Chapter 4 – Nursing Process – Flashcards

1. If a thorough assessment is completed initially, a reassessment should not be necessary. 2. To establish which of two nursing diagnoses is most appropriate is not dependent upon identifying the factors that contributed to (also known as related to or etiology of ) the nursing diagnosis. These factors are identified after the problem statement is identified. 3. To establish which of two nursing diagnoses is more appropriate is not dependent upon analyzing the secondary to factors. Secondary to factors generally are medical conditions that precipitate the related to factors. The secondary to factors are identified after the related to factors of the problem are identified. 4. CORRECT. Review the defining characteristics. ***The first thing the nurse should do to differentiate between two closely associated nursing diagnoses is to compare the data collected to the major and minor defining characteristics of each of the nursing diagnoses being considered.

1. Although completing a nursing admission assessment includes an assessment of the risk for falls, it is only one component of the assessment. 2. Although completing a nursing admission assessment includes an assessment of the skin, it is only one component of the assessment. 3. Although completing a nursing admission assessment helps to initiate the nurse-patient relationship, it is not the primary purpose of completing a nursing admission assessment. 4. CORRECT. Identify important data.*** This is the primary purpose of a nursing admission assessment. Data must be collected and then analyzed to determine significance, and grouped in meaningful clusters before a nursing diagnosis can be made.

1. CORRECT. "I'm not sure that I am going to be able to manage at home by myself." *** This is subjective information because it is the patient's perception and can be verified only by the patient. Subjective data are those adaptations, feelings, beliefs, preferences, and information that only the patient can confirm. 2. This is neither subjective nor objective. It is a statement indicating an understanding of how to seek home care services after discharge. 3. This is neither subjective nor objective. It is a question indicating that the patient wants more information about how to control pain when at home. 4. This is neither subjective nor objective. It is a statement exploring who will provide assistance with care once the patient goes home

1. CORRECT. Goal. *** To evaluate the effectiveness of a nursing action, the nurse needs to compare the actual patient outcome with the expected patient outcome. The expected outcomes are the measurable data that reflect goal achievement, and the actual outcomes are what really happened. 2. The problem is associated with the fi rst half (problem statement) of the Nursing Diagnosis, not the Evaluation, step of the Nursing Process. 3. Etiology is a term used to identify the factors that relate to or contribute to the problem statement of the Nursing Diagnosis, not the Evaluation, step of the Nursing Process. 4. Implementation is a step separate from Evaluation in the Nursing Process. Nursing care must be implemented before it can be evaluated

1. This is not an example of the Implementation step of the Nursing Process. During the Implementation step, planned nursing care is delivered. 2. This is not an example of the Assessment step of the Nursing Process. Although data may be gathered during the Assessment step, the manipulation of the data is conducted in a different step of the Nursing Process. 3. This is not an example of the Evaluation step of the Nursing Process. Evaluation occurs when actual outcomes are compared with expected outcomes, which reflect attainment or nonattainment of the goal. 4. CORRECT. Diagnosis *** During the Diagnosis step of the Nursing Process, data are critically analyzed and interpreted; significance of data is determined; inferences are made and validated; cues and clusters of cues are compared with the defining characteristics of nursing diagnoses; contributing factors are identified; and nursing diagnoses are identified and organized in order of priority.

1. The words identify and recognize have the same definition. They both mean the same as that which is known. The word plan does not fi t the analogy because the definitions of plan and do are different. The word plan means a method of proceeding. The word do means to carry into effect or to accomplish. 2. The words identify and recognize have the same definition. They both mean the same as that which is known. The word evaluate does not fit the analogy because the definitions of evaluate and do are different. The word evaluate means to determine the worth of something, whereas the word do means to carry into effect or to accomplish. 3. The words identify and recognize have the same definition. They both mean the same as that which is known. The word diagnose does not fit the analogy because the definitions of diagnose and do are different. The word diagnose means to identify the patient's human response to an actual or potential health problem. The word do means to carry into effect or to accomplish. 4. CORRECT. Implement. ***This is the correct analogy. The words identify and recognize have the same definition. They both mean the same as that which is known. The words do and implement both have the same definition. They both mean to carry out some action.

