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Unit 1 Nursing 120 Exam (Lectures 1-8) QUESTIONS AND ANSWERS WITH VERIFIED SOLUTIONS
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Unit 1 Nursing 120 Exam (Lectures 1-8) QUESTIONS AND ANSWERS WITH VERIFIED SOLUTIONS
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Unit 1 Nursing 120 Exam (Lectures 1-8) QUESTIONSAND ANSWERS WITH VERIFIED SOLUTIONS
Describe the five phases of the nursing process - ANSWER The five phases of
the nursing process are assessment, diagnosis, planning/outcome identification,
implementation, and evaluation. They can be represented by the acronym ADPIE
for easy recall. The assessment step is where you collect all of your data on the
patient, both objective and subjective. Objective data is data that can be
measured by at least one other like minded individual, meaning another nurse, or
an instructor. Examples of objective data include temperature, color, symmetry,
bruises, vital signs, wounds, and sounds the body makes. Subjective data is data
that is dependent on what someone else feels, perceives, and/or believes,
meaning that it might be right but it might be wrong. Examples of subjective data
are a limp, the chart, and information told to you by the patient or the patient's
family members. Diagnosis means the nursing diagnosis, which is very different
from a medical diagnosis. A medical diagnosis tells what is medically wrong with a
patient. A nursing diagnosis takes this medical diagnosis into consideration, but is
really a nurses judgement on how the patient will react to the medical diagnosis,
or, more so, how the diagnosis will affect the patient and their life as a whole.
Planning and outcome identification is when the nurse comes up with a big goal
and mini goals on where she/he and the patient agree the patient wants to and
should be, and comes up with a sort of plan of action for how to get the patient
there. Simply put, it is when the nurse decides how to treat the patient dependent
upon the nursing diagnosis. Implementation is simply the step during which the
nurse begins to implement and do the things they decided to do. And lastly there
is evaluation which is when the nurse re-examines and evaluates the patient to
see if goals were met and if the course of treatment they decided
Describe the assessment phase - ANSWER The assessment phase is when the
nurse gathers a bunch of different pieces of data on the patient to get a more
thorough understanding of them and their condition. There are two different
,kinds of data that can be collected in an assessment, objective data and subjective
data. Objective data is observable data that can be measured by you, and by
another like minded individual, such as another nurse, peer, or instructor.
Examples of objective data include vital signs, temperature, color/complexion,
bruises, wounds, conditions, and sounds the body makes. The other kind of data
that can be collected is subjective data. This is the kind of data that someone
"says", so it might be right, but it might be wrong. Examples of this kind of data
include what the patient tells you, what the patient's family told you, what other
nurses or health care professionals told you, the chart, and a limp. REMEMBER
THAT A NURSE'S ASSESSMENT OF A PATIENT IS CONTINUOUS.
Identify the components of a nursing diagnosis - ANSWER There are three
parts to a nursing diagnosis, although only all three parts will included if it is an
actual diagnosis, meaning it is a true thing that the patient is currently
experiencing. Only two parts will appear in the diagnosis if the diagnosis is an at
risk diagnosis. This means that the patient is not actually experiencing the nursing
diagnosis, but it is something that could potentially occur, such as a person who is
at risk for impaired skin integrity. The first part of the diagnosis is just the
diagnosis, also referred to as the label. The next part of the diagnosis is the R/T
(related to) also referred to as the etiology, which is the origin or cause of the
nursing diagnosis. The third part that is typically only included in the diagnosis if it
is an actual diagnosis is the AEB (as evidence by), also known as the signs and
symptoms. These are the signs and symptoms that the patient is experiencing
and/or displaying that led you to your nursing diagnosis. An example of a
complete nursing diagnosis is: Impaired physical mobility R/T pain and discomfort
following surgery AEB no ambulation since surgery, limited ROM in right hip, and
statements of pain of 10/10. NOTE THAT THE R/T CAN NOT BE THE MEDICAL
DIAGNOSIS.
Contrast a nursing diagnosis with a medical diagnosis - ANSWER A medical
diagnosis is a diagnosis of what is medically wrong with the patient, or what the
patient is in for and why they are being treated. These can only be given by
medical professionals such as physicians, physician's assistants, and nurse
, practitioners. A nursing diagnosis is a clinical judgement by the nurse of how this
medical diagnosis will affect the patient's life. It takes the medical diagnosis into
account and into consideration, but does not actually state what is medically
wrong with a person as nurses are not in a high enough position to diagnose in
this way. Medical diagnoses stay the same for as long as that medical condition
exists within the patient, but nursing diagnoses constantly change ad adapt based
on how the patient is feeling or reacting to treatment that was chosen.
Describe the process of developing a nursing diagnosis - ANSWER The nurse
must first complete assessment of the patient and collect as much information as
possible on them. He/she must then examine the signs and symptoms that the
patient is presenting as these will now become the defining characteristics of the
nursing diagnosis. The nurse then clusters these signs and symptoms/defining
characteristics together to make a cue. A cue is a group of defining characteristic
that point the nurse in the direction of the proper nursing diagnosis. Based off of
all of this information, the nurse then decides upon the best diagnosis, or
diagnoses. There are often more that one, but at this point in time we will only be
required to identify one per patient. If there is more than one diagnosis, then the
nurse must prioritize these diagnoses from the one of highest importance to
lowest importance to know which one she should address first. The patient should
be included in this decision so you know what is the most important to them to
fix.
Discuss the purpose and benefits of outcome identification - ANSWER
Outcome identification is important because both you and the patient need to
know what it is that you are aiming for, or what you are trying to do. It gives
something for the patient to look forward to and aim for. Many times when given
something to strive for, people take it as a challenge and try as hard as they can to
reach and surpass that goal. Outcome identification helps you and your patient set
whatever goals are desired and work toward something, instead of just randomly
attempting to do something. It sets an intellectual plan of action for you to follow
instead of just doing whatever you or the patient decides they want to do. Doing
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