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Which part of the nursing process includes the statement of the client's actual or potential problems? | nursing diagnosis |
Which of the following is a characteristic of the nursing process? | The client is the central focus of the process |
Implementation of the nursing process involves | giving actual nursing care |
Which skill does the nurse use to determine the meaning of multiple cues when assessing clients? | critical thinking |
The primary reason for nurses to use nursing care plans is to: | ensure consistency of care among all nursing staff |
Which of the following is an example of objective data? | client's respirations are 14/minute |
Which of the following is an example subjective data? | client complains of chest pain |
Which of the following is an example of a client's chief complaint? | "I'm in the hospital for hip surgery." |
A client is admitted to the hospital with complaints of chest pain during exercise. Which of the following questions would be a priority for the nurse to ask? | "What, if anything, helps to relieve your chest pain?" |
After the nurse completes the nursing history and physical examination, which action is most appropriate? | data analysis |
In this nursing diagnosis, "Hyperthermia related to exposure to hot environment as evidenced by temperature 101 Farenheit, skin flushed and warm to touch," which part represents the problem? | Hyperthermia |
In the nursing diagnosis, "Chronic pain related to chronic physical disability as evidenced by patient's statement of pain as usually a 6 out of 10 on the pain scale, restlessness, facial grimacing with movement," which part represents the etiology? | chronic physical disability |
Which of the following is a correctly written goal? | client will demonstrate sterile dressing technique by tomorrow (date) |
Which of the following nursing diagnostic categories has the highest priority? | Ineffective airway clearance |
When writing nursing care plans, the nurse should develop a plan for the client that is: | individualized |
Which of the following is an independent bursing action? | Providing a backrub for a cliet |
Which of the following is a dependent nursing action? | Abministering a routine medication |
Which type of skill is the nurse using when inserting a nasogastric tube? | Technical |
Which of the following best describes the use of evaluation in the nursing process? | The nurse rewrites the nursing care plan because the client is unable to meet the goal of walking in the hallway for 50 feet twice a day. |
Choose all of the following statements that are correct regarding discharge planning. | Discharge planning should begin during the initial nursing interview and assessment. Discharge planning needs to be documented in the client's record. |
Which of the folling is a priority nursing intervention? | Assisting the client to a full-Fowler's position because the client is having difficulty breathing in a supine position. |
The nurse has recorded nursing care in the wrong client's chart. What action should the nurse take? | Cross out the error which a single line and write "error" and his or her initials. |
Which of the following is a correct entry that can be made into a client's chart? | Client's dressing is dry and intact. |
Which of the following is a correct method for documenting subjective data? | Client states, "I feel nauseated." |
On which form would the nurse document vital signs? | Flow sheet |
On which form would the nurse document what a wound looked like during a dressing change procedure? | Progress note |
A client complains of feeling bloated after surgery. Physical examination reveals the abdomen is filled with gas. The nurse would document the findings as: | Distended abdomen |
The _________ is a method by which to provide individualized care. | nursing process |
The primary goal of nursing is to help individuals meet their _______. | basic and higher-level needs |
The nursing process helps the nurse provide care in a structured, purposeful, and ________ | effective way |
Trial and error is an ______ approach to problem-solving | experimental |
Scientists and healthcare researchers use a _____ method to investigate problems and to arrive at solutions | precise |
Nursing process is an important method for providing _______ and observable evidence | measurable |
_______ thinking is an important nursing strategy for problem-solving. | critical |
A form of trial-and-error experimentation is used in _______ studies when testing several solutions to a problem. | laboratory |
A client who lacks a sense of smell often is | anorexic |
_______ data consist of the client's opinions or feelings about what is happening | subjective |
The nurse can draw conclusions about the client's health problems though systematic _______. | data analysis |
Nursing ________ is the systematic and continuous collection and analysis of information about a client's health status. | assessment |
_______ is an assessment tool that relies on the use of the five senses | observation |
_______ observation is involved in the assessment of muscle strength, temperature, moisture, edema, rash, or swelling | tactile |
The problem of a client is a ______ problem if it needs health treatment | clinical |
The ______ part of the diagnostic statement is the cause of the cause of the problem | etiology |
The ________statement connects problem, etiology, and signs and symptoms. | diagnostic |
_________ is the identification of nursing interventions to develop and achieve goals to prevent, reduce, and eliminate problems | planning |
A _________ provides a basis for prognosis and medical treatment decisions | medical diagnosis |
______ of a nursing care plan may also be referred to as providing nursing interventions | implementation |
administering medication is a _______ action | independent |
_______ skills involve knowing and understanding essential information | intellectual |
is the basic skill of identifying a problem and taking steps to resolve it | problem solving |
is an experimental approach that tests ideas to decide which methods work and which do not | trial and error problem solving |
allows researchers to discover the best possible safe and effective treatments for disease or dysfunction | scientific problem solving |
a complicated mix of inquiry, knowledge, intuition, logic, experience, and common sense. | critical thinking |
as a nurse, you combine critical thinking skills with scientific problem solving method to identify client problems and to provide care in a structured, purposeful, and effective way | nursing process |
use the nursing process to develop guidelines when caring for a client. These guidelines are the : | Nursing Care Plans (NCP) |
the systematic and continuous collection of data | nursing assessment |
the statement of the client's actual or potential problem | nursing diagnosis |
