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2023 NUR 155 FOUNDATIONS TO NURSING EXAM 2 LATEST UPDATE GRADED A+
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2023 NUR 155 FOUNDATIONS TO NURSING EXAM 2 LATEST UPDATE GRADED A+
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2023 NUR 155 FOUNDATIONS TO NURSINGEXAM 2 LATEST UPDATE GRADED A+
What is the nursing process? - ANSWER-Systematic, rational method of planning and
proving individualized care.
What do you do in the nursing process? - ANSWER-1. Assessing
2. Nursing Diagnosing
3. Planning
4. Implementing
5. Evaluating
What is the Decision-Making Process? - ANSWER--Choosing the best actions to meet
a desired goal
-Make value decisions
-Time management decisions
-Scheduling decisions
-Priority decisions
The Nursing Process: Assessing - ANSWER--Collecting, organizing, validating and
documenting a patient's health data
-collect data
-organize data
-validate data
-Document data
The Nursing Process: Diagnosing - ANSWER--Analyze date
-Identify health problems, risks, and strengths
-formulate diagnostic statements
The Nursing Process: Planning - ANSWER--Prioritize problems/diagnoses
-Formulate goals/desired outcomes
-Select nursing interventions
-Write nursing interventions
The Nursing Process: Implementing - ANSWER--Reassess the client
-Determine the nurse's need for assistance
-Implementing the nursing interventions
,-Supervise delegated care
-Document nursing activités
The Nursing Process: Evaluating - ANSWER--Collect data related to outcomes
-Compare data with outcomes
-Relate nursing actions to client goals/outcomes
-Draw conclusions about problem status
-Continue, modify, or terminate the client's care plan
What is subjective? - ANSWER-What the patient says
Ex: "I have pain, nausea, fear"
What is objective? - ANSWER--Measurable
Ex: vital signs, labs, drainage, etc.
Methods of data collection? - ANSWER--Observing
-Interviewing
Directive Approach to Interviewing? - ANSWER--Nurse establishes purpose
-Nurse controls the interview
-Used to gather and give information when time is limited, e.g., in an emergency
Nondirective Approach to Interviewing - ANSWER--Rapport-building
-Client controls the purpose, subject matter, and pacing
-Combination of directive and nondirective approaches usually appropriate during the
information-gathering interview
Types of questions: Closed - ANSWER-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:
Are you feeling better today?
May I use the bathroom?
Is the prime rib a special tonight?
Should I date him?
Will you please do me a favor?
Types of questions: Open - ANSWER-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?
Planning the Interview - ANSWER--Time
-Place
-Seating
-Distance
-Language
What are the stages of an Interview? - ANSWER-1. The opening
2. The body of the interview
3. The closing
What is a physical examination? - ANSWER--Use techniques of inspection,
auscultation, palpation, and percussion
-Systematic manner
-Ongoing nursing data collection and examination focuses on the body systems in
which there is a problem or potential problem
The Nursing Process: Assessing
(Organizing Data) - ANSWER--Systematically
-Nursing health history, nursing assessment, or nursing data base
-Differentiate normal from abnormal
The Nursing Process: Assessing
(Validating Data) - ANSWER--Assessment complete
-Objective and related subjective data agree
-Additional data overlooked
-Differentiate between cues and inferences
-Data that is extremely abnormal
-Avoiding jumping to conclusions
What is a nursing diagnoses? - ANSWER-"...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."
Types of nursing diagnoses - ANSWER--Actual
-At-Risk
, -Health Promotion
-Wellness Diagnoses
-NANDA-I nursing diagnoses
Types of nursing diagnoses: Actual diagnoses - ANSWER--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
Types of nursing diagnoses: Risk Diagnoses - ANSWER--An at-risk nursing diagnosis
encompasses potential or likely risk factors in which a patient is vulnerable to
-Example: At risk of infection
-Must be followed by the risk factors pertinent to the "at risk" portion of the diagnosis
--Note that NANDA does not permit "at-risk" nursing diagnoses to be interchangeable
with "actual" nursing diagnoses; for instance, it's not acceptable to swap out "pain" with
"at-risk for pain" (NANDA International, n.d.)
Types of nursing diagnoses: Health Promotion - ANSWER--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
Types of nursing diagnoses: Wellness - ANSWER-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.
Components of a Nursing Diagnoses - ANSWER--Problem statement (diagnostic label)
Describes the client's health problem or response
Use of qualifiers
-Etiology (related factors and risk factors)
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