1. Observation is the deliberate use of all the senses, and involves more than just inspection and examination. It includes surveying, looking, scanning, scrutinizing, and appraising. Although the nurse makes inferences based on data collected by observation, this is not as effective as another data collection method to identify subjective data associated with a patient's anxiety. 2. Inspection involves the act of making observations of physical features and behavior. Although the nurse observes behaviors and makes inferences based on their perceived meaning, another data collection method is more effective in identifying subjective data associated with a patient's anxiety. 3. Auscultation is listening for sounds within the body. This collects objective, not subjective, data, which are measurable. 4. CORRECT. Interviewing. ***Interviewing a patient is the most effective data collection method when collecting subjective data associated with a patient's anxiety. The patient is the primary source for subjective data about beliefs, values, feelings, perceptions, fears and concerns

1. This occurs during the Planning, not Diagnosis, step of the Nursing Process. 2. CORRECT. Identifying the patient's potential risks. *** Potential risk factors are identified during the Diagnosis step of the Nursing Process. Risk diagnoses are designed to address situations where patients have a particular vulnerability to health problems. 3. This occurs during the Planning, not Diagnosis, step of the Nursing Process. 4. This occurs during the Evaluation, not Diagnosis, step of the Nursing Process

1. Hunger is an example of subjective, not objective, data. Subjective data are those adaptations, feelings, beliefs, preferences, and information that only the patient can confirm. 2. Feeling warm is an example of subjective, not objective, data. Subjective data are those adaptations, feelings, beliefs, preferences, and information that only the patient can confirm. 3. CORRECT. "I ate half my lunch." ***The amount of food eaten by a patient can be objectively verified. The nurse measures and documents the percentage of a meal ingested by a patient to quantify the amount of food consumed. 4. Having the urge to void is an example of subjective, not objective, data. Subjective data are those adaptations, feelings, beliefs, preferences, and information that only the patient can confirm.

1. This is an objective, not subjective, statement indicating something that is checkable and measurable. Objective data can be verified. 2. CORRECT. "My pain feels like a 5 on a scale of 1 to 5." ***A patient's perception about a pain level is subjective information. Subjective data are those adaptations, feelings, beliefs, preferences, and information that only the patient can confirm. 3. This is an objective, not subjective, statement indicating something that is checkable and measurable. Objective data can be verified. 4. This is an objective, not subjective, statement indicating something that is checkable and measurable. Objective data can be verified

1. During the Implementation step of the Nursing Process, outcomes are not determined, but rather planned nursing care is delivered. 2. CORRECT. Evaluation. ***Evaluation occurs when actual outcomes are compared with expected outcomes that reflect goal achievement. If the goal is achieved, the patient's needs are met. 3. During the Diagnosis step of the Nursing Process, outcomes are not determined; rather, the nurse diagnoses human responses to actual or potential health problems. 4. During the Planning step of the Nursing Process, expected outcomes are determined, but their achievement is measured in another step of the Nursing Process

1. The definitions of the words observe and assess are similar. Observe means to examine something scientifically, and assess means to determine the significance of something. The word plan does not fit the analogy because the definitions of the words plan and determine are not similar. Determine means to reach a decision. Plan means to carry into effect or to accomplish. 2. The definitions of the words observe and assess are similar. Observe means to examine something scientifically, and assess means to determine the significance of something. The word analyze does not fit the analogy because analyze is not a step in the Nursing Process. The steps in the Nursing Process are Assessment, Diagnosis, Planning, Implementation, and Evaluation. 3. CORRECT. Diagnose. ***The definitions of the words observe and assess are similar. Observe means to examine something scientifically, and assess means to determine the significance of something. The word diagnose appropriately completes the analogy because the definitions of determine and diagnose are similar. Determine means to reach a decision about something and diagnose means to make a decision based on the assessment and analysis of a human response. 4. The definitions of the words observe and assess are similar. Observe means to examine something scientifically, and assess means to determine the significance of something. The word implement does not fi t the analogy because the definitions of determine and implement are not similar. Determine means to reach a decision about something and implement means to carry out some action.

