©SIRJOEL EXAM SOLUTIONS 2024/2025
ALL RIGHTS RESERVED.
NUR230 Test 1 Study Guide.
Assessment - Answers✔collection of data (patient) related to an individuals health
first step in the nursing process and every approach to clinical reasoning
an ongoing process, not just one time at the beginning of care
the nursing process - Answers✔start with assessment, then nursing diagnosis, what is the
patient outcome that I want, plan how to get that outcome, are you going to do it
(implementation), evaluation
if it didn't work go through the cycle again
assessment - Answers✔collect data: review of the clinical record, health history, physical
examination, functional assessment, risk assessment, review of the literature
use evidence-based assessment techniques
document relevant data
collect subjective (what patient says about himself/herself during history taking) and objective
data (nurse observations: inspection, percussion, palpation, auscultation--in that order)
interpret data - Answers✔compare findings (normal/abnormal)
identify nursing diagnosis
outcome identification - Answers✔identify expected outcomes/findings
1|Page
, ©SIRJOEL EXAM SOLUTIONS 2024/2025
ALL RIGHTS RESERVED.
individualize to patient
ensure outcomes: realistic, measurable, time frame
planning - Answers✔establish priorities
develop outcomes
identify interventions
document plan of care
set times for outcomes
integrate evidence-based trends and research
implementation - Answers✔implement interventions in a safe and timely manner
use evidence-based interventions
collaboration with colleagues
use community resources
coordinate care delivery
provide health teaching and health promotion
document care/implementation and any modification
2|Page
, ©SIRJOEL EXAM SOLUTIONS 2024/2025
ALL RIGHTS RESERVED.
evaluation - Answers✔compare established outcomes with actual outcomes
progress toward outcomes
conduct systematic, ongoing criterion-based evaluation
include patient and significant others
use ongoing assessment to revise diagnoses, outcomes, pain
disseminate results to patient and family
identify any roadblocks
modify plan
document evaluation of plan of care
evidence-based practice (EBP) - Answers✔"Systematic approach to practice that emphasizes
the use of best evidence in combination with the clinician's experience, as well as the patient
preferences and values, to make decisions about care and treatment."
Accurate assessment guides you through application of the nursing process as you provide care
Inaccurate assessment could lead to an incorrect nursing diagnosis, interventions, or outcomes
(your plan may be ineffective/inaccurate, incomplete assessments could lead to selection of
inappropriate interventions) - Answers✔Why is thorough assessment necessary?
comprehensive (admission assessment) - Answers✔includes health history and physical exam
enables practitioner to have complete picture of the patients health status
3|Page
, ©SIRJOEL EXAM SOLUTIONS 2024/2025
ALL RIGHTS RESERVED.
episodic/focused (shift assessment) - Answers✔when you're leaving and someone is taking
your shift
emergency assessment - Answers✔focuses on "ABC'c" (airway, breathing, circulation)
follow-up assessment - Answers✔example: pain score after treatment of pain (after treatment)
subjective and objective data - Answers✔What are the two types of patient data?
subjective data - Answers✔What the individual tells you in the interview
What the person says
Information from family members
Examples: family history, past medical history, cultural & spiritual, development, functional,
mental status, pain, nutritional
objective data - Answers✔What you, the nurse, observe, examine, or measure
Also includes data from medical testing, assessments of other healthcare professionals
Examples: general survey/observations, vital signs, head-to-toe assessment of each system
inspection, palpation, percussion, ausculation - Answers✔what are the assessment techniques?
inspection - Answers✔Watching
Look at patient as a whole & each system
Begins as soon as you walk in door
palpation - Answers✔Sense of touch
Light or deep touch
4|Page
ALL RIGHTS RESERVED.
NUR230 Test 1 Study Guide.
Assessment - Answers✔collection of data (patient) related to an individuals health
first step in the nursing process and every approach to clinical reasoning
an ongoing process, not just one time at the beginning of care
the nursing process - Answers✔start with assessment, then nursing diagnosis, what is the
patient outcome that I want, plan how to get that outcome, are you going to do it
(implementation), evaluation
if it didn't work go through the cycle again
assessment - Answers✔collect data: review of the clinical record, health history, physical
examination, functional assessment, risk assessment, review of the literature
use evidence-based assessment techniques
document relevant data
collect subjective (what patient says about himself/herself during history taking) and objective
data (nurse observations: inspection, percussion, palpation, auscultation--in that order)
interpret data - Answers✔compare findings (normal/abnormal)
identify nursing diagnosis
outcome identification - Answers✔identify expected outcomes/findings
1|Page
, ©SIRJOEL EXAM SOLUTIONS 2024/2025
ALL RIGHTS RESERVED.
individualize to patient
ensure outcomes: realistic, measurable, time frame
planning - Answers✔establish priorities
develop outcomes
identify interventions
document plan of care
set times for outcomes
integrate evidence-based trends and research
implementation - Answers✔implement interventions in a safe and timely manner
use evidence-based interventions
collaboration with colleagues
use community resources
coordinate care delivery
provide health teaching and health promotion
document care/implementation and any modification
2|Page
, ©SIRJOEL EXAM SOLUTIONS 2024/2025
ALL RIGHTS RESERVED.
evaluation - Answers✔compare established outcomes with actual outcomes
progress toward outcomes
conduct systematic, ongoing criterion-based evaluation
include patient and significant others
use ongoing assessment to revise diagnoses, outcomes, pain
disseminate results to patient and family
identify any roadblocks
modify plan
document evaluation of plan of care
evidence-based practice (EBP) - Answers✔"Systematic approach to practice that emphasizes
the use of best evidence in combination with the clinician's experience, as well as the patient
preferences and values, to make decisions about care and treatment."
Accurate assessment guides you through application of the nursing process as you provide care
Inaccurate assessment could lead to an incorrect nursing diagnosis, interventions, or outcomes
(your plan may be ineffective/inaccurate, incomplete assessments could lead to selection of
inappropriate interventions) - Answers✔Why is thorough assessment necessary?
comprehensive (admission assessment) - Answers✔includes health history and physical exam
enables practitioner to have complete picture of the patients health status
3|Page
, ©SIRJOEL EXAM SOLUTIONS 2024/2025
ALL RIGHTS RESERVED.
episodic/focused (shift assessment) - Answers✔when you're leaving and someone is taking
your shift
emergency assessment - Answers✔focuses on "ABC'c" (airway, breathing, circulation)
follow-up assessment - Answers✔example: pain score after treatment of pain (after treatment)
subjective and objective data - Answers✔What are the two types of patient data?
subjective data - Answers✔What the individual tells you in the interview
What the person says
Information from family members
Examples: family history, past medical history, cultural & spiritual, development, functional,
mental status, pain, nutritional
objective data - Answers✔What you, the nurse, observe, examine, or measure
Also includes data from medical testing, assessments of other healthcare professionals
Examples: general survey/observations, vital signs, head-to-toe assessment of each system
inspection, palpation, percussion, ausculation - Answers✔what are the assessment techniques?
inspection - Answers✔Watching
Look at patient as a whole & each system
Begins as soon as you walk in door
palpation - Answers✔Sense of touch
Light or deep touch
4|Page
