nursing process

Identify the unique mnemonic used to represent the five sequential steps of the nursing process.

ADPIE

In the nursing process, which step involves the collection, validation, organization, and recording of client data?

Assessment

According to the nursing process, assessment must be a systematic and _____ process.

ongoing

Why is assessment considered a 'guidepost' in the nursing process?

It provides the baseline for reassessment in the evaluation phase to determine changes.

Which specific nursing professional is legally required to perform the initial patient assessment?

Registered Nurse (RN)

True or False: A Registered Nurse can delegate the follow-up assessment of a patient who has just experienced a fall to a CNA.

FALSE

Under what condition may a nurse instruct a CNA or LPN regarding patient assessment data?

The nurse may instruct them to report changes in condition, though the RN must follow up.

What type of assessment data consists of information provided directly by the patient, family, or community through communication?

Subjective data

Information gathered through physical assessment, laboratory results, and diagnostic tests is classified as _____ data.

objective

The phrase 'My head hurts' is an example of which type of assessment data?

Subjective data

In the HELP mnemonic for observation, what does the letter 'H' stand for?

Help (Observe for signs the patient may be in distress)

In the HELP mnemonic for observation, what does the letter 'E' stand for?

Environment/Equipment (Look for safety hazards and working machines)

In the HELP mnemonic for observation, what does the letter 'L' stand for?

Look (Examine the patient thoroughly)

In the HELP mnemonic for observation, what does the letter 'P' stand for?

People (Identify who is in the room and what they are doing)

Which type of assessment is performed when the nurse explores one specific body part or system, such as respiratory distress?

Focused assessment

A _____ assessment is an in-depth, 'head-to-toe' examination including the patient's past medical history.

comprehensive

List three examples of 'Special Needs' assessments identified in the nursing process.

Nutritional, Pain, and Cultural (or Spiritual, Psychosocial, Wellness, Family, Community, Functional ability).

In the context of interviewing, what is the 'Chief Complaint'?

The primary reason the patient is seeking healthcare.

What type of question should a nurse use to encourage a patient to elaborate on a specific topic during an interview?

Open-ended question

When are 'Close-ended' questions most appropriate to use during a nursing assessment?

In emergencies or with patients who have altered mental status.

If a patient states they think their blood pressure is low, but the nurse measures a normal reading, what action must the nurse take regarding the data?

Validate the data (Subjective and objective data do not agree).

What should a nurse do if a patient’s temperature is recorded as $109^{\circ}F$?

Validate the data (the measurement is far out of the normal range and may indicate faulty equipment).

When documenting patient data, nurses must record _____, not inferences.

cues

Why is the statement 'Wound is infected' inappropriate for a nurse to document during the assessment phase?

It is an inference/diagnosis rather than a concrete, observable cue.

According to documentation standards, what color ink must be used for paper-based clinical records?

Black ink

The second step of the nursing process, which involves analyzing cues and drawing conclusions about health status, is called Analysis or _____.

Diagnosis

How does a 'Nursing Diagnosis' differ from a 'Medical Diagnosis' regarding its primary focus?

A nursing diagnosis focuses on human responses to disease, while a medical diagnosis focuses on pathology.

What is the name of the professional organization that provides the standardized language for nursing diagnoses?

NANDA

In data analysis, what is 'Cluster Cues'?

Grouping related cues to derive a nursing diagnosis rather than relying on an isolated cue.

What is an 'inference' in the context of drawing conclusions during the diagnosis phase?

A judgment or interpretation that is not a fact but is based on available data.

In nursing diagnosis, 'Etiology' refers to the factors that are known to _____ the identified problem.

cause (or contribute to)

When prioritizing patient problems, which hierarchical framework suggests that physiological needs must be addressed before psychosocial ones?

Maslow’s Hierarchy of Needs

Using the ABC framework for problem urgency, which three systems receive the highest priority?

Airway, Breathing, and Circulation

A 'collaborative problem' is a health issue that is determined by a medical diagnosis but cannot be prevented by _____ nursing interventions alone.

independent

Which phase of the nursing process involves selecting standardized care plans, identifying goals, and choosing interventions?

Planning

How does a 'Goal' differ from an 'Outcome' in nursing planning?

A goal is a broad, non-specific health change, while an outcome is a specific and measurable criteria.

At what point in the patient's care does 'Discharge Planning' begin?

At the initial assessment

What are the three categories of planning in the nursing process?

