NUR 221 EXAM 2- GILLAM COMPLETE
QUESTIONS & SOLUTIONS
What are the steps of the nursing process in order? - ANSWER ADPIE
(Assessment/Diagnosis/Planning/Implementation/Evaluation)
Define "Assessment" in the nursing process. - ANSWER Gather and identify relevant
data
Define "Diagnosis" in the nursing process. - ANSWER Generate a hypothesis based on
data. Nursing diagnosis is the CLIENT'S RESPONSE to health problem.
Define "Planning" in the nursing process. - ANSWER Set up expected client outcome's
(ECO's) WITH the patient. Best interventions are "evidence based".
Define "Implementation" in the nursing process. - ANSWER Known as the action phase.
Able to delegate action to another member of the healthcare team. Document actions
and client's responses to them.
Define "Evaluation" in the nursing process. - ANSWER Determine whether the ECO's
have been met, partially met, or not met. Modify care plan as needed.
How do you cluster data? - ANSWER Part of the diagnosis phase, group together cues
that could lead to hypothesis.
What is theoretical knowledge? - ANSWER Science based. Includes principles, facts,
and theories.
What is practical knowledge? - ANSWER How to do something. Includes skills,
procedures, and processes.
What is self knowledge? - ANSWER Personal feelings or reasons. Awareness of your
values, beliefs, and biases.
What is ethical knowledge? - ANSWER Sense of right vs. wrong. Understanding your
obligations.
What is subjective data? - ANSWER What the patient says. (symptoms, pain, history)
What is objective data? - ANSWER What professional's observe. (Vitals, tests, lab
work)
What is a initial assessment? - ANSWER First time patient is assessed by medical staff.
, What is an ongoing assessment? - ANSWER Performed as needed or every shift after
initial assessment.
What is a comprehensive assessment? - ANSWER Holistic information about client's
overall health status. Includes observation, physical assessment, and interviewing.
Includes social/situational status and home support.
What is a focused assessment? - ANSWER Explores a single patient complaint or
symptom. May include 1 or more body system.
What are the three parts of a nursing diagnosis statement? - ANSWER Problem,
etiology, symptoms
How would you create a nursing diagnosis statement? - ANSWER Problem related to
Etiology as evidenced by Symptoms.
What is the difference between a medical diagnosis and a nursing diagnosis? -
ANSWER Medical diagnosis is concerned with the disease, illness, or injury and the
treatment. Nursing diagnosis is concerned with the client's response to illness, injury,
disease, and treatment.
T or F: There will always be one nursing diagnosis per medical diagnosis. - ANSWER
False. One medical diagnosis can have one or more nursing diagnosis.
What is actual nursing diagnosis? - ANSWER Problem is present. Addresses problem
with probable cause and observable evidence. Example: Impaired swallowing related to
sore throat.
What is potential nursing diagnosis? - ANSWER Focuses on patient problems that are
not yet present, but they are at risk for. Example: Risk for falls.
What is collaborative nursing diagnosis? - ANSWER Determined by medical diagnosis,
working together with other members. Example: Carry out orders provided by physician.
What is wellness nursing diagnosis? - ANSWER No problem is present, but there are
areas for improvement. Example: Patient is not malnourished, but can still use
improvements in diet to eat healthier.
Describe independent intervention. - ANSWER Interventions that can be performed
without provider's consent. Able to delegate task if needed. Fully capable and qualified
to perform by one's self.
Describe dependent intervention. - ANSWER Requires a provider's orders to carry out
task or action
Describe interdependent intervention. - ANSWER Involves collaboration with ancillary
staff. Example: Pharmacist, dietician, etc.
QUESTIONS & SOLUTIONS
What are the steps of the nursing process in order? - ANSWER ADPIE
(Assessment/Diagnosis/Planning/Implementation/Evaluation)
Define "Assessment" in the nursing process. - ANSWER Gather and identify relevant
data
Define "Diagnosis" in the nursing process. - ANSWER Generate a hypothesis based on
data. Nursing diagnosis is the CLIENT'S RESPONSE to health problem.
Define "Planning" in the nursing process. - ANSWER Set up expected client outcome's
(ECO's) WITH the patient. Best interventions are "evidence based".
Define "Implementation" in the nursing process. - ANSWER Known as the action phase.
Able to delegate action to another member of the healthcare team. Document actions
and client's responses to them.
Define "Evaluation" in the nursing process. - ANSWER Determine whether the ECO's
have been met, partially met, or not met. Modify care plan as needed.
How do you cluster data? - ANSWER Part of the diagnosis phase, group together cues
that could lead to hypothesis.
What is theoretical knowledge? - ANSWER Science based. Includes principles, facts,
and theories.
What is practical knowledge? - ANSWER How to do something. Includes skills,
procedures, and processes.
What is self knowledge? - ANSWER Personal feelings or reasons. Awareness of your
values, beliefs, and biases.
What is ethical knowledge? - ANSWER Sense of right vs. wrong. Understanding your
obligations.
What is subjective data? - ANSWER What the patient says. (symptoms, pain, history)
What is objective data? - ANSWER What professional's observe. (Vitals, tests, lab
work)
What is a initial assessment? - ANSWER First time patient is assessed by medical staff.
, What is an ongoing assessment? - ANSWER Performed as needed or every shift after
initial assessment.
What is a comprehensive assessment? - ANSWER Holistic information about client's
overall health status. Includes observation, physical assessment, and interviewing.
Includes social/situational status and home support.
What is a focused assessment? - ANSWER Explores a single patient complaint or
symptom. May include 1 or more body system.
What are the three parts of a nursing diagnosis statement? - ANSWER Problem,
etiology, symptoms
How would you create a nursing diagnosis statement? - ANSWER Problem related to
Etiology as evidenced by Symptoms.
What is the difference between a medical diagnosis and a nursing diagnosis? -
ANSWER Medical diagnosis is concerned with the disease, illness, or injury and the
treatment. Nursing diagnosis is concerned with the client's response to illness, injury,
disease, and treatment.
T or F: There will always be one nursing diagnosis per medical diagnosis. - ANSWER
False. One medical diagnosis can have one or more nursing diagnosis.
What is actual nursing diagnosis? - ANSWER Problem is present. Addresses problem
with probable cause and observable evidence. Example: Impaired swallowing related to
sore throat.
What is potential nursing diagnosis? - ANSWER Focuses on patient problems that are
not yet present, but they are at risk for. Example: Risk for falls.
What is collaborative nursing diagnosis? - ANSWER Determined by medical diagnosis,
working together with other members. Example: Carry out orders provided by physician.
What is wellness nursing diagnosis? - ANSWER No problem is present, but there are
areas for improvement. Example: Patient is not malnourished, but can still use
improvements in diet to eat healthier.
Describe independent intervention. - ANSWER Interventions that can be performed
without provider's consent. Able to delegate task if needed. Fully capable and qualified
to perform by one's self.
Describe dependent intervention. - ANSWER Requires a provider's orders to carry out
task or action
Describe interdependent intervention. - ANSWER Involves collaboration with ancillary
staff. Example: Pharmacist, dietician, etc.