1. CORRECT. Is dynamic rather than static. ***The Nursing Process is a dynamic five-step problem-solving process (Assessment, Diagnosis, Planning, Implementation, and Evaluation) designed to diagnose and treat human responses to health problems. The nurse moves among the steps in response to the changing needs of the patient. 2. The Nursing Process focuses on the needs of the patient, not the role of the nurse. 3. Moving from the simple to the complex is a principle of teaching, not the Nursing Process. The Nursing Process is a complex interactive five-step problem-solving process designed to meet a patient's needs. It requires an understanding of systems and information-processing theory, and the critical-thinking problem-solving, decision-making, and diagnostic-reasoning processes. 4. The Nursing Process is concerned with a person's human responses to actual or potential health problems, not the patient's medical problem.

1. This is not a goal. This is an action the nurse plans to implement to help a patient achieve a goal. 2. This goal is inappropriate because the word fewer is not specific, measurable, or objective. 3. This is not a goal. This is an action the nurse plans to implement to help a patient achieve a goal. 4. CORRECT. Transfer independently and safely to a commode before discharge. ***This is a correctly worded goal. Goals must be patient-centered, measurable, realistic, and include the time frame in which the expected goal is to be achieved. The word independently indicates that no help is needed, and the word safely indicates that no injury will occur. The time frame is before discharge.

1. Although functioning as a teacher is an important role of the nurse, it is a limited role compared to another option. As a teacher, the nurse helps the patient gain new knowledge about health and health care to maintain or restore health. 2. CORRECT. Advocate. ***When the nurse supports, protects, and defends a patient from a holistic perspective, the nurse functions as an advocate. Advocacy includes exploring, informing, mediating, and affirming in all areas to help a patient navigate the health-care system, maintain autonomy, and achieve the best possible health outcomes. 3. The word surrogate is not the word that best describes this scenario. The nurse is placed in the surrogate role when a patient projects onto the nurse the image of another and then responds to the nurse with the feelings for the other person's image. 4. Although functioning as a counselor is an important role of the nurse, it is a limited role compared to another option. As counselor, the nurse helps the patient improve interpersonal relationships, recognize and deal with stressful psychosocial problems, and promote achievement of self-actualization.

1. The word data (evidence or information) is not associated with the term scientific principles (established rules of action). 2. The word problem (difficulty or crisis) is not associated with the term scientific principles (established rules of action). 3. CORRECT. Rationale. ***The word rationale (justification based on reasoning) is closely associated with the term scientific principles (established rules of action). Scientific principles are based on rationales. 4. The word evaluation (determining the value or worth of something) is not associated with the term scientific principles (established rules of action)

1. Defining characteristics do not contribute to the problem statement but support or indicate the presence of the nursing diagnosis. Defining characteristics are the major and minor signs and symptoms that support the presence of a nursing diagnosis. 2. Outcome criteria are not a part of the nursing diagnosis. Outcome criteria (goals) are part of the Planning step of the Nursing Process. 3. CORRECT. Etiology. *** The etiology (also known as related to or contributing factors) are the conditions, situations, or circumstances that add to the development of the human response identified in the problem statement of the nursing diagnosis. The etiology precipitates the problem just as a pebble dropped in a pond causes ripples on the surface of water. 4. Goals are not part of the nursing diagnosis. Goals are the expected outcomes or what is hoped that the patient will achieve in response to nursing intervention.

1. This is not an example of the Planning step of the Nursing Process. During the Planning step, the nurse identifies and plans the nursing interventions that seem most likely to be effective. 2. This is not an example of the Diagnosis step of the Nursing Process. During the Diagnosis step of the Nursing Process, data are critically analyzed and interpreted; significance of data are determined; inferences are made and validated; signs and symptoms and clusters of signs and symptoms are compared with the defining characteristics of nursing diagnoses; contributing factors are identified; and nursing diagnoses are identified and organized in order of priority. 3. This is not an example of the Evaluation step of the Nursing Process. Evaluation occurs when actual outcomes are compared with expected outcomes that reflect goal achievement. 4. CORRECT. Implementation. ***This is an example of the Implementation step of the Nursing Process. During the Implementation step, planned nursing care is delivered

