Unit 2 The Nursing process UPDATED
ACTUAL Questions and CORRECT
Answers
Definition of the Nursing process - CORRECT ANSWER - diagnose and treat the human response
to health and illness
purpose of the nursing process - CORRECT ANSWER - critical thinking process for the nurse to
utilize to give the best care possible to the client
what is the method of problem solving in the nursing process - CORRECT ANSWER - SADIOUP
-Systematic
-Assertive
-Dynamic
-Interpersonal
-Outcome oriented
-Universally applicable to all nursing situations
-provides a framework for the practice of nursing
phases of the nursing process - CORRECT ANSWER - ADPIE
-Assessment
-Diagnosis
-Planning
-implementation
-Evaluation
Assessment - CORRECT ANSWER - -systematic and continuous collection,validation and
communication of pt data to establish a baseline
-the process of obtaining a health history and performing a physical examination.
,subjective data - CORRECT ANSWER - "symptoms" collected by interviewing the patient.what
the patient says
objective data - CORRECT ANSWER - "signs" data that can be observed or measured. what the
nurse sees, touches, hears, smells
primary data source - CORRECT ANSWER - the patient unless child, coma then family is primary
secondary data source - CORRECT ANSWER - all other sources (family, friends, caregivers)
methods utilized to collect data - CORRECT ANSWER - -the interview
-the physical exam
Interview - CORRECT ANSWER - subjective data- previous health history/medications
Physical exam - CORRECT ANSWER - objective data
compare: pt data to pre-established norms/base line data
ex:inspection,palpation,percussion,auscultation
comprehensive assessment - CORRECT ANSWER - detailed assessment of one body system or
many body systems, including those not directly involved in presenting a problem or admission diagnosis
-head to toe assessment
focused assessment/initial - CORRECT ANSWER - abbreviated assessment that focuses on one or
more body systems that are the focus of care
- assessment related to a specific problem (pneumonia,specific abnormal labs.)
-monitors for signs of new problems
, emergency assessment - CORRECT ANSWER - limited to assessing life threatening conditions
(anaphylaxis, shock...)
-conducted to ensure survival
-A-airway
-B-Breathin
-C-circulation
-D-disability
-after lifesaving interventions are initiated, perform brief systematic assessment to identify any and all
other injuries
OCC views on Gordon functional health pattern - CORRECT ANSWER - framework for the
nursing assessments
Gordon functional health patterns - CORRECT ANSWER - document pt data within categories
1) health and perception/management - CORRECT ANSWER - focuses on the pts perceived level
of health and well-being and personal practices for maintaining health.
ex) reason for placement,past medical/surgical history, code state, allergies, advanced directives
2) nutritional-metabolic pattern - CORRECT ANSWER - ingestion, digestion, absorption and
metabolism
ex) hight/weight/bmi/diet, problems eating, digestion, oral mucosa, nails, skin
3) elimination - CORRECT ANSWER - assess bowel, bladder, skin function
ex) bowel habits/elimination, stool, ostomy, bladder function
ACTUAL Questions and CORRECT
Answers
Definition of the Nursing process - CORRECT ANSWER - diagnose and treat the human response
to health and illness
purpose of the nursing process - CORRECT ANSWER - critical thinking process for the nurse to
utilize to give the best care possible to the client
what is the method of problem solving in the nursing process - CORRECT ANSWER - SADIOUP
-Systematic
-Assertive
-Dynamic
-Interpersonal
-Outcome oriented
-Universally applicable to all nursing situations
-provides a framework for the practice of nursing
phases of the nursing process - CORRECT ANSWER - ADPIE
-Assessment
-Diagnosis
-Planning
-implementation
-Evaluation
Assessment - CORRECT ANSWER - -systematic and continuous collection,validation and
communication of pt data to establish a baseline
-the process of obtaining a health history and performing a physical examination.
,subjective data - CORRECT ANSWER - "symptoms" collected by interviewing the patient.what
the patient says
objective data - CORRECT ANSWER - "signs" data that can be observed or measured. what the
nurse sees, touches, hears, smells
primary data source - CORRECT ANSWER - the patient unless child, coma then family is primary
secondary data source - CORRECT ANSWER - all other sources (family, friends, caregivers)
methods utilized to collect data - CORRECT ANSWER - -the interview
-the physical exam
Interview - CORRECT ANSWER - subjective data- previous health history/medications
Physical exam - CORRECT ANSWER - objective data
compare: pt data to pre-established norms/base line data
ex:inspection,palpation,percussion,auscultation
comprehensive assessment - CORRECT ANSWER - detailed assessment of one body system or
many body systems, including those not directly involved in presenting a problem or admission diagnosis
-head to toe assessment
focused assessment/initial - CORRECT ANSWER - abbreviated assessment that focuses on one or
more body systems that are the focus of care
- assessment related to a specific problem (pneumonia,specific abnormal labs.)
-monitors for signs of new problems
, emergency assessment - CORRECT ANSWER - limited to assessing life threatening conditions
(anaphylaxis, shock...)
-conducted to ensure survival
-A-airway
-B-Breathin
-C-circulation
-D-disability
-after lifesaving interventions are initiated, perform brief systematic assessment to identify any and all
other injuries
OCC views on Gordon functional health pattern - CORRECT ANSWER - framework for the
nursing assessments
Gordon functional health patterns - CORRECT ANSWER - document pt data within categories
1) health and perception/management - CORRECT ANSWER - focuses on the pts perceived level
of health and well-being and personal practices for maintaining health.
ex) reason for placement,past medical/surgical history, code state, allergies, advanced directives
2) nutritional-metabolic pattern - CORRECT ANSWER - ingestion, digestion, absorption and
metabolism
ex) hight/weight/bmi/diet, problems eating, digestion, oral mucosa, nails, skin
3) elimination - CORRECT ANSWER - assess bowel, bladder, skin function
ex) bowel habits/elimination, stool, ostomy, bladder function
