The Five Steps of the Nursing Process – Flashcards
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A nurse is ready to set goals for a patient who is recovering from a hip replacement. The nurse sets goals for the first three days and for the first three weeks. What part of the nursing process is this?
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Planning
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What word does the nurse use to describe the five steps?
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Process
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A nurse is admitting a new patient who has heart failure and pitting edema. At each step of the nursing process, what is likely to happen?
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Information from other steps will be used to complete the plan of care
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A nurse is caring for a patient at risk for appendicitis. When considering the assessment, why should the nurse use the five-step nursing process?
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To systematically identify actual or potential patient problems
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A nurse is caring for a patient who is cyanotic and has edema. The nurse is making a list of the patient's physical, psychological, emotional, environmental, cultural, and spiritual health. What stage of the nursing process is this?
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Assessment
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A nurse is caring for a 10-year-old tracheotomy patient admitted the previous night. When assessing the patient's pain level, is the nurse assessing subjective or objective data?
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Subjective date, because only the patient can experience the pain
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A nurse is caring for a patient who just had a colostomy. What type of nursing diagnosis (actual, risk, or health-promotion) should the nurse select when developing the plan of care?
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Risk, since the patient is at risk for infection at the site of the surgical incision
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A nurse is caring for a patient with a UTI. The nurse's selection of two nursing diagnoses includes acute pain and impaired urinary function. What evidence would lead the nurse to diagnose acute pain?
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Low back aching Burning upon urination
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A nurse is caring for a patient with decubitus ulcers who is dehydrated and suffering from malnutrition. In the evaluation stage, what evidence about the decubitus ulcers should initiate the nurse to change the nursing care plan?
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New decubitus ulcers have formed
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The nurse is receiving a report on a patient recovering from a myocardial infarction with low oxygen saturation. With a nursing diagnosis of low blood oxygen, what other interdisciplinary professionals may be consulted for collaboration of this patient?
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Respiratory therapist, cardiologist, and pulmonologist
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A nurse is caring for a patient for a UTI. Which of these interventions address the patient's short-term goals?
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Applying a heating pad to the low back or abdomen Refraining from sexual intercourse
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A nurse determines the patient's goal of decreased reflux by sleeping on a pillow wedge was not totally met. How does the plan need to be revised?
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Add a step to avoid eating after 7 p.m.
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A nurse is evaluating the care plan for a pregnant patient. What is the main reason the nurse would ask the patient about support systems and eating habits?
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Ensure individualized care
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A patient has a painful jaw that clicks during chewing. The nurse developed a care plan and taught the patient how to use a bite guard. What step of the nursing process did the nurse exhibit by teaching use of the bite guard?
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Implementation
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A patient with diabetes reports to the clinic for diabetes education. The nurse learns that the patient's wife prepares the family meals. Why is it important to include the patient's wife in the teaching?
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The wife can learn how to follow his new diet too
