Chapter 1: An Overview of Nursing Diagnosis
Main Concepts:
Nursing Diagnosis Definition: A clinical judgment about individual, family, or
community responses to actual or potential health problems/life processes.
History and Evolution: Introduction of nursing diagnoses to distinguish the role of
nurses in patient care and decision-making.
Importance of Evidence-Based Practice: Emphasizes the need for nursing care to be
supported by the best available scientific evidence.
NANDA-I Framework: A globally recognized system for categorizing nursing
diagnoses, ensuring a standardized language for nursing care.
Key Components of Nursing Diagnosis:
o Problem (the issue to be addressed)
o Etiology (causes or contributing factors)
o Symptoms (evidence supporting the diagnosis)
Key Evidence-Based Practices:
Use of standardized care plans based on validated nursing diagnoses to streamline care
across different settings.
Critical thinking in nursing diagnosis to ensure accuracy in identifying problems and
selecting the appropriate interventions.
Ongoing assessment and evaluation: Nurses must continually reassess patients’
conditions and modify care plans accordingly.
Patient Outcomes:
Accurate diagnoses should lead to improved patient outcomes, including better
management of symptoms, reduced complications, and enhanced recovery.
Measurable patient outcomes include changes in patient status such as symptom relief,
improved mobility, or patient-reported satisfaction.
Case Studies/Patient Scenarios:
Example Scenario 1: A 70-year-old patient presents with signs of confusion and
weakness. The nurse assesses the patient and suspects a nursing diagnosis of "Impaired
cognition related to electrolyte imbalance." Develop a care plan focusing on
interventions, expected outcomes, and necessary evaluations.
Example Scenario 2: A new mother is having difficulty breastfeeding her newborn. The
nurse identifies a diagnosis of "Ineffective breastfeeding related to lack of knowledge."
Create a care plan to assist the mother with successful breastfeeding techniques and
follow-up evaluations.
,Sample Test Bank for Chapter 1:
Multiple-Choice Questions:
1. Which of the following best describes a nursing diagnosis? a) A medical condition b) A
clinical judgment about individual, family, or community responses to health problems c)
A prescription for treatment by a physician d) A plan of care
Answer: b
2. The NANDA-I framework for nursing diagnoses is important because: a) It provides
physicians with treatment plans b) It standardizes medical diagnoses c) It ensures a
standardized language for nursing diagnoses and interventions d) It offers an educational
tool for medical students
Answer: c
3. Which component of a nursing diagnosis identifies the underlying cause of a problem? a)
Symptoms b) Etiology c) Assessment d) Outcome
Answer: b
Short Answer/Essay Questions:
1. Explain how evidence-based practice is integrated into nursing diagnosis and care
planning. Provide an example.
2. Discuss the importance of reassessment in nursing care plans. Why is ongoing evaluation
essential for patient outcomes?
Matching Exercise:
Match the following terms with their definitions:
1. Nursing diagnosis
2. Etiology
3. Symptom
a) The underlying cause of a health problem
b) A clinical judgment regarding health conditions
c) Evidence that supports the diagnosis
Answer:
1-b
,2-a
3-c
Case-Based Question:
Case Study: A nurse assesses a patient who reports chronic pain due to arthritis. Based on this
assessment, the nurse identifies a nursing diagnosis of "Chronic pain related to joint
inflammation as evidenced by patient reports of pain, reduced mobility, and facial grimacing."
Develop a care plan based on this diagnosis. Include specific interventions, measurable
outcomes, and how the nurse will evaluate the effectiveness of the interventions.
Multiple-Choice Questions with Rationale:
1. Which of the following is a defining characteristic of a nursing diagnosis? a)
Identifies a medical condition
b) Focuses on potential or actual health problems nurses can address
c) Always requires a physician’s intervention
d) Centers on disease pathology
Answer: b
Rationale: A nursing diagnosis focuses on how patients respond to potential or actual
health problems that nurses can address, unlike medical diagnoses that are concerned
with disease pathology.
2. The etiology component of a nursing diagnosis refers to: a) The nursing interventions
needed
b) The underlying cause or contributing factors of the problem
c) The signs and symptoms experienced by the patient
d) The patient’s emotional response to their illness
Answer: b
Rationale: Etiology describes the cause or contributing factors of a patient’s health
problem, providing the basis for selecting nursing interventions.
