Nursing 206 Nursing Process Exam
Questions and Answers
Nursing Process - ANSWER-"A systematic, rationale method of planning and providing
individualized nursing care. Its purpose is to identify client's health status, actual or
potential healthcare problems or needs, to establish plans to meet those needs and to
deliver specific nursing interventions to meet those needs".
Steps of the Nursing Process
-Assessment (collecting data)
-Diagnosis (analyze data)
-Planning (prioritize problems and formulate goals)
-Implementation (determine need for assistance and implement interventions)
-Evaluation (collect and compare data, draw conclusions)
Problem-Solving & Priority Setting - ANSWER-Priority Setting:
-Determine client health values & beliefs
-Establish priorities from highest to lowest
-Determine urgency or the problem
Problem-Solving:
-Once problem is identified, collect data
-Analyze the data & identify an action-plan
-Implement the plan, observing initial responses
-Evaluate the results
Assessment Phase - ANSWER--Collect data
-organize data
-validate data
-document data
-Systematic and continuous collection, analysis, validation, and communication of
patient data
-How is it different form Medical Assessment
-Medical assessments target data pointing to pathologic conditions
-Nursing assessments focus on the patient's response to health problems
Things to think about:
-ACCURATELY Assessing systematically and comprehensively to identify nursing and
medical concerns
-Detecting bias and determining the credibility of information sources
, -Distinguishing normal from abnormal findings and identifying the risks for abnormal
findings
-Making judgments about the significance of data, distinguishing relevant from irrelevant
data
-Identifying assumptions and inconsistencies, checking accuracy and reliability, and
recognizing missing information
-MAKE sure you RECORD!!!!!
-Identifying Trends!!!! Failure to rescue
Establishing Assessment Priorities
Things to take into account
-Health orientation of patient-Based on patient habits, beliefs, behaviors, attitudes,
values.
-Remember this is basis of patient centered care
-Developmental stage
-Culture
-Need for nursing
Length of stay
Dependence versus self care
Home environment
Assessment Data - ANSWER-Subjective Data
- The client states " . . ."
-pain, patients perception
Objective Data
- Vital signs/lab values
- Physical assessments
- Previous documentation
Sources of Data
-Patient
-Family and significant others
Confidentiality-make sure this is ok with patient
-Patient record
May still need to verify things
-Medical history, physical examination, progress notes
-Consultations
-Reports of laboratory and other diagnostic studies
-Monitors
-Reports of therapies by other health care professionals
-Nursing and other health care literature
Taking a Patient History/Interview - ANSWER--Should include info
-Literacy
-Culture
Questions and Answers
Nursing Process - ANSWER-"A systematic, rationale method of planning and providing
individualized nursing care. Its purpose is to identify client's health status, actual or
potential healthcare problems or needs, to establish plans to meet those needs and to
deliver specific nursing interventions to meet those needs".
Steps of the Nursing Process
-Assessment (collecting data)
-Diagnosis (analyze data)
-Planning (prioritize problems and formulate goals)
-Implementation (determine need for assistance and implement interventions)
-Evaluation (collect and compare data, draw conclusions)
Problem-Solving & Priority Setting - ANSWER-Priority Setting:
-Determine client health values & beliefs
-Establish priorities from highest to lowest
-Determine urgency or the problem
Problem-Solving:
-Once problem is identified, collect data
-Analyze the data & identify an action-plan
-Implement the plan, observing initial responses
-Evaluate the results
Assessment Phase - ANSWER--Collect data
-organize data
-validate data
-document data
-Systematic and continuous collection, analysis, validation, and communication of
patient data
-How is it different form Medical Assessment
-Medical assessments target data pointing to pathologic conditions
-Nursing assessments focus on the patient's response to health problems
Things to think about:
-ACCURATELY Assessing systematically and comprehensively to identify nursing and
medical concerns
-Detecting bias and determining the credibility of information sources
, -Distinguishing normal from abnormal findings and identifying the risks for abnormal
findings
-Making judgments about the significance of data, distinguishing relevant from irrelevant
data
-Identifying assumptions and inconsistencies, checking accuracy and reliability, and
recognizing missing information
-MAKE sure you RECORD!!!!!
-Identifying Trends!!!! Failure to rescue
Establishing Assessment Priorities
Things to take into account
-Health orientation of patient-Based on patient habits, beliefs, behaviors, attitudes,
values.
-Remember this is basis of patient centered care
-Developmental stage
-Culture
-Need for nursing
Length of stay
Dependence versus self care
Home environment
Assessment Data - ANSWER-Subjective Data
- The client states " . . ."
-pain, patients perception
Objective Data
- Vital signs/lab values
- Physical assessments
- Previous documentation
Sources of Data
-Patient
-Family and significant others
Confidentiality-make sure this is ok with patient
-Patient record
May still need to verify things
-Medical history, physical examination, progress notes
-Consultations
-Reports of laboratory and other diagnostic studies
-Monitors
-Reports of therapies by other health care professionals
-Nursing and other health care literature
Taking a Patient History/Interview - ANSWER--Should include info
-Literacy
-Culture
