than one or two words. This option demonstrates the open-ended question technique. This question limits the client's answers to one or two words. It is an example of a closed-ended question. The question in this option limits the client's answer to one or two words such as "yes" or "no." It is an example of a closed-ended question. This option only requires a few words to form an answer. It does not use the open-ended question technique.

=Frequency The intervention statement does not include how frequently the warm soaks should be applied. The method is applying warm, wet soaks to the patient's leg while awake. The quantity is warm, wet soaks. The qualification of the person who will perform the action is the designation of "the nurse."

="Output will be at least 100 mL/hour of clear yellow urine within 24 hours." "Output will be at least 100 mL/hour of clear yellow urine within 24 hours." is client-centered, singular, observable, measurable, time-limited, and realistic. "Vital signs will return to within normal levels for a middle aged adult." is not measurable (i.e., guidelines for normal are not stated), and it is not time-limited (e.g., by when?). "Nursing assistant will ambulate the client in the hallway 3 times each day." is not client-centered. "Lungs will be clear to auscultation and respiratory rate will be 20/minute." is not singular and it is not time-limited.

=Singular =Realistic =Observable =Measurable

=Desirable changes in the patient's health status Outcomes describe changes in the patient's health status in response to nursing rather than medical interventions. Outcomes relate to patient behavior, not nursing behaviors. Outcomes are a measure of the effectiveness of nursing care for a specific nursing diagnosis, not whether the nursing diagnosis is appropriate.

=Frequently checking the time while waiting for the client to answer Clients are less likely to fully reveal the nature of their health care problems when nurses show little interest, appear rushed, or are easily distracted by activities around them. As long as the nurse had the client's permission, this would not require follow-up. While interrupting an assessment is not recommended, a page is an example of an acceptable exception and so this would not require follow-up. If the nurse were confirming the information, it would not require follow-up. If the mentor felt the nurse was questioning the validity of client's pain rating, a follow-up would be appropriate because a client's pain rating should not be questioned.

=Review the problem and etiology of the nursing diagnosis. The process of choosing interventions is first to review the nursing diagnosis and etiology; then review the desired outcomes; identify several interventions or actions; choose the best interventions for the patient; and then individualize standardized interventions to meet the patient's unique needs.

=They are both thinking methods used to solve a problem. Critical thinking and the Nursing Process are ways of thinking that can be used in problem-solving (although critical thinking can be used for other than problem-solving applications). Neither method of thinking is linear. The Nursing Process has specific steps; critical thinking does not.

=Administering a cleansing enema in preparation for radiological testing Preparing a client for a diagnostic test is an example of a physician-initiated intervention. Teaching a client to administer his or her insulin injection is an example of a nurse-initiated intervention. Assisting a new mother with breast-feeding is an example of a nurse-initiated intervention. Notifying a nutritionist of a client's dietary preferences is a collaborative intervention.

=Increased airway secretions Increased airway secretions is a condition that responds to nursing interventions and therefore would be an appropriate etiology for a nursing diagnosis. Myocardial infarction would not be an appropriate etiology for a nursing diagnosis because it is a medical diagnosis. Nursing interventions will not alter the medical diagnosis of myocardial infarction. Cardiac catheterization is a diagnostic procedure and would not be an appropriate etiology for a nursing diagnosis. Rather, the client's response to the procedure would be the area of nursing concern. Abnormal blood gas levels would not be an appropriate etiology for a nursing diagnosis because it is not a causative factor, but rather it is a defining characteristic of a problem.

=Collaboration Collaboration means working with other caregivers to plan, make decisions, and perform interventions. Delegation is the transfer to another person of the authority to perform a task in a selected situation. Coordination of care involves scheduling treatments and activities with other departments, putting together all the patient data to obtain "the big picture." Supervision is the process of directing, guiding, and influencing the outcome of an individual's performance of an activity or task.

=Reject them all and type in appropriate interventions. The nurse can reject all the suggested interventions if they do not address patient needs. Nearly all computer programs have a screen that allows you to type in interventions and nursing orders. It is the nurse's responsibility to choose interventions: He cannot abdicate this responsibility and let the computer "choose." As a professional, this nurse has already validated the data, nursing diagnosis, and goals, so he can feel reasonably certain that there is nothing wrong with the plan to that point. Although consultation with other nurses may be a wise and prudent step to take at times, the nurse caring for the patient would likely have the most familiarity with the healthcare needs and is in a better position to make sound judgments than another nurse who does not know the patient. Therefore, it might not be productive or efficient to consult another nurse or restart the computer.

=Pain The Joint Commission requires that pain and nutrition assessment be performed on all patients. Other special needs assessments should be performed when cues indicate there are risk factors.

=Impaired gas exchange A potential etiology for impaired gas exchange may be atelectasis. Atelectasis would not support the diagnostic label for decreased cardiac output. Atelectasis would not be an etiology for ineffective airway clearance. Increased tenacious sputum production would be a possible etiology for ineffective airway clearance. Impaired spontaneous ventilation would not be an appropriate diagnostic label for atelectasis. Previous Next