Exam (elaborations)
NUR3031 - FOUNDATIONS OF NURSING - EXAM 1
NUR3031 - FOUNDATIONS OF NURSING - EXAM 1
Systematicywayyofygatheringyandyusingyinformationytoyplanyandyprovideyindividualiz edypatientycarey-yCORRECTyANSWER-Nursingyprocess
Whatyareythey5ystepsytoyorganizeyandyprioritizeypatientycarey-yCORRECTyANSWER- Assessing,ydiagnosing,yplanning,yimplementin...
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NUR3031 - FOUNDATIONS OF NURSING - EXAM 1
Systematicywayyofygatheringyandyusingyinformationytoyplanyandyprovideyindividualiz
edypatientycarey-yCORRECTyANSWER-Nursingyprocess
Whatyareythey5ystepsytoyorganizeyandyprioritizeypatientycarey-yCORRECTyANSWER-
Assessing,ydiagnosing,yplanning,yimplementing,yevaluating
-systematic,ydynamicywayytoycollectyandyanalyzeydatayaboutyayclienty
-primaryysourceyofyinformationyisyfromytheyclienty-yCORRECTyANSWER-Assessment
Analyzingypatientydataytoyidentifyypatientystrengthsyandyproblemsy-
yCORRECTyANSWER-Diagnosing
Specifyingypatientyoutcomesy(goals)yandyrelatedynursingyinterventionsy-
yCORRECTyANSWER-Planning
Carryingyoutytheyplanyofycare;yTheyphaseyofytheynursingyprocessyinywhichytheynursin
gycareyplanyisyputyintoyactiony-yCORRECTyANSWER-Implementing
Measuringyextentytoywhichypatientyachievedyoutcomesy-yCORRECTyANSWER-
Evaluating
Whatyareysomeyofytheycharacteristicsyofytheynursingyprocess?y-yCORRECTyANSWER-
Systemic,ydynamic,yinterpersonal,youtcomeyoriented,yuniversallyyapplicable
BenefitsyofytheynursingyprocessytoytheyPATIENT:y-yCORRECTyANSWER-
Scientificallyybase,yholisticyindividualizedypatientycare.yContinuityyofycare.yClear,yeffi
cient,ycost-effectiveyplanyofyaction.
BenefitsyofytheynursingyprocessytoyotheryNURSES:y-yCORRECTyANSWER-
Opportunityytoyworkycollaborativelyywithyotheryhealthcareyworkers,ysatisfactionyofy
makingyaydifferenceyinylivesyofypatients,yopportunityytoygrowyprofessionally.
Typesyofyassessment:y-yCORRECTyANSWER-Initial,yfocused,yemergency,ytime-lapse
Performedyshortlyyafterytheypatientyisyadmittedytoyayhealthycareyagencyyoryservice.y
Mostyinstitutionsyhaveypoliciesyspecifyingytheytimeyintervalywithinywhichythisyassess
mentymustybeycompleted.yTheypurposeyofythisyassessmentyisytoyestablishyaycompletey
databaseyforyproblemyidentificationyandycareyplanning.y-yCORRECTyANSWER-
Initialyassessment
Assessmentyusedytoyidentifyynewyoryover-
ylookedyproblems.yTheynurseygathersydatayaboutyayspecificyproblemythatyhasyalready
ybeenyidentified.yHelpfulyquestionsyinclude:
,yWhatyareyyourysignsyandysymptoms?
yWhenydidytheyystart?
yWereyyouydoingyanythingydifferentythanyusualywhenythey
started?
yWhatymakesyyourysymptomsybetter?yWorse?
yAreyyouytakingyanyyremediesy(medicalyorynatural)yforyyour
symptoms?y-yCORRECTyANSWER-Focusedyassessment
Anyassessmentyusedytoyidentifyylife-ythreateningyproblems.yEx:yAylong-
termycareyfacilityyresidentywhoybeginsychokingyinytheydiningyroom,yaybleedingypatien
tybroughtytoytheyemergencyydepartmentywithyaystabywound.y-yCORRECTyANSWER-
Emergencyyassessment
Anyassessmentyscheduledytoycompareyaypatient'sycurrentystatusytoytheybaselineydatay
obtainedyearlier.