3. Which of the following is NOT a component of a nursing diagnosis? a) Problem
b) Symptoms
, c) Etiology
d) Medical treatment plan
Answer: d
Rationale: Nursing diagnoses focus on problems that nurses address independently. The
medical treatment plan is part of the broader healthcare plan but not a component of the
nursing diagnosis.
4. NANDA-I is important for nursing because: a) It allows nurses to diagnose medical
conditions
b) It standardizes nursing diagnoses, ensuring clarity and consistency
c) It provides legal protection for nurses
d) It eliminates the need for patient assessment
Answer: b
Rationale: NANDA-I standardizes nursing diagnoses, creating a unified language that
ensures consistency across nursing practice worldwide.
5. Which of the following best describes the purpose of nursing diagnoses? a) To
prescribe medications for patient care
b) To identify and treat medical conditions
c) To assist in recognizing and managing patient responses to health issues
d) To focus on the disease process exclusively
Answer: c
Rationale: Nursing diagnoses help identify and manage patient responses to health
conditions, emphasizing the role of nurses in patient care and holistic management.
6. Which of the following is an example of a well-formulated nursing diagnosis? a)
Diabetes mellitus
b) Acute pain related to tissue injury as evidenced by verbal reports of pain
c) Appendicitis
d) Congestive heart failure
Answer: b
Rationale: The correct nursing diagnosis identifies the patient’s issue (acute pain), the
cause (tissue injury), and evidence (verbal reports of pain).
, 7. In the nursing diagnosis process, which step comes after identifying the problem? a)
Planning interventions
b) Analyzing symptoms
c) Formulating goals
d) Documenting the diagnosis
Answer: b
Rationale: After identifying the problem, the nurse analyzes the symptoms and the
contributing factors (etiology) before proceeding to planning interventions.
8. What is the primary difference between a nursing diagnosis and a medical
diagnosis? a) Nursing diagnoses focus on disease pathology
b) Nursing diagnoses involve patient responses to health problems
c) Medical diagnoses focus on patient symptoms
d) Medical diagnoses require nursing intervention
Answer: b
Rationale: Nursing diagnoses center on patient responses to actual or potential health
problems, while medical diagnoses focus on disease pathology.
9. Which is a key outcome of using a standardized nursing diagnosis like those from
NANDA-I? a) It minimizes the need for clinical judgment
b) It increases clarity and communication among healthcare providers
c) It allows nurses to prescribe medications
d) It eliminates the need for interdisciplinary care
Answer: b
Rationale: Standardized nursing diagnoses improve communication between healthcare
providers, leading to more coordinated and effective care.
10. What type of nursing diagnosis addresses the potential for complications? a) Actual
diagnosis
b) Risk diagnosis
c) Wellness diagnosis
d) Syndrome diagnosis
Answer: b
Rationale: A risk diagnosis identifies conditions that place a patient at risk for developing health
complications, allowing for preventive interventions.
, 11. Which term refers to the evidence supporting a nursing diagnosis? a) Etiology
b) Assessment
c) Symptoms
d) Outcome
Answer: c
Rationale: Symptoms are the subjective and objective data (evidence) supporting the nursing
diagnosis.
12. When selecting nursing interventions, which factor is most critical to consider? a)
The physician’s orders
b) The patient’s medical diagnosis
c) The etiology of the nursing diagnosis
d) The nurse’s experience level
Answer: c
Rationale: Nursing interventions are directly tied to the etiology of the nursing diagnosis.
Understanding the cause allows for targeted interventions.
13. Which of the following is an example of a risk nursing diagnosis? a) Ineffective
airway clearance
b) Risk for infection
c) Impaired physical mobility
d) Activity intolerance
Answer: b
Rationale: “Risk for infection” is a risk diagnosis, indicating a potential problem that requires
preventive care.
14. In nursing care, which of the following outcomes is critical for evaluating the
effectiveness of a nursing diagnosis? a) Patient satisfaction
b) Improvement in medical condition
c) Achievement of nursing goals
d) Discharge from care
Answer: c
Rationale: Evaluating whether the patient has achieved the set nursing goals (e.g., symptom
relief, mobility improvement) is essential for determining the effectiveness of nursing care.
, 15. What is the primary role of critical thinking in nursing diagnosis? a) To ensure
nurses make the right medical diagnosis
b) To provide a method for evaluating patient outcomes
c) To ensure accurate and appropriate nursing diagnoses
d) To document care plans
Answer: c
Rationale: Critical thinking is essential for making accurate nursing diagnoses, as it involves
assessing, analyzing, and interpreting patient data.
