Patient Centered Care/Nursing
Process Exam/ 66 Questions
and Answers/A+ Rated
A patient is prescribed an enema so the nurse goes into the patients
room and notifies them. The patient replies "that's not what the doctor
told me". What does the Nurse do? - -double check to make sure the
prescription is correct
-A nurse enters a room of a client who becomes verbally abusive. What
would be the appropriate action for the nurse to take? - -leave the room
-a nurse is working with a group of clients assisted by an assistive
personnel (AP). The nurse should make what determination before
delegating a task to the AP? - -The task must be within the AP's scope of
practice
-a nurse is planning care for four clients and is assigning tasks to a
nursing assistant. which of the following should the nurse assign to the
NA?
A. Complete an admission assessment for a client who has severe
breathing problems
B. Measure I&O for a client with an indwelling urinary catheter - -B!!
-Steps of the nursing process acronym - -ADPIE
-nursing process acronym also used - -ADOPIE
-assessment phase (A) - -evaluation/appraisal of patient's health state
-steps of the nursing process (5) - -assess, diagnose, planning/outcome,
implement care, evaluate outcomes of what has been implemented
-diagnosis phase (D) - -clinical act of identifying problems
-planning/outcomes phase (P) - -making and documenting patient goals
-implementation phase (I) - -initiation of the plan and the patient's
response
-evaluation phase (E) - -determine if plan was successful or not
-Physical examination techniques (4) - -inspection, palpation,
percussion, auscultation
, -inspection technique - -visual examination of patient beginning with
first contact
-what is noted during inspection? - -color, shape, symmetry, etc. of
body parts
-palpation technique - -use of touch to determine size, shape, and
configuration of body structures
-percussion technique - -one or both hands are used to strike body
surface to produce 'percussion note'--determines density/hollowness
-what exactly is percussion used for? - -used to discover location of
organs, tenderness of kidneys, or identification of tumors
-auscultation technique - -listening to the body sounds with stethoscope
-percussion definition - -technique where both hands are used to strike
body surface to produce percussion note
-sources of data (2) - -primary and secondary
-secondary source function - -to provide data to supplement, clarify, or
validate info obtained from patient
-primary source - -information collected directly from patient
-validation definition - -double-checking information
-example of nursing diagnosis - -Ineffective airway clearance related to
thick tracheobronchial secretions
-subjective data - -symptoms and covert cues--patient's perspective
(i.e. "I feel tired")
-objective data - -signs and overt cues--quantifiable
-what does data validation mean? - -confirming/double checking
-types of assessments (4) - -admission, focus, time-lapse, emergency
-admission assessment aim - -collection of data concerning
actual/potential dysfunction--baseline for reference
-admission assessment time frame - -after admission to health care
facility
-focus assessment aim - -determine status of problem identified during
previous assessment
Process Exam/ 66 Questions
and Answers/A+ Rated
A patient is prescribed an enema so the nurse goes into the patients
room and notifies them. The patient replies "that's not what the doctor
told me". What does the Nurse do? - -double check to make sure the
prescription is correct
-A nurse enters a room of a client who becomes verbally abusive. What
would be the appropriate action for the nurse to take? - -leave the room
-a nurse is working with a group of clients assisted by an assistive
personnel (AP). The nurse should make what determination before
delegating a task to the AP? - -The task must be within the AP's scope of
practice
-a nurse is planning care for four clients and is assigning tasks to a
nursing assistant. which of the following should the nurse assign to the
NA?
A. Complete an admission assessment for a client who has severe
breathing problems
B. Measure I&O for a client with an indwelling urinary catheter - -B!!
-Steps of the nursing process acronym - -ADPIE
-nursing process acronym also used - -ADOPIE
-assessment phase (A) - -evaluation/appraisal of patient's health state
-steps of the nursing process (5) - -assess, diagnose, planning/outcome,
implement care, evaluate outcomes of what has been implemented
-diagnosis phase (D) - -clinical act of identifying problems
-planning/outcomes phase (P) - -making and documenting patient goals
-implementation phase (I) - -initiation of the plan and the patient's
response
-evaluation phase (E) - -determine if plan was successful or not
-Physical examination techniques (4) - -inspection, palpation,
percussion, auscultation
, -inspection technique - -visual examination of patient beginning with
first contact
-what is noted during inspection? - -color, shape, symmetry, etc. of
body parts
-palpation technique - -use of touch to determine size, shape, and
configuration of body structures
-percussion technique - -one or both hands are used to strike body
surface to produce 'percussion note'--determines density/hollowness
-what exactly is percussion used for? - -used to discover location of
organs, tenderness of kidneys, or identification of tumors
-auscultation technique - -listening to the body sounds with stethoscope
-percussion definition - -technique where both hands are used to strike
body surface to produce percussion note
-sources of data (2) - -primary and secondary
-secondary source function - -to provide data to supplement, clarify, or
validate info obtained from patient
-primary source - -information collected directly from patient
-validation definition - -double-checking information
-example of nursing diagnosis - -Ineffective airway clearance related to
thick tracheobronchial secretions
-subjective data - -symptoms and covert cues--patient's perspective
(i.e. "I feel tired")
-objective data - -signs and overt cues--quantifiable
-what does data validation mean? - -confirming/double checking
-types of assessments (4) - -admission, focus, time-lapse, emergency
-admission assessment aim - -collection of data concerning
actual/potential dysfunction--baseline for reference
-admission assessment time frame - -after admission to health care
facility
-focus assessment aim - -determine status of problem identified during
previous assessment