Initial, Ongoing, and Discharge planning

A nursing goal must be broad, but it must include _____ outcomes to allow for evaluation.

expected

List the five essential components of a well-written nursing outcome statement.

Subject, Action verb, Performance criteria, Target time, and Special conditions.

Outcomes that are expected to be achieved within a few hours or days are classified as _____ outcomes.

short-term

In what healthcare settings are 'long-term' outcomes most common?

Home healthcare, extended care, and rehabilitation.

An intervention that involves physical care, emotional support, or teaching is classified as _____ care.

direct

Advocacy and managing the patient's environment are examples of _____ nursing interventions.

indirect-care

What defines an 'Independent' nursing intervention?

An action that a nurse is licensed to prescribe and perform without a provider's prescription.

A _____ intervention is one that is prescribed by a physician but carried out by the nurse.

dependent

What is the primary goal of Evidence-Based Practice (EBP) in selecting interventions?

To use firm scientific data to identify the most effective and cost-efficient treatments.

True or False: Nursing orders can be implemented by LPNs or CNAs as instructed by the RN.

TRUE

List the five components required in a 'Nursing Order'.

Date, Subject, Action verb, Time and limits, and Signature.

Why is it critical for a nurse to 'Individualize' standardized nursing interventions?

To ensure the intervention specifically meets the unique needs of the individual patient.

In the nursing process, 'Implementation' is the phase where the nurse executes the _____.

plan of care

Which step of the nursing process is used to appraise the effectiveness of the care plan?

Evaluation

What must a nurse do if the evaluation shows that the desired patient outcomes were not achieved?

Revise the nursing process/care plan.

What type of data is 'Elevated Temperature'?

Objective data

A patient stating 'I hate my mother' is considered _____ to document because it may indicate potential home issues or abuse.

appropriate

Identify the performance criterion in the outcome: 'Walk 10 feet in the hallway by the end of the day.'

10 feet

In the process for selecting interventions, what is the first step the nurse should take?

Review the nursing diagnosis.

A collaborative problem focuses on _____ problems, whereas medical diagnoses focus on existing ones.

potential

According to the slide on Interviewing, biographical data includes information such as _____.

gender (and other identifying facts)

During interview preparation, why should a nurse clarify that all information is kept confidential?

To establish a therapeutic relationship and encourage the patient to share more info.

Which phase of analysis involves identifying 'missing pieces of clinical data'?

Step 3: Identify Gaps and Inconsistencies.

When prioritizing by urgency, 'Low Priority' issues include things like _____.

skin issues, water, emotions, or being sad/angry.

Initial planning begins when the patient _____.

first comes in (admission)

Planning goals and outcomes form the _____ for the evaluation phase.

criteria

In the outcome statement 'Client will learn,' what part of the outcome components is the word 'learn'?

Action verb

An outcome is considered 'measurable' if it includes _____ criteria.

performance

In the nursing process graphic record, 'Fingerstick Glucose' is found under the _____ section.

MISC (Miscellaneous)

According to the sample clinical record, what was the patient's respiratory rate at 10:00 AM on 6/24?

21 br/min

Why is 'Nursing diagnosis not medical diagnosis' emphasized in the Analysis phase?

Nurses focus on the patient's response to the medical condition, not the physical wrong itself.

In the context of documentation, what are 'cues'?

Directly observed facts or reported symptoms (as opposed to what the nurse thinks).

List two factors that might interfere with accurate measurement during data validation.

Faulty equipment and broken thermometers.

What is the purpose of 'Review of body systems and functional abilities' during an interview?

To assess the patient's physical status and their ability to perform daily tasks.

True or False: A nurse should avoid difficult topics during a patient interview if the patient seems angry.

FALSE

Which specific step in Analysis involves using anatomy and physiology skills to Identify Significant Cues?

Step 1

Nursing interventions are 'generated for a patient' by choosing strategies to _____ the factors contributing to their problems.

reduce or remove

How does 'Ongoing Planning' differ from 'Initial Planning'?

Ongoing planning happens while other care is already being provided/happening.

In the evaluation phase, the nurse determines if the patient's condition is getting _____.

better or worse

A nurse obtaining vital signs is performing a _____ nursing intervention.

direct-care

What is the primary function of 'Nursing Orders' in a long-term care or nursing home setting?

To provide specific instructions for LPNs, CNAs, or ULAs to follow.

According to the student learning outcomes, the nursing process is a tool used for problem solving and _____.

critical thinking