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NUR 155 Foundations to Nursing EXAM 2
1. What is the nursing process?: Systematic, rational method of planning and
proving individualized care.
2. What do you do in the nursing process?: 1. Assessing
2. Nursing Diagnosing
3. Planning
4. Implementing
5. Evaluating
3. What is the Decision-Making Process?: -Choosing the best actions to meet a
desired goal -Make value decisions -Time management decisions -Scheduling decisions -Priority decisions
4. The Nursing Process: Assessing: -Collecting, organizing, validating and docu-
menting a patient's health data
-collect data -organize data -validate data
9. What is subjective?: What the patient says Ex:
"I have pain, nausea, fear"
10. What is objective?: -Measurable Ex:
vital signs, labs, drainage, etc.
11. Methods of data collection?: - Observing
-Interviewing
12. Directive Approach to Interviewing?: -Nurse establishes purpose
-Nurse controls the interview -Used to gather and give information when time is limited, e.g., in an emergency
13. Nondirective Approach to Interviewing: -Rapport-building
-Client controls the purpose, subject matter, and pacing -Combination of directive and nondirective approaches usually appropriate during the information-gathering interview
14. Types of questions: Closed: If you can answer a question with only a "yes" or
"no" response, then you are answering a close-ended type of question. Examples of close-ended questions are:
Is the prime rib a special tonight? Should I date him? Will you please do me a favor?
15. Types of questions: Open: Open-ended questions are ones that require more than
one word answers. The answers could come in the form of a list, a few sentences or something longer such as a speech, paragraph or essay. Here are some examples of open-ended questions: What were the most important wars fought in the history of the United States? What are you planning to buy today at the supermarket? How exactly did the fight between the two of you start?
16. Planning the Interview: - Time
-Place -Seating -Distance -Language
17. What are the stages of an Interview?: 1. The opening
2. The body of the interview
3. The closing
18. What is a physical examination?: -Use techniques of inspection, auscultation,
-Avoiding jumping to conclusions
21. What is a nursing diagnoses?: "...a clinical judgment about individual, family, or
community responses to a actual or potential health problem/life processes. A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for
which the nurse is accountable."
22. Types of nursing diagnoses: - Actual
-At-Risk -Health Promotion -Wellness Diagnoses -NANDA-I nursing diagnoses
23. Types of nursing diagnoses: Actual diagnoses: -An actual nursing diagnosis
addresses an issue pertaining to the human response within the patient, family or community to a disease, life situation, or other health condition -Examples: Pain or Hypothermia Must be followed by defining characteristics or factors that relate to the "actual" portion of the diagnosis
24. Types of nursing diagnoses: Risk Diagnoses: -An at-risk nursing
diagnosis encompasses potential or likely risk factors in which a patient is vulnerable to -Example: At risk of infection
pain" (NANDA International, n.d.)
25. Types of nursing diagnoses: Health Promotion: -Readiness for enhances
family coping -A health promotion nursing diagnosis is a clinical judgment that encompasses a patient's desire and motivation for a readiness of enhanced state of health or factor that may lead to improved level -A health promotion nursing diagnosis does not require a current level of wellness -Example: Readiness for enhanced learning
26. Types of nursing diagnoses: Wellness: Wellness nursing diagnoses focus on the
patient's progress or potential progress towards healthier behaviors rather than on a problem. They were created to remedy a situation in which only negative issues were addressed, leaving out diagnoses for patients in a healthy setting. A wellness diagnosis indicates a readiness to advance from the current level of health to a higher level.
27. Components of a Nursing Diagnoses: -Problem statement (diagnostic label)
Describes the client's health problem or response Use of qualifiers
-Etiology (related factors and risk factors) Identifies one or more probable causes of the health problem Do not
presence of a particular diagnostic label Have signs and symptoms Constipation R/T medication use AEB infrequent passage of stool and hard, dry stool.
29. Components of a Nursing Diagnoses: Defining characteristics for risk prob-
lems For risk for nursing diagnoses have no signs/symptoms Factors that cause the client to be more vulnerable to the problem form the etiology or a risk for nursing diagnoses Risk for Infection R/T break in skin integrity.
30. Differentiating Nursing Diagnosis from Medical Diagnosis: -Nursing Diag-
nosis Nursing judgment Describes human response Changes as client responds -Medical Diagnosis
Made by physician Disease process Stays the same
-AEB observed choking (Observed evidente of difficulty in swallowing
34. PRACTICE: nursing diagnoses:
A newborn has a temp of 97.1 Ax.: - Hypothermia -R/T immature body system -AEB Ax temp of 97.
35. PRACTICE: nursing diagnoses:
A client comes to the clinic and states he can't handle the stress anymore.: - -Ineffective coping -R/T inadequate coping -AEB verbalization of the inability to cope
36. PRACTICE: nursing diagnoses:
An assessment on a post-operative client reveals rhonchi. The client refuses to cough due to pain.: -ineffective airway clearance -R/T ineffective cough -AEB abnormal breath sounds
37. PRACTICE: nursing diagnoses:The nurse is caring for a post-operative surgical
client. The nurse identifies the client is at risk for developing infection. The client does not have symptoms of an infection at this time.: -Risk for infection -R/T surgical incision
38. The nursing process: Planning: Nurse and the client in collaboration
Set priorities