1. The Physician's History and Physical contains a history of the patient, a physical, and the medical problems on the day of admission to the hospital. The admission medical diagnosis may be different after diagnostic tests are completed. 2. Although the patient's medical diagnosis might be documented on the patient's Social Service Record, it is not the major source for this information. 3. This is the best source for identifying the patient's admitting medical diagnosis, but it will not contain the current medical diagnosis if the diagnosis changed after completion of diagnostic tests. 4. CORRECT. Progress Notes. ***Generally the Progress Notes contain documentation by all members of the health team. After a patient is admitted and diagnostic tests completed, the patient's medical diagnosis may change. The ongoing changes and current status of the patient are documented in the Progress Notes

1. CORRECT. Diagnosis. *** During the Diagnosis step of the Nursing Process, data are critically analyzed and interpreted; significance of data is determined; inferences are made and validated; signs and symptoms and clusters of signs and symptoms are compared with the defining characteristics of nursing diagnoses; contributing factors are identified; and nursing diagnoses are identified and organized in order of priority. 2. Clustering data is not a step in the Nursing Process. Clustering data occurs during the Diagnosis step. 3. Collection is not a step in the Nursing Process. During the Assessment step data are collected from different sources using various methods. 4. During the Assessment step of the Nursing Process data are collected from different sources using various methods

1. This goal is inappropriate because the word lower is not specific, measurable, or objective. 2. This is not a goal. This is an action the nurse plans to implement to help a patient achieve a goal. 3. This is not a goal. This is an action the nurse plans to implement to help a patient achieve a goal. 4. CORRECT. Maintain fluid intake sufficient to prevent dehydration. *** This is a well written goal. Goals must be patient-centered, specific, measurable, realistic, and have a time frame in which the expected outcome is to be achieved. The words sufficient and dehydration are based on generally accepted criteria against which to measure the patient's actual outcome. The word maintain connotes continuously, which is a time frame.

1. Establishing outcomes is part of the Planning, not Evaluation, step of the Nursing Process. 2. Determining priorities is part of the Diagnosis, not Evaluation, step of the Nursing Process. Priority setting is a decision-making process that ranks a patient's nursing diagnoses in order of importance. 3. CORRECT. Take corrective action. ***Corrective action takes place in the Evaluation step of the Nursing Process. If during evaluation it is determined that the goal was not met, the reasons for failure have to be identified and the plan modified. 4. Setting time frames for goals to be achieved is part of the Planning, not Evaluation, step of the Nursing Process.

1. This does not occur during the Implementation step of the Nursing Process. During the Implementation step, the nurse puts the plan of care into action. Nursing interventions include actions that are dependent (requiring a physician's order), independent (autonomous actions within the nurse's scope of practice), and interdependent (interventions that require a physician's order but that permit the nurse to use clinical judgment in their implementation). 2. This does not occur during the Assessment step of the Nursing Process. During the Assessment step, the nurse uses various skills such as observation, interviewing, and physical examination to collect data from various sources. 3. This does not occur during the Diagnosis step of the Nursing Process. A nursing Diagnosis is made when the nurse identifies the patient's human responses to actual or potential health problems. 4. CORRECT. Planning. *** The identification of nursing actions designed to help a patient achieve a goal occurs during the Planning step of the Nursing Process.

1. CORRECT. Defining characteristics. *** The defining characteristics are the major and minor cues that form a cluster that support or validate the presence of a Nursing Diagnosis. At least one major defining characteristic must be present for a nursing diagnosis to be considered appropriate for the patient. 2. Planned interventions do not support the Nursing Diagnosis. They are the nursing actions designed to help resolve the related to or contributing to factors and achieve expected patient outcomes that reflect goal achievement. 3. The diagnostic statement cannot support the Nursing Diagnosis because it is the first part of the Nursing Diagnosis. A Nursing Diagnosis is made up of two parts, the diagnostic statement (also known as the problem statement) and the related to factors (also known as factors that contribute to the problem or the etiology). 4. Related risk factors cannot support the Nursing Diagnosis because they are the second part of the nursing diagnosis. A nursing diagnosis is made up of two parts, the diagnostic statement (also known as the problem statement) and the related to factors (also known as factors that contribute to the problem or the etiology).

