Nur 215 Fundamentals Of Nursing Exam 1
Detailed Questions And Expert Answers
Nursing Process - ANS ADPIE; systemic problem solving process that guides all
nursing actions
Nursing Process Assessment - ANS Use open ended questions to gather subjective
data and look at lab tests and a physical assessment for objective data which you
then cluster together to analyze
CAN COME FROM OTHER HEALTHCARE PROVIDERS AND THEIR OBSERVATIONS AS
WELL AS PATIENTS FAMILY
Nursing Process Diagnoses - ANS What statement best fits the patients situation
and leads us to the intervention phase where we can then pick interventions and
create goals; diagnosis r/t aeb (PES; problem, etiology and symptoms)
This is where you select a label with information of why you selected and the
evidence you used to back it up
Nursing Process Planning - ANS Prioritize problems/diagnoses (ABC's) and then
decide client specific outcomes you want, goals for the client to get them there
and the interventions you as a nurse will take; SMART goals (Specific, Measurable,
Attainable, Realistic, and timed)
,Outcomes and interventions
Can use NOC list for outcomes or develop a appropriate outcome statement.
Nursing Process Implementation - ANS Phase where you put plan into action and
involve delegation to other healthcare providers (CNA, PCT, PT, LPN, Speech
Therapist, etc)
MAKE SURE THE IMPLEMENTATIONS ARE AGREED UPON BY PATIENT AND FAMILY
(if needed)
Nursing Process Evaluation - ANS Did the goal fail or prosper? If the goal failed
what contributed to the failure. Reassess and go back through ADPIE to make sure
client care does not need to change.
How to Prioritize Care - ANS 1. ABC's
2. Hierarchy of needs
3. Acute/Chronic
Sources of Data - ANS Subjective: Communicated by client
Objective: Gathered through assessment/tests and can be observed by a nurse
Primary: Objective/Subjective obtained from the client
,Secondary: Secondhand; from a med record, family member, or other healthcare
provider
Types of Assessment - ANS Initial: Completed when client first walks in (static)
Ongoing: Preformed as needed (dynamic)
Comprehensive: Provides holistic data about patients overall health status
(observation, physical assessment and nursing interview
Focused assessment: preformed to obtain data about a problem with a specific
body part or system (initial is used to followup with client complaints and ongoing
is used to evaluate status of existing problems)
Special Needs Assessment: Type of focused that provides in depth information
about a particular area of client functioning
Etiologies are always inferences b/c? - ANS B/c you can never observe a link b/w
etiology and problem
Types of Planning - ANS Formal: Conscious/deliberate critical thinking and ends in
holistic care plan
Informal: Occurs during other nursing processes
, Discharge Planning: Process of planning for self-care and continuity of care after
the patient leaves healthcare setting
Critical Pathway - ANS Outcome based, interdisciplinary plans that sequence
patient care according to case type. (emphasis on med problems/interventions)
Integrated Plans of Care: Standardized plans that function as both care plan and
documentation
Types of Interventions - ANS Direct-care: through interactions with client
Indirect: preformed away from the client but on behalf of them
Independent: RN's are licsensed to prescribe, preform or delegate based on their
knowledge
Dependent: Prescribed by a physician or advanced practice nurse but carried out
by bedside nurse
Collaborative (interdependent): Carried out in collab with other healthcare team
members
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