UNIT 15A nclex adpie

Slide 1 - What does ADPIE stand for?

Assessment; Diagnosis; Planning; Implementation; Evaluation

Slide 1 - What is the purpose of the nursing process?

To guide nursing decisions and provide individualized patient care

Slide 2 - Which thinking skills are essential for nursing decision-making?

Critical thinking; clinical reasoning; clinical judgment

Slide 2 - What should the nurse use when making clinical decisions?

Current assessment findings; prior knowledge; clinical judgment

Slide 3 - What is critical thinking in nursing?

Questioning assumptions and considering alternative explanations

Slide 3 - What is clinical judgment in nursing?

Deciding what is happening with a patient and what action to take

Slide 3 - What is situational awareness?

Recognizing what is happening now and anticipating what may happen next

Slide 4 - What are the four phases of Tanner's Clinical Judgment Model?

Noticing; interpreting; responding; reflecting

Slide 4 - A nurse notices an unexpected change in a patient's condition. Which Tanner phase is demonstrated?

Noticing

Slide 4 - A nurse examines assessment findings to determine their meaning. Which Tanner phase is demonstrated?

Interpreting

Slide 4 - A nurse takes action based on assessment findings. Which Tanner phase is demonstrated?

Responding

Slide 5 - What is reflection-in-action?

Thinking and adjusting while actively caring for a patient

Slide 5 - What is reflection-on-action?

Reviewing a clinical experience afterward to improve future care

Slide 5 - A student discusses clinical decisions during post-conference. Which reflection is demonstrated?

Reflection-on-action

Slide 6 - What is Lasater's Clinical Judgment Rubric based on?

Tanner's four phases of clinical judgment

Slide 6 - What are the six steps of the NCSBN Clinical Judgment Model?

Recognize cues; analyze cues; prioritize hypotheses; generate solutions; take actions; evaluate outcomes

Slide 6 - Which clinical judgment model is used to guide NCLEX questions?

NCSBN Clinical Judgment Model

Slide 7 - Why is the nursing process described as cyclical?

Evaluation leads to reassessment and changes in care

Slide 7 - How is the nursing process different from a care plan?

The nursing process guides ongoing thinking while a care plan documents planned care

Slide 8 - What is nursing assessment?

Systematic and continuous collection; analysis; validation; communication of patient data

Slide 8 - Why does the nurse collect assessment data?

To judge health status; plan person-centered care; determine appropriate delegation

Slide 8 - How does nursing assessment differ from medical assessment?

Nursing assessment focuses on patient responses and care needs while medical assessment focuses on identifying disease

Slide 9 - What three characteristics should guide every nursing assessment?

Purposeful; prioritized; relevant

Slide 9 - A patient develops an urgent change in condition. What should guide the nurse's assessment?

Prioritize the most urgent and relevant findings

Slide 10 - What two characteristics help ensure a thorough nursing assessment?

Complete and systematic data collection

Slide 10 - Why should nurses use a systematic assessment approach?

To organize data collection and reduce missed information

Slide 11 - How should nursing assessment findings be documented?

Factually and accurately using a standardized format

Slide 11 - Why must nurses avoid unsupported assumptions in documentation?

Documentation must reflect factual and accurate assessment findings

Slide 12 - What are the six types of nursing assessments?

Initial; focused; time-lapsed; quick priority; emergency; triage

Slide 12 - Which assessments are considered planned or routine?

Initial; focused; time-lapsed

Slide 12 - Which assessments are urgent or time-sensitive?

Quick priority; emergency; triage

Slide 12 - Which assessment provides comprehensive baseline information?

Initial assessment

Slide 12 - Which assessment concentrates on a specific problem?

Focused assessment

Slide 12 - Which assessment compares a patient's condition over time?

Time-lapsed assessment

Slide 12 - Which assessment rapidly identifies the most important current findings?

Quick Priority Assessment

Slide 12 - Which assessment is used during an immediate health emergency?

Emergency assessment

Slide 12 - Which assessment helps determine urgency among patients needing care?

Triage assessment

Slide 13 - Which factors affect how the nurse performs an assessment?

Health orientation; developmental stage; culture; patient needs; condition; environment; setting

Slide 13 - Why should the nurse consider a patient's developmental stage during assessment?

Assessment approaches should match the patient's developmental needs

Slide 14 - What are the three methods of collecting nursing assessment data?

Observation; nursing history; physical assessment

Slide 14 - What is the purpose of obtaining a nursing history?

To collect information about the patient's health and care needs

Slide 15 - What should the nurse do when a patient has difficulty answering interview questions?

Identify the communication barrier and adjust the interview approach

Slide 15 - Why should the nurse address problems during the interview?

To obtain more complete and accurate assessment information

Slide 16 - What information should be entered into a patient's concept care map?

Relevant assessment data that support identified patient problems

Slide 16 - Why must nursing diagnoses be supported by assessment findings?

To ensure identified problems reflect the patient's actual condition

Slide 17 - Which nursing process step follows assessment?

Diagnosis

Slide 17 - What is the relationship between assessment and diagnosis?

Assessment data are analyzed to identify patient problems

Slide 18 - What is a health problem?

A condition requiring intervention to prevent or resolve illness or promote wellness

Slide 18 - What is a nursing diagnosis?

A clinical judgment about the patient's response to a health problem

Slide 18 - How does a medical diagnosis differ from a nursing diagnosis?