Ex:yMostypatientsyinyresidentialysettingsyandythoseyreceivingynursingycareyoverylonge
ryperiodsyofytime,y-yCORRECTyANSWER-Time-lapsedyassessment
Informationyperceivedyonlyybyytheyaffectedyperson;ytheseydataycannotybeyperceivedy
oryverifiedybyyanotheryperson.yExamples:yfeelingynervous,ynauseated,yorychilly,yandye
xperiencingypain.ySymptomsyorycovertydata.y-yCORRECTyANSWER-Subjectiveydata
Observableyandymeasurableydataythatycanybeyseen,yheard,yfelt,yorymeasuredybyysome
oneyotherythanytheypersonyexperiencingythem.yDataythatyisyobservedybyyoneypersony
canybeyverifiedybyyanotherypersonyobservingytheysameypatient.yExamplesyofyobjectiv
eydatayareyanyelevatedytemperatureyreadingy(e.g.,y101°F),yskinythatyisymoist,yandyrefu
salytoylookyatyoryeatyfood.y-yCORRECTyANSWER-Objectiveydata
Whoyisytheyprimaryyandyusuallyytheybestysourceyofyinformationytoycollectydata?y-
yCORRECTyANSWER-Patient
Providesycommonylanguageyforynurses.yAnyassociationythatyidentifies,ydevelops,yandy
classifiesynursingydiagnosesy-yCORRECTyANSWER-NANDA-I
Describesypatientyproblemsynursesycanytreatyindependentlyy-yCORRECTyANSWER-
NursingyDiagnosis
Describesyproblemsyforywhichytheyphysicianydirectsytheyprimaryytrreatmenty-
yCORRECTyANSWER-MedicalyDiagnosis
physiologicalyneeds-->safetyyneeds-->love-->esteem-->self-actualization.y-
yCORRECTyANSWER-Maslow'syHierarchyyofyneeds
Determineytheypatient'synewyorycontinuingyneedyforyassistance.
Promoteyself-care.
, Assistytheypatientytoyachieveyvaluedyhealthyoutcomes.y-yCORRECTyANSWER-
Implementing
Cognitive—increaseyinypatientyknowledge
Askingypatientytoyrepeatyinformationyoryapplyynewyknowledge
Psychomotor—patient'syachievementyofynewyskills
Askingytheypatientytoydemonstrateynewyskill
Affective—changesyinypatientyvalues,ybeliefs,yandyattitudes
Observingypatientybehavioryandyconversation
Physiologic—physicalychangesyinytheypatient
Usingyphysicalyassessmentyskillytoycollectyandycompareydatay-yCORRECTyANSWER-
FouryTypesyofyOutcomes:yEvaluating
WhatyisytheypurposeyofyVS?y-yCORRECTyANSWER-
Toymonitorytheyfunctionsyofytheybody
WhatydoesyVSyconsistyofy-yCORRECTyANSWER-BodyyTemperature
Pulse
Respirations
BloodyPressure
PainyandyPulseyOximetry
Whenytoyassesyvitalysignsy-yCORRECTyANSWER-
1.yOnyadmissionytoyanyyhealthycareyagencyyoryinstitution
2.yBasedyonyagencyyoryinstitutionalypolicyyandyprocedures
3.yAnyytimeythereyisyaychangeyinytheypatientsycondition
4.yAnyytimeythereyisyaylossyofyconsciousness
5.yBeforeyandyafteryanyysurgicalyoryinvasiveydiagnosticyprocedure
6.yBeforeyandyafteryactivityythatymayyincreaseyrisk,ysuchyasyambulationyafterysurgery
7.yBeforeyadministeringymedicationsythatyaffectycardiovascularyandyrespiratoryyfunc
tion
TyoryF.yNursesyobtainyvitalysignsyasyoftenyasyaypatient'syconditionyrequiresysuchyasse
ssment,yprioritizingyandyadaptingyassessmentyofyvitalysignsytoyaddressytheypatient'sy
uniqueysituationy-yCORRECTyANSWER-True
Whatyareytheyfactorsyaffectingybodyytemperaturey-yCORRECTyANSWER-Age
DiurnalyVariationsy(CircadianyRhythms)
Exercise
Hormones
Stressy
Environment
Underlyingydiseaseyoryconditionsy(infections/endocrineydisorders)
Whatyfactorsyincreaseymetabolism?y(4)y-yCORRECTyANSWER-
Hormones,ymuscle,ymovements,yexercise