ch5- intro nurs process – Flashcards
Unlock all answers in this set
Unlock answersquestion
What is the purpose of the nursing process?
answer
Organizing the ways nurses think about patient care
question
A patient comes to the emergency department complaining of nausea and vomiting. What should the nurse ask the patient about first?
answer
Severity and duration of the nausea and vomiting
question
An alert, oriented patient is admitted to the hospital with chest pain. Who is the best source of primary data on this patient?
answer
Patient
question
What is the primary purpose of the nursing diagnosis?
answer
Communicating patient needs
question
On what premise is a nursing diagnosis identified for a patient?
answer
Clustered data
question
Which statement is an appropriately written short-term goal?
answer
Patient will walk to the bathroom independently without falling within 2 days after surgery.
question
What should be the primary focus for nursing interventions?
answer
Patient needs
question
Which nursing action is critical before delegating interventions to another member of the health care team?
answer
Know the scope of practice for the other team member.
question
A patient reports feeling tired and complains of not sleeping at night. What action should the nurse perform first?
answer
Identify reasons the patient is unable to sleep.
question
What action should the nurse take regarding a patient's plan of care if the patient appears to have met the short-term goal of urinating within 1 hour after surgery?
answer
Monitor patient urine output to evaluate the need for the current plan of care.
question
What term best describes the nature of the nursing process?
answer
Dynamic
question
A disoriented patient is admitted to the hospital accompanied by his spouse. From whom should the nurse collect subjective data on this patient?
answer
The patient's wife
question
Prior to identifying accurate nursing diagnoses, what action must be taken by the nurse?
answer
Clustering related patient data
question
A nurse admits a 5-year-old female to the postanesthesia unit following a tonsillectomy. The child is crying. What should be the nurse's first action?
answer
Assess the child to determine why she is crying.
question
Which statement is a correctly written example of an actual nursing diagnosis?
answer
Activity intolerance related to imbalance between oxygen supply and demand as evidenced by dyspnea on exertion and significant drop of oxygen saturation from 98% to 88% with activity
question
Which long-term goal is written correctly?
answer
Patient will return to professional sports activities within 6 months.
question
What phrase best describes the essence of critical thinking?
answer
Seeking solutions to problems
question
Which body is responsible for defining and disseminating information on nursing diagnoses?
answer
North American Nursing Diagnosis Association International
question
The statement "ongoing collection of data" best describes which phase of the nursing process?
answer
Assessment
question
Which statement illustrates the most measurable outcome indicator?
answer
Demonstrates dressing change
question
A nurse admits a patient to the cardiac care unit following the placement of a cardiac stent. Which step of the nursing process does the nurse do first?
answer
Assessment
question
What should be the focus of all nursing interventions?
answer
Providing patient-centered care
question
Which action should the nurse take 30 minutes after administering oral pain medication to a patient?
answer
Evaluate the effectiveness of the administered pain medication.
