NUR 155 Foundations to Nursing EXAM 2
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1. What is the nursing process? Systematic, rational method of planning and
proving individualized care.
2. What do you do in the nursing 1. Assessing
process? 2. Nursing Diagnosing
3. Planning
4. Implementing
5. Evaluating
3. What is the Decision-Making -Choosing the best actions to meet a desired
Process? goal
-Make value decisions
-Time management decisions
-Scheduling decisions
-Priority decisions
4. The Nursing Process: As- -Collecting, organizing, validating and docu-
sessing menting a patient's health data
-collect data
-organize data
-validate data
-Document data
5. The Nursing Process: Diag- -Analyze date
nosing -Identify health problems, risks, and
strengths
-formulate diagnostic statements
6. The Nursing Process: Plan- -Prioritize problems/diagnoses
ning -Formulate goals/desired outcomes
-Select nursing interventions
-Write nursing interventions
7. The Nursing Process: Imple- -Reassess the client
menting -Determine the nurse's need for assistance
-Implementing the nursing interventions
, NUR 155 Foundations to Nursing EXAM 2
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-Supervise delegated care
-Document nursing activités
8. The Nursing Process: Evalu- -Collect data related to outcomes
ating -Compare data with outcomes
-Relate nursing actions to client goals/out-
comes
-Draw conclusions about problem status
-Continue, modify, or terminate the client's
care plan
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 Inter- -Nurse establishes purpose
viewing?
-Nurse controls the interview
-Used to gather and give information when
time is limited, e.g., in an emergency
13. Nondirective Approach to In- -Rapport-building
terviewing
-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 answer-
ing a close-ended type of question.
, NUR 155 Foundations to Nursing EXAM 2
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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?
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 In- 1. The opening
terview? 2. The body of the interview
3. The closing
18. What is a physical examina- -Use techniques of inspection, auscultation,
tion? palpation, and percussion
-Systematic manner
-Ongoing nursing data collection and exami-
, NUR 155 Foundations to Nursing EXAM 2
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nation focuses on the body systems in which
there is a problem or potential problem
19. The Nursing Process: As- -Systematically
sessing
(Organizing Data) -Nursing health history, nursing assess-
ment, or nursing data base
-Differentiate normal from abnormal
20. The Nursing Process: As- -Assessment complete
sessing -Objective and related subjective data agree
(Validating Data) -Additional data overlooked
-Differentiate between cues and inferences
-Data that is extremely abnormal
-Avoiding jumping to conclusions
21. What is a nursing diagnoses? "...a clinical judgment about individual, fam-
ily, or community responses to a actual or
potential health problem/life processes. A
nursing diagnosis provides the basis for se-
lection of nursing interventions to achieve
outcomes for which the nurse is account-
able."
23. Types of nursing diagnoses: -An actual nursing diagnosis addresses an
Actual diagnoses issue pertaining to the human response
within the patient, family or community to a
disease, life situation, or other health condi-
tion
-Examples: Pain or Hypothermia
Must be followed by defining characteristics
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