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NURS 3138 Exam 1 Guide With Complete Solution
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NURS 3138 Exam 1 Guide WithComplete Solution
Five steps of the nursing process
1- assessment
2- diagnosis
3- planning
4- implementation
5- evaluation
assessment phase of the nursing process
gather information about patient's condition
collection of both subjective and objective data
admission assessment
comprehensive
"head to toe"
when arriving into medical unit
focus assessment
more specific
looking at one area
,speciality visit
emergency assessment
rapid assessment
ABCs (airway, breathing, circulation)
subjective data
symptoms
statement from cilents
cannot be measured
obtained through interviewing
objective data
signs
observable/measurable
primary source of data
patient
both subjective and objective
most reliable
secondary source of data
family members/significant others
past/current health records
which of the following items of subjective cilent data would be documented
,in the medical record by the nurse?
cilent feels nauseated
3 multiple choice options
what stage of the nursing process is the foundation for the nursing
diagnosis?
assessment stage
diagnosis phase of the nursing process
derives meaning from your assessment finding
provides basis for selection of nursing interventions
what is a nursing diagnosis based on?
based on SIGNS and SYMPTOMS
3 types of nursing diagnosis
actual nursing diagnosis
risk nursing diagnosis
wellness diagnosis
actual nursing diagnosis
3 part statement
diagnostic label R/T related factors AEB defining characteristics
AEB
as evidenced by
, example of actual nursing diagnosis
ineffective airway clearance r/t tracheobronchial narrowing AEB tachycardia,
tachypena, hypoxia, adventitious breath sounds, cyanosis
risk nursing diagnosis
has potential to occur
2 part statement
diagnostic label R/T risk factors
example of risk nursing diagnosis
risk for acute confusion related to dehydration
planning phase of nursing diagnosis
determine urgency of identified problems (ABCs)
priotize cilent needs
determine the OUTCOMES for the cilent
determine interventions needed for cilent
outcomes
cilents response to interventions
SMART goals
SMART goals
Specific
Measurable
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