Medical diagnosis names a disease while nursing diagnosis identifies the patient's response

Slide 18 - Who formulates a nursing diagnosis?

The nurse using clinical judgment

Slide 18 - A patient has pneumonia and difficulty clearing secretions. Which is the nursing diagnosis?

Ineffective airway clearance

Slide 19 - What should the nurse recognize immediately when identifying diagnoses?

Safety and infection risks

Slide 19 - What should the nurse identify when analyzing patient problems?

How symptoms and treatments affect function and independence

Slide 19 - What should the nurse anticipate when identifying nursing diagnoses?

Potential complications and preventive actions

Slide 19 - Should the nurse delay urgent treatment to complete a nursing diagnosis?

No; urgent interventions must not be delayed

Slide 20 - What are the three types of nursing diagnoses?

Problem-focused; risk; health promotion

Slide 20 - What is a problem-focused nursing diagnosis?

A problem the patient currently has

Slide 20 - What is a risk nursing diagnosis?

A problem the patient could develop

Slide 20 - What is a health promotion nursing diagnosis?

A patient's desire to improve health or well-being

Slide 21 - What does PPMP stand for?

Predict; Prevent; Manage; Promote

Slide 21 - What does Predict mean in nursing care?

Recognize potential problems before they occur

Slide 21 - What does Prevent mean in nursing care?

Take action to stop potential problems from developing

Slide 21 - What does Manage mean in nursing care?

Address problems that already exist

Slide 21 - What does Promote mean in nursing care?

Help patients achieve better health and well-being

Slide 22 - What is the purpose of comparing medical and nursing diagnoses in patient scenarios?

To distinguish the disease from the patient's response to it

Slide 22 - What should guide the selection of a nursing diagnosis in a case study?

The patient's specific assessment findings and care needs

Slide 23 - A patient has a total hip replacement and difficulty moving. Which nursing diagnosis is appropriate?

Impaired physical mobility

Slide 23 - A patient with COPD has increased sputum production. Which nursing diagnosis is appropriate?

Ineffective airway clearance

Slide 23 - A patient newly diagnosed with diabetes needs instruction about an insulin pump. Which problem is identified?

Knowledge deficit related to the new treatment regimen

Slide 23 - A stroke survivor cannot independently complete personal care. Which nursing problem is identified?

Self-care deficit

Slide 23 - An older adult with a UTI develops confusion. Which nursing diagnosis is identified?

Acute confusion

Slide 23 - A patient with heart failure has fluid overload. Which nursing diagnosis is identified?

Excessive fluid volume

Slide 24 - What are the four main steps of planning nursing care?

Prioritize problems; set expected outcomes; select interventions; communicate the plan

Slide 24 - Who should participate in planning patient care?

Patient; family; healthcare providers

Slide 24 - What is the difference between formal and informal care planning?

Formal planning uses a written care plan while informal planning uses a quick mental plan

Slide 25 - What are the three stages of nursing care planning?

Initial; ongoing; discharge

Slide 25 - Why is discharge planning included in the nursing process?

To anticipate patient needs after leaving the care setting

Slide 26 - Which three considerations help nurses prioritize care?

Maslow's hierarchy; patient preferences; consequences of delaying action

Slide 26 - Which needs should generally receive priority according to Maslow's hierarchy?

Physiological needs before higher-level needs

Slide 27 - What questions should the nurse ask when prioritizing care?

What cannot wait; who is responsible; is there a standard plan; what is missing

Slide 27 - Why should the nurse consider the consequences of delaying an intervention?

To identify problems requiring immediate attention

Slide 28 - What does SMART stand for when writing outcomes?

Specific; measurable; attainable; realistic; time-bound

Slide 28 - What is the difference between short-term and long-term outcomes?

Short-term outcomes occur within hours to days while long-term outcomes take a week or longer

Slide 28 - Why should nursing outcomes be measurable?

To determine whether the patient achieved the expected result

Slide 28 - Which statement is a patient outcome rather than a nursing intervention?

By the end of the shift the patient will drink 60 mL of fluid every 2 hours while awake

Slide 29 - What is a nursing intervention?

An action the nurse takes to help the patient achieve an expected outcome

Slide 29 - What should guide the selection of nursing interventions?

The cause of the problem; evidence; patient needs; expected outcomes

Slide 29 - What is an independent nursing intervention?

An intervention that does not require a provider's order

Slide 30 - Which four questions should guide intervention selection?

Can I prevent it; can I manage it; is it individualized; is it safe

Slide 30 - Why should nurses evaluate the possible harm of an intervention?

To reduce risks while helping the patient achieve outcomes

Slide 31 - Which types of nursing interventions are identified in the slides?

Direct care; indirect care; protocols; standing orders; care bundles

Slide 31 - What is the difference between direct and indirect nursing care?

Direct care involves patient interaction while indirect care supports care without direct patient contact

Slide 32 - What is implementation in the nursing process?

Carrying out planned nursing interventions

Slide 32 - What should a student nurse consider before implementing care?

Scope of practice and appropriate supervision

Slide 33 - What should the nurse do before implementing an intervention?

Reassess the patient and determine whether the intervention is still appropriate

Slide 33 - Why should the nurse explain an intervention before performing it?

To promote patient understanding and participation

Slide 34 - What is evaluation in the nursing process?

Determining whether nursing interventions achieved the expected outcomes

Slide 34 - What are the three possible evaluations of an expected outcome?

Met; partly met; not met

Slide 34 - What is concurrent evaluation?

Evaluating care while it is being provided