Assessment - correct answer. -Collect data
-Organize data
-Validate data
-Document data
Nursing diagnosis - correct answer. -Analyze data
-Identify health problems, risks, and strengths
-Formulate diagnostic statements
Planning - correct answer. -Prioritize problems and diagnoses
-Formulate goals and designed health outcomes
-Identify nursing interventions
Implementation - correct answer. -Reassess the patient
, -Determine the nurse's need for assistance
-Implement nursing interventions
-Supervise delegated care
-Document nursing activities
Evaluation - correct answer. -Collect data related to outcomes
-Complete data with outcomes
-Relate nursing actions to patient goals/outcomes
-Draw conclusions about problem status
-Continue, modify, or end the patient's care plan
Focused assessment - correct answer. -Gathers specific details about the presenting
concern to either confirm or rule out abnormalities
Time-lapsed assessment - correct answer. -To reevaluate the patient's status and
identify whether the condition has improved, worsened, or stayed the same
Emergency assessment - correct answer. -To ensure the patient has a patent airway,
is breathing, and has adequate circulation
-To identify the primary cause of the problem
Types of data - correct answer. -Subjective-What the patient says (sometimes
patient's family)
-Objective-What the nurse collects or observes (physical assessment, medical records,
patient sometimes)
Health interview - correct answer. A health *interview* is a structured interaction
between you and the patient. The *rules* governing this interaction should be *clearly
outlined and agreed on* by you and the patient at the start of the interview. Your mutual
*goal* is the *patient's optimal health*.
-Provides opportunity for communication, gathering information, and form a therapeutic
relationship with the patient
Four senses to use - correct answer. Sight- Colour of patient's skin, presence of
abnormal movement, patient's level of consciousness, patient's response to touch
Smell-Unique smells
Touch-Changes in skin temperature or fluid volume
Sound
5 vital signs - correct answer. 1. temperature
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