16. Which of the following nursing diagnoses would likely involve collaboration with
other healthcare providers? a) Risk for falls
b) Imbalanced nutrition: Less than body requirements
c) Chronic pain related to arthritis
d) Impaired gas exchange
Answer: d
Rationale: Diagnoses like “impaired gas exchange” often require collaboration with respiratory
therapists, physicians, or other specialists for comprehensive care.
17. Which of the following elements is most important for creating a measurable patient
outcome? a) The patient’s symptoms
b) A specific time frame for achieving the outcome
c) The nurse’s opinion
d) The patient’s medical condition
Answer: b
Rationale: A measurable patient outcome should include a specific time frame for when the goal
will be achieved, ensuring that progress can be monitored.
18. What is the purpose of using a care plan in nursing? a) To provide a standard
treatment for all patients
b) To outline the patient’s medical diagnosis and treatment
c) To provide a framework for individualized, evidence-based patient care
d) To eliminate the need for physician input
,Answer: c
Rationale: Care plans provide individualized, evidence-based care tailored to each patient’s
specific nursing diagnosis and health needs.
19. In which scenario would a wellness diagnosis be most appropriate? a) A patient with
uncontrolled diabetes
b) A pregnant woman seeking advice on healthy nutrition
c) A patient recovering from surgery with pain
d) A patient experiencing a myocardial infarction
Answer: b
Rationale: A wellness diagnosis focuses on enhancing a patient’s health and well-being, such as
in the case of a pregnant woman seeking advice on nutrition.
20. Which of the following is essential for reassessing a patient’s nursing diagnosis? a)
Waiting for a physician to update the medical diagnosis
b) Reviewing the patient’s progress toward goals
c) Ensuring the nursing interventions were documented
d) Writing a new care plan
Answer: b
Rationale: Reassessing a nursing diagnosis involves reviewing the patient’s progress toward the
established goals and determining whether the interventions are effective.
Chapter 2: The Nursing Process: Assessment, Diagnosis, Planning,
Implementation, and Evaluation
Main Concepts:
1. The Nursing Process Overview:
o The nursing process is a systematic, patient-centered method used to ensure
quality care. It includes five steps: assessment, diagnosis, planning,
implementation, and evaluation (ADPIE).
o Each step is interconnected and requires critical thinking to address the patient's
holistic needs.
2. Assessment:
o The first step involves gathering patient data through observation, interviews,
physical exams, and diagnostic results.
, o Types of Data: Subjective (what the patient reports) and objective (what the
nurse observes/measures).
3. Diagnosis:
o Based on the data collected, the nurse identifies actual or potential health
problems, formulating nursing diagnoses using NANDA-I taxonomy.
4. Planning:
o Once a diagnosis is made, the nurse creates a plan of care, setting patient-centered
goals and expected outcomes. Goals must be Specific, Measurable, Achievable,
Relevant, and Time-bound (SMART).
5. Implementation:
o The nurse carries out the interventions detailed in the care plan, adjusting as
necessary based on the patient's condition.
o Nursing interventions can be independent (nurse-initiated), dependent (physician-
ordered), or collaborative (team-based).
6. Evaluation:
o The nurse evaluates the patient’s progress toward achieving the planned
outcomes. Reassessment may lead to modifications in the care plan if goals are
unmet.
Key Evidence-Based Practices:
Holistic and comprehensive assessment: Combining subjective and objective data
ensures that all aspects of the patient's health are addressed.
Critical thinking and collaboration: Both are essential in each step of the nursing
process to ensure the most accurate diagnosis and effective interventions.
Ongoing reassessment: This ensures that interventions remain effective and that goals
are adjusted according to the patient’s changing status.
Patient Outcomes:
Successful implementation of the nursing process should lead to:
o Accurate identification of health problems.
o Measurable improvement in patient conditions.
o Achievement of patient-centered goals.
o Enhanced patient satisfaction with care.
Case Studies/Patient Scenarios:
Scenario 1: A 45-year-old patient is admitted with chronic obstructive pulmonary disease
(COPD). The nurse performs a comprehensive assessment, identifying subjective data
, (patient reports shortness of breath) and objective data (SpO2 of 89%, wheezing on
auscultation). Develop a care plan addressing the nursing diagnosis of "Ineffective airway
clearance related to bronchoconstriction."
Scenario 2: An elderly patient recovering from surgery has difficulty moving due to
postoperative pain. The nurse diagnoses "Impaired physical mobility related to
postoperative pain as evidenced by patient reports of pain when attempting to ambulate."