1. Although trust and rapport may be established during the assessment phase of the Nursing Process, they are not the primary purpose. The development of trust and rapport generally takes time. 2. CORRECT. Collect and cluster data. *** The primary purpose of the Assessment step of the Nursing Process is to collect data from various sources using a variety of approaches. After data are collected, they are clustered into meaningful categories and interpreted during the Diagnosis step of the Nursing Process. 3. When a five-step Nursing Process is followed, identifying goals and outcomes occur during the Planning, not Assessment, step of the Nursing Process. 4. Identifying and validating the medical diagnosis are not within a Registered Nurse's legal scope of nursing practice.

1. A patient's perception about a pain level is an example of subjective, not objective, data. Subjective data are those adaptations, feelings, beliefs, preferences and information that only the patient can confirm. 2. CORRECT.Collect and cluster data. *** A radial pulse is objective, not subjective, information. Objective data are measurable and checkable. 3. A patient's complaint about shortness of breath is an example of subjective, not objective, data. Subjective data are those adaptations, feelings, beliefs, preferences, and information that only the patient can confirm. 4. A patient's complaint about dizziness is an example of subjective, not objective, data. Subjective data are those adaptations, feelings, beliefs, preferences, and information that only the patient can confirm.

1. CORRECT. Related factors. *** Related factors (i.e., contributing to factors, etiology) contribute to the problem statement of the Nursing Diagnosis and directly impact on the Planning step of the Nursing Process. Nursing interventions are selected to minimize or relieve the effects of the related factors. If nursing interventions are appropriate and effective, the human response identified in the problem statement part of the Nursing Diagnosis will be resolved. 2. The Planning step of the Nursing Process includes setting a goal, identifying the outcomes that will reflect goal achievement, and planning nursing interventions. Although the wording of the goal is directly influenced by the diagnostic label (problem statement of the Nursing Diagnosis), the selection of nursing interventions is not. 3. Secondary factors generally have only a minor influence on the Planning step of the Nursing Process. 4. The medical diagnosis does not influence the Planning step of the Nursing Process. The nurse is concerned with human responses to actual or potential health problems, not the medical diagnosis.

1. Goals are designed after a Nursing Diagnosis is identified, not after data are collected. 2. Once data are collected, the nurse must first organize and cluster the data to determine significance and make inferences. After all this is accomplished, then the nurse can formulate a Nursing Diagnosis. 3. Nursing care is planned after Nursing Diagnoses and goals are identified, not immediately after data are collected. 4. CORRECT. Determine the significance of the information. *** After data are collected, they are clustered to determine their significance.

1. CORRECT. Nausea.*** Nausea is an unpleasant, wavelike sensation in the back of the throat, epigastrium, or abdomen that may lead to vomiting. It is considered subjective data because it cannot be measured by the nurse objectively. It is experienced only by the patient. 2. A yellow color of the skin, whites of the eyes, and mucous membranes (jaundice) because of deposition of bile pigments from excess bilirubin in the blood is objective, not subjective, information. Objective data are measurable and checkable. 3. CORRECT. Dizziness. *** This is subjective information because it is the patient's perception and can be verified only by the patient. Subjective data are those adaptations, feelings, beliefs, preferences, and information that only the patient can confirm. 4. Excessive sweating (diaphoresis) is objective, not subjective, information. Objective data are measurable and checkable. 5. Abnormally low systolic and diastolic blood pressure levels (hypotension) can be measured and verified and therefore are objective data.

Answer: CORRECT ORDER IS 2, 3, 4, 1, 5 2. "What brought you to the hospital today?" Objective and subjective data must be collected, verified, and communicated during the Assessment step of the Nursing Process. 3. "The patient's adaptations indicate that he is dehydrated." Data is clustered, analyzed, and their significance determined (which all lead to a conclusion about the patient's condition) during the Diagnosis step of the Nursing Process. 4. "The patient will have a bowel movement in the morning." Identifying goals, projecting outcomes, setting priorities, and identifying interventions are all part of the Planning step of the Nursing Process. 1. "I am going to give you an enema." Planned actions are initiated and completed during the Implementation step of the Nursing Process. 5. "Did you sleep last night after I gave you the sleeping medication?" Identifying responses to care, comparing actual outcomes to expected outcomes, analyzing factors that affected outcomes, and modifying the plan of care if necessary are all part of the Evaluation step of the Nursing Process.