Fundamental concepts and skills for nursing exam 2
5 components of nursing diagnosis - (correct Answer) - Assessment, nursing diagnosis,
planning,implementation,evaluation
Assessment - (correct Answer) - Is obtained from patient, the family, the physician, tests, and info about
patient from other health professionals
Assessment - (correct Answer) - Collecting,organizing, documenting, and validating data about a patients
health status
Nursing diagnosis - (correct Answer) - the process by which the assessment data are sorted and analyzed
so that specific actual and potential health problems are identified.
Nursing diagnosis - (correct Answer) - the factors contributing to the problems are considered, and
specific nursing diagnoses are chosen for the patients care plan
planning - (correct Answer) - a series of steps by which the nurse and the patient set priorities and goals
to eliminate or diminish the identified problems. The goals are stated as specific expected outcomes.
planning - (correct Answer) - the nurse and the patient collaborate and choose specific interventions for
each nursing diagnosis. the interventions assist the patient in meething the expected outcomes. the
expected outcomes and nursing interventions are listed on patients nursing care plan.
implementation - (correct Answer) - carrying out the nursing interventions in a systematic way. the nurse
carries out the interventions. the patients response to the care give is documented
Evaluation - (correct Answer) - assessing the patients response to the nursing interventions. the
responses are compared with the expected outcomes to determine whether they have been achieved.
The entire care plan is reassessed and any changes needed are made
nursing process - (correct Answer) - is a way of thinking and acting based on the scientific method. It is a
tool for identifying patients problems or potential problems and an organized method for meeting
patients needs.
nursing process was created in what year - (correct Answer) - 1950's to describe nurses' independent
role in providing patient care. they are taught to use this framework consistently and methodically.
Goals of nursing process - (correct Answer) - to explore patients' health status,identify actual or potential
health care problems, determine outcomes, to deliver specific interventions to help solve problems and
promote health, and to evaluate care given and determine if outcomes have been met.
who does the assessment - (correct Answer) - The RN is designated to perform the intitail admission
assessment of each patient. But the lpn can assist with vitals and weight. Or even setting up the room
and getting a urine sample. they can even help with physical exam.
when is the assessment done? - (correct Answer) - the assessment is done within an allotted time when
they get admitted. for long term care it is reassessed every 90 days.
, is the client involved? - (correct Answer) - yes the client is involved with giving any personal information
that is needed to assess the patient
how is an assessment done? - (correct Answer) - it is done by collecting data and putting it into a
database and than documented, it also requires a planning stage in which it includes health status of
patient and family.
What is focused assessment? - (correct Answer) - factors causing or affecting the pain. It is focused on
one very specific problem
what is an example of focused assessment.. - (correct Answer) - if the patient has slurred speech and
doesnt know whats going on. you would than order a head scan and check eyes out and run tests to see
if its neurologic.
What is subjective data? - (correct Answer) - data obtained from patient directly.
What is objective data? - (correct Answer) - What the nurse sees/ovbserves.
An example of subjective and objective - (correct Answer) - subjective- I have a headache
objective- temperature is 101.4
What is implementation? - (correct Answer) - giving care to a patient. making a plan
What is intervention? - (correct Answer) - are the actions listed on nursing care plan that are carried out.
what is dependent nursing action? - (correct Answer) - requires a physician order. such as ordering a
heating pad or administering medications.
what is independent nursing action? - (correct Answer) - does not require a physician order. Such as
giving side affects to patient on medications or giving a back massage.
What does a medical record contain? - (correct Answer) - all orders, tests,treatments,and care that
occurred while the person was under the care of the health care provider
What is the purpose of a medical record? - (correct Answer) - it is used for communication for all health
care members assisting that patient. also used for reimbursement from insurance companies.Used for
court of law if necessary. but can be used for research purposes as well. it provides a way to show that
standards of care have been met.
What is problem oriented medical record charting? - (correct Answer) - POMR focuses on patient
status,emphasizing the problem solving approach to patient care and providing a method for
communicating what when and how things are to be done to meet patients needs.
POMR has five basic parts - (correct Answer) - Database, problem list, plan, progress notes, discharge
summary
Database - (correct Answer) - initial assessment, general health history, findings from exams, diagnostic
and lab tests, psycho-social info, nursing assessment, and patients response to illness or problem.