Create a plan of care focusing on pain management and mobilization.
Sample Test Bank for Chapter 2:
Multiple-Choice Questions:
1. What is the first step of the nursing process?
a) Diagnosis
b) Assessment
c) Implementation
d) Planning
Answer: b
Rationale: Assessment is the first step of the nursing process, where the nurse gathers
subjective and objective data to understand the patient's health status.
2. Which of the following is an example of subjective data?
a) The patient’s blood pressure is 150/90 mmHg
b) The patient reports feeling dizzy
c) The patient’s heart rate is 85 beats per minute
d) The nurse observes a wound on the patient's leg
Answer: b
Rationale: Subjective data refers to what the patient reports, such as feeling dizzy, while
objective data includes measurable or observable facts.
3. A nursing diagnosis is formulated based on which of the following?
a) Nursing interventions
b) Medical diagnosis
c) Assessment data
d) Patient preferences
Main Concepts:
Nursing Diagnosis Definition: A clinical judgment about individual, family, or
community responses to actual or potential health problems/life processes.
History and Evolution: Introduction of nursing diagnoses to distinguish the role of
nurses in patient care and decision-making.
Importance of Evidence-Based Practice: Emphasizes the need for nursing care to be
supported by the best available scientific evidence.
NANDA-I Framework: A globally recognized system for categorizing nursing
diagnoses, ensuring a standardized language for nursing care.
Key Components of Nursing Diagnosis:
o Problem (the issue to be addressed)
o Etiology (causes or contributing factors)
o Symptoms (evidence supporting the diagnosis)
Key Evidence-Based Practices:
Use of standardized care plans based on validated nursing diagnoses to streamline care
across different settings.
Critical thinking in nursing diagnosis to ensure accuracy in identifying problems and
selecting the appropriate interventions.
Ongoing assessment and evaluation: Nurses must continually reassess patients’
conditions and modify care plans accordingly.
Patient Outcomes:
Accurate diagnoses should lead to improved patient outcomes, including better
management of symptoms, reduced complications, and enhanced recovery.
Measurable patient outcomes include changes in patient status such as symptom relief,
improved mobility, or patient-reported satisfaction.
Case Studies/Patient Scenarios:
Example Scenario 1: A 70-year-old patient presents with signs of confusion and
weakness. The nurse assesses the patient and suspects a nursing diagnosis of "Impaired
cognition related to electrolyte imbalance." Develop a care plan focusing on
interventions, expected outcomes, and necessary evaluations.
Example Scenario 2: A new mother is having difficulty breastfeeding her newborn. The
nurse identifies a diagnosis of "Ineffective breastfeeding related to lack of knowledge."
Create a care plan to assist the mother with successful breastfeeding techniques and
follow-up evaluations.
,Sample Test Bank for Chapter 1:
Multiple-Choice Questions:
1. Which of the following best describes a nursing diagnosis? a) A medical condition b) A
clinical judgment about individual, family, or community responses to health problems c)
A prescription for treatment by a physician d) A plan of care
Answer: b
2. The NANDA-I framework for nursing diagnoses is important because: a) It provides
physicians with treatment plans b) It standardizes medical diagnoses c) It ensures a
standardized language for nursing diagnoses and interventions d) It offers an educational
tool for medical students
Answer: c
3. Which component of a nursing diagnosis identifies the underlying cause of a problem? a)
Symptoms b) Etiology c) Assessment d) Outcome
Answer: b
Short Answer/Essay Questions:
1. Explain how evidence-based practice is integrated into nursing diagnosis and care
planning. Provide an example.
2. Discuss the importance of reassessment in nursing care plans. Why is ongoing evaluation
essential for patient outcomes?
Matching Exercise:
Match the following terms with their definitions:
1. Nursing diagnosis
2. Etiology
3. Symptom
a) The underlying cause of a health problem
b) A clinical judgment regarding health conditions
c) Evidence that supports the diagnosis
Answer:
1-b
,2-a
3-c
Case-Based Question:
Case Study: A nurse assesses a patient who reports chronic pain due to arthritis. Based on this
assessment, the nurse identifies a nursing diagnosis of "Chronic pain related to joint
inflammation as evidenced by patient reports of pain, reduced mobility, and facial grimacing."
Develop a care plan based on this diagnosis. Include specific interventions, measurable
outcomes, and how the nurse will evaluate the effectiveness of the interventions.
