NR - 410 - QUIZ #3 QUESTIONS WITH COMPLETE SOLUTIONS

NR - 410 - QUIZ #3 QUESTIONS WITH
COMPLETE SOLUTIONS




Sourcespoofpoassessmentpo-poans--
ComprehensivepoInitialpoassessment:poperformedposhortlypoafterpoapopatientpoispoadmittedp
otopoapohealthpocarepoagencypoorposervice.


focusedpoassessment:potheponursepogatherspodatapoaboutpospecificpoproblemspothatpohavep
oalreadypobeenpoidentified.poSignspoandposymptoms,powhenpodidpotheypostart,powhatpomake
sposymptomspobetterpoorpoworse,poarepoyoupotakingpoanyporemediespoforpoyourposymptoms,p
owerepoyoupodoingpoanythingpooutpoofpotheponormpowhenpotheypostarted


Emergencypoassessment:poidentifiespolifepothreateningpoproblemspoconcerningpophysiologi
calpoorpophycologicalpocrisispo

Time-
Lapsedpoassessment:poisposcheduledpotopocomparepoapopatientspocurrentpostatuspotopothepo
baselinepodatapoobtainedpoearlier

QuickpoPriority:poshort,pofocused,poprioritizedpoassessmentsponursespodopotopogainpothepom
ostpoimportantpoinformationpotheyponeedpotopohavepofirst

Assessmentpoincludespothepofollowing:po-poans--
Systematicpocollectionpoofpoinformationpoaboutpothepoclient
Frompodataposources;pophysicalpoassessment,povitalposigns,poenvironmentalpoandpoindividu
alposafety
Frompothepoclient
Frompothepofamily
Frompootherpohealthpocarepoprofessionals
Categorizationpoofpoinformationpo(organizing)
Verificationpoofpoinformation
Analysispoofpoinformationpoaspoapobasispoforponursingpodiagnoses

Whatpoispoclusteringpo-poans--clusteringporelatedpodatapoandpoidentifyingpopatters

,RecognizepoGordon'spoFunctionalpoHealthpoPatternpoclassificationspo(11pogeneralpoones)po
-poans--1.poHealthpoPerception/Management
2.poActivitypo&poExercise
3.poNutrition
4.poElimination
5.poSleep-Rest
6.poCognitive-perceptual
7.poSelfpoperception-selfpoconcept
8.poRole-relationship
9.poSexuality-reproductive
10.poCoping-stresspotolerance
11.poValues-beliefs

Objectivepodatapo-poans--
arepoobservablepoandpomeasurablepodatapothatpocanpobeposeen,poheard,pofelt,poorpomeasur
edpobyposomeonepootherpothanpothepopersonpoexperiencingpothem

Subjectivepodatapo-poans--
arepoinformationpoperceivedpoonlypobypothepoeffectedpoperson;pothesepodatapocannotpobepop
erceivedpoorpoverifiedpobypoanotherpoperson

Identifypothepoprimaryposourcepoforpoassessmentpodatapo-poans--
***ThepoPATIENTpoispoyourpoprimaryposourcepoofpodatapoAllpootherpodatapoispoconsideredpos
econdary

Whatpoisponeededpothroughoutpotheponursingpoprocesspo-poans--Reassessment!!po
Aspothepoclientpostatuspochangespoyoupomustpogopobackpoandpo
REASSESS!
poYouposhouldpobepoassessingpoyourpopatientspoCONTINUOUSLY,pothroughoutpoyourposhif
t
**Nursespoareporesponsiblepoforpoalertingpothepoappropriatepohealthpocarepoprofessionalpow
heneverpoassessmentpodatapodifferposignificantlypofrompothepopatient'spobaseline,poindicatin
gpoapopotentiallyposeriouspoproblem.poInterventionspoforpowhichpotheponursepomaypobepolega
llyporesponsiblepoincludepoincreasingpothepofrequencypoofpoassessmentspoandpoinitiatingpon
ecessarypochangespoinpothepotreatmentporegimen.

WhatpoarepothepoJointpoCommissionpoGuidelinesporelatedpotopoassessment?
poHINT:poWhopoispoallowedpotopocompletepothepoassessment?po-poans--theponursepoonly!!
poCannotpobepodelegated


Examplespoofpotypespoofpodatapothatponeedpotopobepovalidated...Hintpo=poincongruentpoinfor
mationpo-poans--
whenpotherepoispoapodiscrepancypoinpowhatpoapopersonpoisposayingpoandpowhatpoyoupoarepos
eeing

whenpothepodatapolackspoobjectivitypo(suspicionspoareponotpoobjective)

, Explainpowhatpotheponursepodoespotopoformulatepoaponursingpodiagnosispo(Whatpoisponeede
d?)po-poans--1.poStartpowithpoaporeviewpoofpoassessmentpodata
2.poAnalyzepoandpointerpretpothepodata
Lookpoforpopatternspoandpoclusterpoorpocategorizepodatapo&poComparepopatternspowithponor
ms
3.poIdentifypothepoclientponeedspoorpoproblems
4.poFormulatepotheponursingpodiagnosis

DEFINITIONpoofpoapoNursingpoDiagnoses:po-poans--
Apostatementpothatpodescribespothepoclient'spoactualpoand/
orpopotentialporesponsepotopoapohealthpoproblempothatpotheponursepoispolicensedpotopotreat

PurposepoofpoapoNursingpoDiagnoses:po-poans--
Providespoapobasispoforpothepodevelopmentpoofpoaponursingpoplanpoofpocarepo(outcomes),
Guidespotheposelectionpoofpointerventionspotopoachievepooutcomespoforpowhichpotheponursep
oisporesponsible
Helpspoindividualizepocare
Nursingpodiagnosespochangepoaspothepoclientpochanges

Bepoablepotopogiveporeasonspowhypowepouseponursingpodiagnosespo-poans--
(1)poidentifypohowpoapoperson,pogroup,poorpocommunityporespondspotopoactualpoorpopotential
pohealthpoandpolifepoprocesses;po
(2)poidentifypofactorspothatpocontributepotopoorpocausepohealthpoproblemspo(etiologies);poand
po
(3)poidentifyporesourcespoorpostrengthspothatpothepoperson,pogroup,poorpocommunitypocanpod
rawpoonpotopopreventpoorporesolvepoproblems

Knowpohowpotopowritepoaponursingpodiagnosispo-poans--FollowpothepoP-E-SpoFormat
Ppo-poProblem
Epo-poEtiologypo(relatedpoorpocausativepofactors)po[R/T]
Spo-poSymptomspo(definingpocharacteristics)po[AEB]

Knowpothepodifferentpotypespoofpoerrorsposeenpoinpowritingpoaponursingpodiagnosispo-poans--
writingpoapomedicalpodiagnosisporatherpothanpoaponursingpodiagnosis

Recognizepothepodifferentpopartspoofpoaponursingpodiagnosispo(NANDApodiagnosticpolabel,po
etiology,podefiningpocharacteristics/signspo&posymptoms)po-poans--
1.poProblempoidentifiedpobypothepoNANDAponursingpodiagnosticpolabelpo(frompolist)

2.poEtiology/healthpocondition/
lifepoprocessespothatpoarepounderlyingpocauses.poThesepoarepodistinguishedpobypothepoword
spo"relatedpoto"po(r/t).poCANNOTpoUSEpoApoMEDICALpoDIAGNOSIS!

3.poSigns/
Symptoms,poAKApoDefiningpoCharacteristics.poThesepoarepoindicatedpobypothepowordspo"as
poevidencedpoby"po(AEB)