Problem list - (correct Answer) - list of problems derived from the info in the database. it is continually
5 components of nursing diagnosis - (correct Answer) - Assessment, nursing diagnosis,
planning,implementation,evaluation
Assessment - (correct Answer) - Is obtained from patient, the family, the physician, tests, and info about
patient from other health professionals
Assessment - (correct Answer) - Collecting,organizing, documenting, and validating data about a patients
health status
Nursing diagnosis - (correct Answer) - the process by which the assessment data are sorted and analyzed
so that specific actual and potential health problems are identified.
Nursing diagnosis - (correct Answer) - the factors contributing to the problems are considered, and
specific nursing diagnoses are chosen for the patients care plan
planning - (correct Answer) - a series of steps by which the nurse and the patient set priorities and goals
to eliminate or diminish the identified problems. The goals are stated as specific expected outcomes.
planning - (correct Answer) - the nurse and the patient collaborate and choose specific interventions for
each nursing diagnosis. the interventions assist the patient in meething the expected outcomes. the
expected outcomes and nursing interventions are listed on patients nursing care plan.
implementation - (correct Answer) - carrying out the nursing interventions in a systematic way. the nurse
carries out the interventions. the patients response to the care give is documented
Evaluation - (correct Answer) - assessing the patients response to the nursing interventions. the
responses are compared with the expected outcomes to determine whether they have been achieved.
The entire care plan is reassessed and any changes needed are made
nursing process - (correct Answer) - is a way of thinking and acting based on the scientific method. It is a
tool for identifying patients problems or potential problems and an organized method for meeting
patients needs.
nursing process was created in what year - (correct Answer) - 1950's to describe nurses' independent
role in providing patient care. they are taught to use this framework consistently and methodically.
Goals of nursing process - (correct Answer) - to explore patients' health status,identify actual or potential
health care problems, determine outcomes, to deliver specific interventions to help solve problems and
promote health, and to evaluate care given and determine if outcomes have been met.
who does the assessment - (correct Answer) - The RN is designated to perform the intitail admission
assessment of each patient. But the lpn can assist with vitals and weight. Or even setting up the room
and getting a urine sample. they can even help with physical exam.
when is the assessment done? - (correct Answer) - the assessment is done within an allotted time when
they get admitted. for long term care it is reassessed every 90 days.
, is the client involved? - (correct Answer) - yes the client is involved with giving any personal information
that is needed to assess the patient
how is an assessment done? - (correct Answer) - it is done by collecting data and putting it into a
database and than documented, it also requires a planning stage in which it includes health status of
patient and family.
What is focused assessment? - (correct Answer) - factors causing or affecting the pain. It is focused on
one very specific problem
what is an example of focused assessment.. - (correct Answer) - if the patient has slurred speech and
doesnt know whats going on. you would than order a head scan and check eyes out and run tests to see
if its neurologic.
What is subjective data? - (correct Answer) - data obtained from patient directly.
What is objective data? - (correct Answer) - What the nurse sees/ovbserves.
An example of subjective and objective - (correct Answer) - subjective- I have a headache
objective- temperature is 101.4
What is implementation? - (correct Answer) - giving care to a patient. making a plan
What is intervention? - (correct Answer) - are the actions listed on nursing care plan that are carried out.
what is dependent nursing action? - (correct Answer) - requires a physician order. such as ordering a
heating pad or administering medications.
what is independent nursing action? - (correct Answer) - does not require a physician order. Such as
giving side affects to patient on medications or giving a back massage.
What does a medical record contain? - (correct Answer) - all orders, tests,treatments,and care that
occurred while the person was under the care of the health care provider
What is the purpose of a medical record? - (correct Answer) - it is used for communication for all health
care members assisting that patient. also used for reimbursement from insurance companies.Used for
court of law if necessary. but can be used for research purposes as well. it provides a way to show that
standards of care have been met.
What is problem oriented medical record charting? - (correct Answer) - POMR focuses on patient
status,emphasizing the problem solving approach to patient care and providing a method for
communicating what when and how things are to be done to meet patients needs.
POMR has five basic parts - (correct Answer) - Database, problem list, plan, progress notes, discharge
summary
Database - (correct Answer) - initial assessment, general health history, findings from exams, diagnostic
and lab tests, psycho-social info, nursing assessment, and patients response to illness or problem.
Problem list - (correct Answer) - list of problems derived from the info in the database. it is continually
