Nursing Process - 1

Question 1

the process of intentional higher-level thinking to define a client’s problem, examine the evidence-based practice of caring for the client, and make choices in the delivery of care

Answer 1

Critical Thinking

Question 2

is the application of critical thinking to the clinical situation

Answer 2

Clinical reasoning

Question 3

Use of Critical Thinking Skills:

Answer 3

Nurses use knowledge from other subjects and fields
Nurses deal with change in stressful environments
Nurses make important decisions
Critical thinking guides nurses in the process of solving problems of patients and the decision-making process with creativity to enhance the effect

Question 4

Approaches to problem-solving:

Answer 4

1. Trial And Error
2. Intuition
   3. Use of scientific basis
3. Use of the nursing process

Question 5

In —, a number of approaches are tried until a solution is found.

The use of this method in nursing care can be dangerous because the client might suffer harm if an approach is inappropriate.

However, nurses often use this in the home setting due to logistics, equipment, and client lifestyle.

Answer 5

1. Trial And Error

Question 6

is a problem-solving approach that relies on a nurse’s inner sense.

It is a legitimate aspect of a nursing judgment in the implementation of care (Wilkinson, 2012).

Clinical judgment in nursing is a decision-making process to ascertain the right nursing action to be implemented at the appropriate time in the client’s care.

Answer 6

2. Intuition

Question 7

Involves asking questions from resource persons, reading about information and evidence, and figuring out conclusions.

All of these actions are the basis for this method.

Answer 7

3. Use of scientific basis

Question 8

CRITICAL THINKING ATTITUDES

Answer 8

• Independence
• Fair-mindedness - Insight
• Intellectual humility
• Intellectual courage to challenge status quo/rituals -Integrity
• Perseverance
• Confidence
• Curiosity

Question 9

It is the systematic and continuous collection, validation, and communication of client data as compared to what is standard/norm.

It includes the client’s perceived needs, health problems, related experiences, health practices, values, and lifestyles.

It is a critical thinking process that professional nurses use to apply the best available evidence to caregiving and promoting human functions and responses to health and illness (ANA,2010)

Answer 9

Nursing Process

Question 10

Purposes of the nursing process:

Answer 10

• To identify a client’s health status and actual or potential healthcare problems or needs.
• To establish plans to meet the identified needs.
• To deliver specific nursing interventions to meet those needs.

Question 11

Characteristics of Nursing

1. According to Kozier

Answer 11

Cyclic and dynamic
Client-centered
Universally applicable
Focus on problem-solving
Presence of Interpersonal Collaboration
Use of critical thinking

Question 12

Characteristics of Nursing

2. According to Udan

Answer 12

Goal-oriented
Organized
Systematic`
Humanistic plan of care
Efficient and Effective Nursing Care

Question 13

Characteristics of Nursing

1. According to Kozier

Each phase provides input for the next phase

Answer 13

Cyclic and dynamic:

Question 14

Characteristics of Nursing

1. According to Kozier

It is an organized plan of care based on the client’s problems and needs

Answer 14

Client-centered

Question 15

Characteristics of Nursing

1. According to Kozier

It is used as a framework for nursing care.

Answer 15

Universally applicable

Question 16

Characteristics of Nursing

1. According to Kozier

Communicate with client, family, nursing/medical team, community, etc.

Answer 16

Presence of Interpersonal Collaboration

Question 17

Characteristics of Nursing

1. According to Kozier

Important in formulating the plan of care for clients.

Answer 17

Use of critical thinking

Question 18

Steps of the Nursing Process

Answer 18

ADPIE

Question 19

is the systematic and continuous collection, organization, validation, and documentation of data (information).

1. Nursing Health History taking
2. Physical Assessment
3. Physician history and physical assessment
4. Laboratory Results & other diagnostic test results

Answer 19

ASSESSMENT

Question 20

Types of assessment

Answer 20

1. Initial nursing assessment
   2. Problem-focused assessment
   3. Emergency assessment:
2. Time-lapsed reassessment

Question 21

Types of assessment

Performed within a specified time after admission.
To establish a complete database for problem identification.

Answer 21

1. Initial nursing assessment

Question 22

Types of assessment

During emergency situation identify any life-threatening situations.
Rapid assessment of an individual

Answer 22

3. Emergency assessment:

Question 22

Types of assessment

To determine the status of a specific problem identified in an earlier assessment.

