patient is admitted to the hospital with shortness of breath. As the nurse assesses
this patient, the nurse is using the process of
A. Evaluation.
B. Data collection.
C. Problem identification.
D. Testing a hypothesis. - ANSWER B. Data collection.
A patient is admitted to the hospital with shortness of breath. As the nurse assesses
this patient, the nurse is using the process of
A. Evaluation.
B. Data collection.
C. Problem identification.
D. Testing a hypothesis. - ANSWER B. Data collection.
What are the 3 priorities in the Nursing Process? - ANSWER 1) High—Emergent-life
threatening (anything that blocks airways, heart attack symptoms.)
2) Intermediate-health threatening
3) Low—Affects patients' future well-being and developmental needs
What does reviewing and revising the care plan mean? - ANSWER -After you reassess your
patient, review the care plan, compare assessment data to validate the nursing diagnoses,
and determine whether the nursing interventions remain the most appropriate for the clinical
situation.
-If the patient's status has changed and the nursing diagnosis and related interventions are
no longer appropriate, modify the nursing care plan.
What are the 4 steps to modifying the written care plan: - ANSWER 1. Revise data in the
assessment section to reflect the patient's current status. (Date any new data to inform
other health team members of the time that the change occurred.)
2. Revise nursing diagnoses. ( Delete diagnoses that are no longer relevant, and add and
date any new diagnoses. It is necessary to revise related factors, as well as the patient's
goals, outcomes, and priorities.)
3. Revise specific interventions (that correspond to the new nursing diagnoses and goals. This
revision should reflect the patient's present status.)
,4. Determine the method of evaluation to achieve outcomes.
Why are Cultural considerations important? - ANSWER -Cultural considerations must be
considered to make accurate and complete assessments.
-Cultural considerations involve not imposing your own attitudes and beliefs (avoid making
assumptions or stereotyping).
What are sources of Data collection? - ANSWER -Patient
-Family & significant others
-Health care team
-Medical Records
-Other records and literature
What are Cues and inferences? - ANSWER -Cue- information that you obtain through use
of senses
-Inference- your judgment or interpretation of these cues
What is Data Validation - ANSWER 1) Validation of ASSESSMENT consists of comparison of data
with another source in order to determine the accuracy of the data- sources for validation
include the patient, medical records, other health team members and family.
2) Validation of physical examinations and observations can be done by reviewing medical
records, asking the patient questions, consulting other members of the healthcare team.
3) Validation allows you to accurately analyze and interpret the patient's clinical picture.
A patient tells the nurse, "I have had this dull ache in my side now for 4 days; it really hurts
when I bend over." The nurse responds, "All right, go on." The nurse's response is an example
of:
A) inference.
B) a cue.
C) back-channeling.
,D)open-ended question. - ANSWER B) a cue.
Subjective data perceived and reported by the patient can also be called? - ANSWER -Symptoms
-Covert information, such as feelings, perceptions, thoughts, sensations, or concerns that are
shared by the patient and can only be verified by the patient.
Objective data that is observed, felt, heard or measured can all be called? - ANSWER -Signs
-Overt, measurable assessments collected via the senses, such as sight, touch, smell, or
hearing, and compared to an accepted standard.
Client tells the nurse, "My shoulder is really, really sore. This is an example:
A) Subjective Data
B) Objective Data - ANSWER A) Subjective Data
The patient grimaces when attempting to brush her hair with her left arm.
This is an example:
A) Subjective Data
B) Objective Data - ANSWER B) Objective Data
Name the type of data: Pain
A) Subjective Data
B) Objective Data - ANSWER A) Subjective
The wife of the patient says that his leg hurts everyday.
This is an example:
A) Subjective Data
B) Objective Data - ANSWER A) Subjective Data
, Name the type of data: Temperature of 100.6 degrees Fahrenheit
A) Subjective Data
B) Objective Data - ANSWER B) Objective Data
Physical Therapy note in the chart states that the left shoulder has decreased range of
motion and strength.
This is an example:
A) Subjective Data
B) Objective Data - ANSWER B) Objective Data
Name the type of data: cyanosis (bluish discoloration) of the skin
A) Subjective Data
B) Objective Data - ANSWER Correct answer: Objective
Name the type of data: Presence of 1+ pitting edema to the bilateral lower extremities
A) Subjective Data
B) Objective Data - ANSWER B) Objective Data
Name the type of data: Sweating
A) Subjective Data
B) Objective Data - ANSWER A) Subjective.
-If the patient states " I feel sweaty" this would be SUBJECTIVE data and is considered
a symptom.
-At the same time if the nurse observes excessive sweating (aka diaphoresis) it would
be OBJECTIVE data and is considered a sign.
Name the type of data: Nausea
A) Subjective Data
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