Inquire through: | Professional | Confidential Support
HAFN Exam 3 Verified and Updated
Questions and Answers (100% Correct
Answers)
Nursing Process
Answer: Assessing
Diagnosing
Outcome Identification and Planning
Implementing
Evaluating
Assessment Purpose
Answer: o Establish baseline information
o Determine normal function
o Determine presence of dysfunction
o Appraisal of total patient situation
-Physical
-Psychological
-Emotional
-Sociocultural
-Spiritual
o Synthesize data to determine nursing diagnoses
Assessment Data
Answer: o Primary sources of data
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o Secondary sources of data
o Subjective vs objective
Assessment isn't a judgement but rather a
Answer: clinical observation
Subjective/objective data is in reference to the same things as
Answer: primary and secondary data
· Equal pupillary reaction =
Answer: when you shine light into the pupils they constrict
Can I observe or measure this? If so then it is _____ data
Answer: objective
Subjective or objective? Takes medication on a regular basis
Answer: Subjective because you cannot measure or observe this (in the context of
them reporting their medication concordance)
Nursing diagnoses come from a common language
Answer: o NANDA (North American Nursing Diagnosis Association)
o Identifies patient problems
o AKA nursing diagnoses
o Provides the basis for nursing interventions
Nursing Diagnoses
Answer: o Types of nursing diagnoses
-Actual
-Risk
o Diagnostic label
-Describes the essence of the problem
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Actual Nursing Diagnoses: 3 part statements
Answer: -Diagnostic label-Choose an appropriate label
-Related factors-Etiology (causes)
-Defining characteristics-Signs and symptoms, Validates the diagnosis, Written as:
· As manifested by (AMB)
· As evidenced by (AEB)
(chose AMB or AEB, not both)
Nursing Dx:
Data=Pain, R tibial fracture, 6/10 pain, grimacing
Answer: Pain related to right tibial fracture as evidenced by facial grimacing and
stating pain of 6:10.
· Dx label = pain
r/t
Answer: related to
Risk Nursing Diagnoses
Ex. Constipation, PND
Answer: 2 part statements:
-Diagnostic label-Choose an appropriate label
-Related factors-Etiology (causes)
Ex.
Risk for constipation r/t decreased mobility and narcotic pain medication.
Risk for peripheral neurovascular dysfunction r/t fall and cast on RLE causing
immobilization
, Inquire through: | Professional | Confidential Support
Outcome/Patient Goals
Answer: o Goals directly relate back to the nursing diagnosis
o Realistic, patient centered, and measurable
o Goals are written as behavioral statements
Types of Outcome Criteria: Cognitive
Answer: Patient shows an increase in knowledge about a condition.
Outcome Criteria
Answer: o Patient centered, specific, measurable, and realistic
o (Who) Starts with the patient as the subject
o (What action) Contains an action verb
o (How well) Contains performance criteria
o (When) Has a time frame
Nursing Interventions-Examples
Answer: o Direct patient care activities
o Assist the patient to meet specific outcomes
o Promote continuity of care
o Focus documentation requirements
Nursing Interventions should be
Answer: o Appropriate to the diagnosis and outcomes
o Consistent with the evidence and standards of care
o Realistic in terms of abilities, time and resources available to the nurse and patient
o Compatible with the patient's values, beliefs, and psychosocial background
o Compatible with other planned therapies
HAFN Exam 3 Verified and Updated
Questions and Answers (100% Correct
Answers)
Nursing Process
Answer: Assessing
Diagnosing
Outcome Identification and Planning
Implementing
Evaluating
Assessment Purpose
Answer: o Establish baseline information
o Determine normal function
o Determine presence of dysfunction
o Appraisal of total patient situation
-Physical
-Psychological
-Emotional
-Sociocultural
-Spiritual
o Synthesize data to determine nursing diagnoses
Assessment Data
Answer: o Primary sources of data
,Inquire through: | Professional | Confidential Support
o Secondary sources of data
o Subjective vs objective
Assessment isn't a judgement but rather a
Answer: clinical observation
Subjective/objective data is in reference to the same things as
Answer: primary and secondary data
· Equal pupillary reaction =
Answer: when you shine light into the pupils they constrict
Can I observe or measure this? If so then it is _____ data
Answer: objective
Subjective or objective? Takes medication on a regular basis
Answer: Subjective because you cannot measure or observe this (in the context of
them reporting their medication concordance)
Nursing diagnoses come from a common language
Answer: o NANDA (North American Nursing Diagnosis Association)
o Identifies patient problems
o AKA nursing diagnoses
o Provides the basis for nursing interventions
Nursing Diagnoses
Answer: o Types of nursing diagnoses
-Actual
-Risk
o Diagnostic label
-Describes the essence of the problem
,Inquire through: | Professional | Confidential Support
Actual Nursing Diagnoses: 3 part statements
Answer: -Diagnostic label-Choose an appropriate label
-Related factors-Etiology (causes)
-Defining characteristics-Signs and symptoms, Validates the diagnosis, Written as:
· As manifested by (AMB)
· As evidenced by (AEB)
(chose AMB or AEB, not both)
Nursing Dx:
Data=Pain, R tibial fracture, 6/10 pain, grimacing
Answer: Pain related to right tibial fracture as evidenced by facial grimacing and
stating pain of 6:10.
· Dx label = pain
r/t
Answer: related to
Risk Nursing Diagnoses
Ex. Constipation, PND
Answer: 2 part statements:
-Diagnostic label-Choose an appropriate label
-Related factors-Etiology (causes)
Ex.
Risk for constipation r/t decreased mobility and narcotic pain medication.
Risk for peripheral neurovascular dysfunction r/t fall and cast on RLE causing
immobilization
, Inquire through: | Professional | Confidential Support
Outcome/Patient Goals
Answer: o Goals directly relate back to the nursing diagnosis
o Realistic, patient centered, and measurable
o Goals are written as behavioral statements
Types of Outcome Criteria: Cognitive
Answer: Patient shows an increase in knowledge about a condition.
Outcome Criteria
Answer: o Patient centered, specific, measurable, and realistic
o (Who) Starts with the patient as the subject
o (What action) Contains an action verb
o (How well) Contains performance criteria
o (When) Has a time frame
Nursing Interventions-Examples
Answer: o Direct patient care activities
o Assist the patient to meet specific outcomes
o Promote continuity of care
o Focus documentation requirements
Nursing Interventions should be
Answer: o Appropriate to the diagnosis and outcomes
o Consistent with the evidence and standards of care
o Realistic in terms of abilities, time and resources available to the nurse and patient
o Compatible with the patient's values, beliefs, and psychosocial background
o Compatible with other planned therapies
