Chapter 11

Question 0

1. Analyze data
2. Identify health problems, risk, and strengths
3. Formulate diagnostic statements

Answer 0

Diagnosing

Question 1

1. Collect data
2. Organize data
3. Validate data
4. Document data

Answer 1

Assessing

Question 2

1. Prioritize problems/diagnosises
2. Formulate goals
3. Select nursing interventions
4. Write nursing interventions

Answer 2

Planning

Question 3

1. Reassess the client
2. Determine the nurses need for assistance
3. Implement the nursing interventions
4. Supervise delegated care
5. Document nursing activities

Answer 3

Implementing

Question 4

1. Collect data related to outcomes
2. Compare data with outcomes
3. Relate nursing actions to clients goals/outcomes
4. Draw conclusions about problem status
5. Continue, modify, or terminate the clients cars plan

Answer 4

Evaluating

Question 5

Establish database about the clients response to health concerns or illness and the ability to manage health care needs

Answer 5

Assessing

Question 6

1. Obtain a nursing history
2. Conduct physical assessment
3. Review client records
4. Review nursing literature
5. Consult support persons
6. Consult health professionals
   - organize data
   - validate data
   - communicate/document data

Answer 6

Assessing

Question 7

Identify client strengths and health problems that can be prevented or resolved by collaborative and independent nursing interventions

Answer 7

Diagnosing

Question 8

Compare data against standards 
Cluster or group data 
Generate hypothesis 
-determine clients  strengths, risk 
Formulate nursing diagnosis

Answer 8

Diagnosing

Question 9

Develop individualized care plan that specifies client goals/desired outcomes, and related nursing interventions

Answer 9

Planning

Question 10

Set priorities and goals/outcomes in collaboration with client
Write goals/desired outcomes
Consult other health professionals

Answer 10

Planning

Question 11

Assist the client to meet desired goals/outcomes, promote wellness, prevent illness and disease, restore health, And facilitate coping with altered functioning

Answer 11

Implementing

Question 12

Reassess client
Determine need for assistance
Perform planned nursing interventions
Document care and client response

Answer 12

Implementing

Question 13

Determine whether to continue, modify, or terminate the plan of care

Answer 13

Evaluating

Question 14

Judge whether goals/outcomes have been achieved
Review and modify the care plan as indicated or terminate nursing care
Document achievement of outcomes and modification of the care plan

Answer 14

Evaluating

Question 15

All info about client

1. Nursing health history
2. Physical assessment
3. Lab results & diagnostic test
4. Primary care provider history
5. Past history

Answer 15

Database

Question 16

Symptoms
Apparent only to person
Clients sensation, feelings, values, beliefs, attitudes, perception of personal health status or concern

Answer 16

Subjective data

Question 17

Signs
Detectable by an observer or can be measured or tested against accepted standard
Obtained by observation or physical examination

Answer 17

Objective

Question 18

1. Assessing
2. Diagnosing
3. Planning
4. Implementing
5. Evaluating

Answer 18

Nursing Process

Question 19

Head-to-toe approach begins rh examination at the head, profess to the neck, thorax, abdomen, and extremities, and ends at toes.

Answer 19

Cephalcaudal

Question 20

1. Physiological needs
2. Safety and security needs
3. Love and belonging needs
4. Self-actualization

Answer 20

Maslow hierarchy of needs

Question 21

Subjective or objective data that can be directly observed by the nurse

That is what client says or wear the nurse can see, hear, feel, smell, or measure

Answer 21

Cues

Question 22

Are the nurses interpretation or conclusions made based on the cues a nurse observes the cues a nurse observes

Answer 22

Inferences