The Nursing Process
- Extrapolate findings
- Prioritize the findings
- Formulate the plan of care
- Implement the plan of care
- ADPIE (assessing, diagnosis, planning, implementation, evaluation)
For which of the following patients would a comprehensive health history be appropriate?
A new patient with the chief complaint of "I am here to establish care"
The nurse compares subjective data and objective data to achieve which of the following?
Validation of data
You are seeing an older patient who has not had medical care for many years. Her vital signs taken by your office staff are: T 37.2, HR 78, BP 118/92, and RR 14, and she denies pain. You notice that she has some hypertensive changes in her retinas and you find mild proteinuria on a urine test in your office. You expected the BP to be higher. She is not on any medications. What do you think is causing this BP reading, which doesn't correlate with the other findings?
It is caused by an "auscultatory gap."
A 55-year-old bookkeeper comes to your office for a routine visit. You note that on a previous visit for treatment of contact dermatitis, her blood pressure was elevated. She does not have prior elevated readings and her family history is negative for hypertension. You measure her blood pressure in your office today. Which of the following factors can result in a false high reading?
Blood pressure cuff is tightly fitted.
A nurse is assessing the pain of a client who has had major surgery. The client also has been experiencing depression. Which of the following would the nurse need to keep in mind when assessing the client's pain?
It is likely that the client's pain rating will be less than what he is feeling.
The main purpose of the nursing care plan is to:
communicate the patient's progress in a standard way.
A nurse is interpreting and making inferences from the data. The nurse is involved in which phase of the nursing process?
You arrive at the bedside of an elderly woman who has had a stroke, affecting her entire right side. She cannot speak (aphasia). You are supposed to examine her. You notice that the last examiner left her socks at the bottom of the bed, and although sensitive areas are covered by a sheet, the blanket is heaped by her feet at the bottom of the bed. What would you do next?
Put her socks back on and cover her completely before beginning the evaluation.
An 18-year-old college freshman presents to the clinic for evaluation of gastroenteritis. You measure the patient's temperature and it is 104 degrees Fahrenheit. What type of pulse would you expect to feel during his initial examination?
Large amplitude, forceful
A group of students is reviewing information about auscultation in preparation for a test. The students demonstrate understanding of the material when they identify which of the following?
The diaphragm should be held firmly against the body part.
A nurse is preparing to assess an adult client's body temperature. At which time of the day would the nurse expect to obtain the lowest body temperature?
A patient complains of knee pain on your arrival in the room. What should your first sentence be after greeting the patient?
Could you please describe what happened?
What is the importance of assessing vital signs? (Mark all that apply.)
- To establish a baseline
- To monitor risks for alterations in health
- To evaluate the patient's responses to treatment