the development of goals for care and possible activities to meet them | Planning |
the giving of actual nursing care | implementation |
the measurement of the effectiveness of nursing care | evaluation |
the needs of the client are identified, not the needs of the nurse, family, or other healthcare providers | client-oriented |
goals, objectives, or expected outcomes are established as an early part of the nursing process | goal-oriented |
are measurable outcomes that can be achieved in hours, days, or weeks, depending on the individual problem | short-term goals |
take the short-term goals into consideration but also provide guidance for the days, weeks, or months during and after the time a client is seen by a health provider | long-term goals |
existing needs often are the priority over ______. which are often listed as 'at risk for'. | potential needs |
include all the measurable and observable pieces of information about the client and his or her overall state of health | objective data |
consist of the client's opinions or feelings about what is happening. | subjective data |
an assessment tool that relies on the use of the five senses (sight, touch, hearing, smell, and taste) to discover information about the client. | observation |
a way of soliciting information from the client | health interview or nursing history |
the nursing progress notes are commonly referred to as the : | nurses' notes |
Through systematic ______, you can draw conclusions about the client's health problems. You also use critical thinking skills to ponder other questions that might be important. | data analysis |
a statement about the actual or potential health concerns of the client that can be managed through independent nursing interventions.They are clear, concise, client-centered, and client-specific statements | nursing diagnosis |
means that you will work together with the physician or other healthcare providers | collaborative problem |
the development of goals to prevent, reduce, or eliminate problems and to identify nursing interventions that will assist clients in meeting these goals. | planning |
a measurable client behavior that indicates whether the person has achieved the expected benefit of nursing care. it may also be called a goal or objective | expected outcome |
an expected outcome or goal that a client can reasonably meet in a matter of hours or a few days | short-term objective |
an outcome that the client ultimately hopes to achieve but that requires a longer period of time to accomplish | long-term objective |
also called 'nursing orders or nursing actions', are activities that will most likely produce the desired outcomes. | nursing interventions |
the entire nursing team usually formulates the nursing care plan at a meeting called a: | nursing care conference or team conference |
a flip-file with card slots or a notebook for each client being treated by a unit or nursing care team. Contains records of backround information and care related to the client's medical treatment | Kardex |
_____ of a nursing care may also be referred to as providing nursing interventions | implementations |
actions that carry out a physician's orders regarding medication or treatments are ______ that you must follow explicitly. | dependent actions |
are those that you perform collaboratively with other care providers; the physician may write orders for some of these actions. | interdependent actions |
are nursing actions that do not require a physician's order. | independent actions |
an important aspect of legal requirements of nursing practice | accountability |
involve knowing and understanding essential information before caring for clients | intellectual skills |
involve believing, behaving, and relating to others. | interpersonal skills |
such as changing a sterile dressing or administering an injection, require safe and competent performance | technical skills |
measuring the effectiveness of assessing, diagnosing, planning, and implementing. analyzing the client's responses, identifying factors contributing to success or failure, and planning for future care. | evaluation |
the process by which the client is prepared for continued care outside the healthcare facility or for independent living at home | discharge planning |
a manual or electronic (computer) account of a client's relationship with a healthcare facility. | health record |
the health record is ______ that the healthcare agency and providers have acted responsibility and effectively. | documented evidence |
MIS | medical information system |
a collection of various forms and documents | manual health record |
essentially summarizes the progress of the client toward achieving his or her care plan goals. | progress notes. |
a type of nurses' notes that essentially documents what is occurring throughout the day in a chronological manner | narrative charting |
When _____ charting is used, the whole healthcare team works collaboratively to identify priority problems, and they work collectively to solve these problems. also called focus charting | problem-oriented medical records (POMR) |
a type of narrative charting that usually uses a flow sheet listing body systems and their typical findings, such as lung sounds: clear, rales, or rhochi. | Charting by exception (CBE) |
which the emphasis is on quality care that is delivered in the most cost-effective manner. also known as case studies, care mapping, collaborative pathways, or critical pathways. | case management |
lists all medications that the physician has ordered for the client, with spaces for the caregiver to mark when medications are given. | medication administration record (MAR) |
a means of exchanging information between the outgoing and incoming staff on each shift | change-of-shift reporting |
caregivers move from client to client, discussing pertinent information. | walking rounds |
erasures and the use of correction fluid on the client's health record are : | illegal |
What is the best description of a nursing diagnosis?
According to NANDA-I, the official definition of the nursing diagnosis is: “Nursing diagnosis is a clinical judgment about individual, family, or community responses to actual or potential health problems/life processes.
Which of the following best describe the nursing process quizlet?
Which of the following definitions best describe the nursing process? A systematic problem solving approach that guides all nursing actions.
What is nursing diagnosis in nursing process?
The nursing diagnosis is the nurse's clinical judgment about the client's response to actual or potential health conditions or needs.
Which of the following is most representative of the nursing diagnosis phase of the nursing process?
Which of the following behaviors is most representative of the nursing diagnosis phase of the nursing process? 1. Identifying major problems or needs.