Answer 22

2. Problem-focused assessment

Question 23

Types of assessment

Several months after the initial assessment. To compare the client’s current health status with the data previously obtained.

Answer 23

4. Time-lapsed reassessment

Question 24

Steps of assessment

Answer 24

Steps of assessment 1. Collection of data 2. Organizing data 3. Validating data 4. Documenting data

Question 25

Steps of assessment It is the process of gathering information on a client's health status It includes the health history, physical examination, results of laboratory and diagnostic tests, and material contributed by other health personnel.

Answer 25

1. Collection of data

Question 26

Types of Data also referred to as symptoms or covert data, are clear only to the person affected and can be described only by that person.

Answer 26

1. Subjective data

Question 27

Types of Data

Answer 27

1. Subjective data 2. Objective data

Question 28

Types of Data also referred to as signs or overt data, are detectable by an observer or can be measured or tested against an accepted standard. They can be seen, heard, felt, or smelled, and they are obtained by observation or physical examination.

Answer 28

2. Objective data

Question 29

Sources of Data

Answer 29

Primary Secondary

Question 30

Sources of Data It is the direct source of information. The client is the primary source of data.

Answer 30

Primary

Question 31

Sources of Data All sources other than the client's Family members, health professionals, records and reports, laboratory and diagnostic results

Answer 31

Secondary

Question 32

Methods of Data Collection

Answer 32

Observation Interview Examination

Question 33

 It is gathering data by using the senses. Vision, Smell, and Hearing are used

Answer 33

Observation

Question 34

It is a planned communication or a conversation with a purpose.

Answer 34

Interview

Question 35

is highly structured and directly asks questions. And the nurse controls the interview.

Answer 35

The directive interview

Question 36

or rapport-building interview and the nurse allows the client to control the interview.

Answer 36

A non-directive interview

Question 37

Types of interview questions:

Answer 37

- Closed questions (Are you having pain now?) - Open-ended question (what brought you to the hospital?) - Neutral questions (how do you feel about that?) - Leading questions (you are stressed about surgery tomorrow aren't you?)

Question 38

Planning the interview and setting:

Answer 38

- Time - Place - Seating arrangement - Distance - Language

Question 39

An interview has three major stages:

Answer 39

1. The opening or introduction 2. The body or development 3. The closing

Question 40

Examination should be conducted systematically:

Answer 40

Focused

Question 41

head-to-toe assessment

Answer 41

Cephalocaudal approach

Question 42

examine all the body system

Answer 42

Body System approach

Question 43

examine only particular area affected 

Answer 43

Review of System approach

Question 44

Components of a Nursing Health History:

Answer 44

Biographic data Reason for visit/Chief complaint History of present Illness Past Health History Family History Review of systems Lifestyle Social data Psychological data Patterns of healthcare

Question 45

Components of a Nursing Health History:

Answer 45

Biographic data Reason for visit/Chief complaint History of present Illness Past Health History Family History Review of systems Lifestyle Social data Psychological data Patterns of healthcare

Question 46

name, address, age, sex, marital status, occupation, religion.

Answer 46

Biographic data

Question 47

the primary reason why the client seeks consultation or hospitalization.

Answer 47

Reason for visit/Chief complaint

Question 48

includes usual health status, chronological story, family history, and disability assessment.

Answer 48

History of present Illness

Question 49

includes all previous immunizations, and experiences with illness.

Answer 49

Past Health History

Question 50

reveals risk factors for certain disease diseases (Diabetes, hypertension, cancer, mental illness).

Answer 50

Family History

Question 51

review of all health problems by body systems

Answer 51

Review of systems

Question 52

includes personal habits, diets, sleep or rest patterns, activities of daily living, recreation, or hobbies.

Answer 52

Lifestyle

Question 53

include family relationships, ethnic and educational background, economic status, home and neighborhood conditions.

Answer 53

Social data

Question 54

information about the client's emotional state.

Answer 54

Psychological data

Question 55

includes all healthcare resources: hospitals, clinics, health centers, and family doctors.

Answer 55

Patterns of healthcare

Question 56

The nurse uses a format that organizes the assessment data systematically. This is often referred to as a nursing health history or nursing assessment form.

Answer 56

2. Organizing data