1. List 6 ways of collecting data during the Assessment process.

2. What is assessed for in the Neurological assessment?

3. In the Circulatory assessment?

4. In the Respiratory assessment?

5. In the GI assessment?

6. In the GU assessment?

7. Name 3 things that may be observed about a person’s culture?

8. Name the 4 types of Assessments:

9. A nursing assessment helps to focus on a patient’s ____________ to a health problem.

10.   Symptoms and things a patient says are what type of data?

11.   Signs, and what is detected by observation & testing are what type of data?

12.   A systematic, rational method of planning and providing nursing care is the definition of _______________________?

13. _______________ based nursing practice uses recent research findings in developing clinical practice and clinical decision-making.

14.   Name the five steps in the Assessment process:

      1.

      2.

      3.

      4.

      5.

15. Name some resources you would use to collect data?

16. Putting data into categories and identifying any gaps is part of which step in the Assessment?

17.   In reporting data, report only things which appear ____________.  Do not report your own judgements or opinions.

18.   What is the PRIMARY purpose of Assessment?

19.   What is the second step in the Nursing Process?

20.   An accurate diagnosis depends on ____________________________________.

21.   Name 3 types of assessments which are done:

      1.

      2.

      3.

22. Name 5 things which are a result of errors made in diagnosis:

      1.

      2.

      3.

      4.

      5.

23. Name the 3 types of Diagnoses:

      1.

      2.

      3.

24. What is the organization who determines the list of Nursing Diagnoses?

25. Nursing Diagnoses are ______  ________ about individual, family, or community responses to ________  or ___________ health problems or life processes.  They provide the basis for selection of ________  _____________ to achieve outcomes for which the nurse is accountable.

26.   _________  diagnoses require the expertise of a physician and usually refer to problems with ________  or  __________ .

27.   __________  diagnoses are those patient problems that can be helped by both medical and nursing interventions.  They usually start with the terminology “potential complication.”

28.   A Nursing Diagnosis is written as a ___ -part statement.  Name the parts and where you would get them from.

29. Which type of diagnosis is only a 2-part statement? 

30.   Name the 2 parts from #29 and where the information comes from.

31.   What is missing from the 2-part statement above and why is it missing?

32.   What is the reasoning for writing the 2-part statement?  What is your goal?

33.   Guidelines for writing nursing diagnoses say not to write them in certain ways, name 6 ways.

34.   Don’t write a nursing diagnosis on something you can’t ___________.

35.   What is the 3^rd step in the Nursing Process?

36.   What is happening during this process?

37.   What is always the #1 goal of the 3^rd step of the Nursing Process?

38.   What are some characteristics of your expected outcome/final goal?

39.   Name the 2 types of outcomes/goals? 

40.   When writing an outcome/goal, what are some of the criteria you would include?

41.   Name 3 measurable verbs.

42.   What are 3 types of outcomes you wish to see?

      1.

      2.

      3.

43. When writing Nursing interventions, make sure they are __________ and that they ______  ________ to YOUR patient.

44. When writing nursing interventions, it is important that it is as ________ as possible.  Leave no room for error or misinterpretation.

45.   When determining a nursing intervention, you would look to the ___________ part of the nursing diagnosis.

46.   What is the final product of the Planning stage, which must be produced for JCAHO to show evidence that the nursing process has been used?

47.   What is the 4^th step of the Nursing Process?

48.   This step is the act of getting it _______.

49.   Name the 3 types of nursing roles/actions:

      1.

      2.

      3.

50. Name 2 things you look at when you begin thinking about Health Teaching?

      1.

      2.

51. Important quote to remember:  IF IT’S NOT ____________ IT WAS NOT DONE!

52. When doing interventions, be sure to document the patient’s _________ to the intervention. 

53. Always draw a line through ______ _______ on the chart as a safety precaution for you so that nothing can be inserted or written in.

54.   Do this to your entry if you make an error: ________________________

55.   Name the 5^th and final step in the Nursing Process.

56.   What types of things are done during this process?

57. Name the 3 possible results in the final step:

      1.

      2.

      3.

58.  The ANA is the group who oversees the nursing ______________  ___  ___________.