Multiple-Choice Questions with Rationale:
1. Which of the following is a defining characteristic of a nursing diagnosis? a)
Identifies a medical condition
b) Focuses on potential or actual health problems nurses can address
c) Always requires a physician’s intervention
d) Centers on disease pathology
Answer: b
Rationale: A nursing diagnosis focuses on how patients respond to potential or actual
health problems that nurses can address, unlike medical diagnoses that are concerned
with disease pathology.
2. The etiology component of a nursing diagnosis refers to: a) The nursing interventions
needed
b) The underlying cause or contributing factors of the problem
c) The signs and symptoms experienced by the patient
d) The patient’s emotional response to their illness
Answer: b
Rationale: Etiology describes the cause or contributing factors of a patient’s health
problem, providing the basis for selecting nursing interventions.
3. Which of the following is NOT a component of a nursing diagnosis? a) Problem
b) Symptoms
, c) Etiology
d) Medical treatment plan
Answer: d
Rationale: Nursing diagnoses focus on problems that nurses address independently. The
medical treatment plan is part of the broader healthcare plan but not a component of the
nursing diagnosis.
4. NANDA-I is important for nursing because: a) It allows nurses to diagnose medical
conditions
b) It standardizes nursing diagnoses, ensuring clarity and consistency
c) It provides legal protection for nurses
d) It eliminates the need for patient assessment
Answer: b
Rationale: NANDA-I standardizes nursing diagnoses, creating a unified language that
ensures consistency across nursing practice worldwide.
5. Which of the following best describes the purpose of nursing diagnoses? a) To
prescribe medications for patient care
b) To identify and treat medical conditions
c) To assist in recognizing and managing patient responses to health issues
d) To focus on the disease process exclusively
Answer: c
Rationale: Nursing diagnoses help identify and manage patient responses to health
conditions, emphasizing the role of nurses in patient care and holistic management.
6. Which of the following is an example of a well-formulated nursing diagnosis? a)
Diabetes mellitus
b) Acute pain related to tissue injury as evidenced by verbal reports of pain
c) Appendicitis
d) Congestive heart failure
Answer: b
Rationale: The correct nursing diagnosis identifies the patient’s issue (acute pain), the
cause (tissue injury), and evidence (verbal reports of pain).
, 7. In the nursing diagnosis process, which step comes after identifying the problem? a)
Planning interventions
b) Analyzing symptoms
c) Formulating goals
d) Documenting the diagnosis
Answer: b
Rationale: After identifying the problem, the nurse analyzes the symptoms and the
contributing factors (etiology) before proceeding to planning interventions.
8. What is the primary difference between a nursing diagnosis and a medical
diagnosis? a) Nursing diagnoses focus on disease pathology
b) Nursing diagnoses involve patient responses to health problems
c) Medical diagnoses focus on patient symptoms
d) Medical diagnoses require nursing intervention
Answer: b
Rationale: Nursing diagnoses center on patient responses to actual or potential health
problems, while medical diagnoses focus on disease pathology.
9. Which is a key outcome of using a standardized nursing diagnosis like those from
NANDA-I? a) It minimizes the need for clinical judgment
b) It increases clarity and communication among healthcare providers
c) It allows nurses to prescribe medications
d) It eliminates the need for interdisciplinary care
Answer: b
Rationale: Standardized nursing diagnoses improve communication between healthcare
providers, leading to more coordinated and effective care.
10. What type of nursing diagnosis addresses the potential for complications? a) Actual
diagnosis
b) Risk diagnosis
c) Wellness diagnosis
d) Syndrome diagnosis
Answer: b
Rationale: A risk diagnosis identifies conditions that place a patient at risk for developing health
complications, allowing for preventive interventions.
, 11. Which term refers to the evidence supporting a nursing diagnosis? a) Etiology
b) Assessment
c) Symptoms
d) Outcome
Answer: c
Rationale: Symptoms are the subjective and objective data (evidence) supporting the nursing
diagnosis.
12. When selecting nursing interventions, which factor is most critical to consider? a)
The physician’s orders
b) The patient’s medical diagnosis
c) The etiology of the nursing diagnosis
d) The nurse’s experience level
Answer: c
Rationale: Nursing interventions are directly tied to the etiology of the nursing diagnosis.
Understanding the cause allows for targeted interventions.
13. Which of the following is an example of a risk nursing diagnosis? a) Ineffective
airway clearance
b) Risk for infection
c) Impaired physical mobility
d) Activity intolerance
Answer: b
Rationale: “Risk for infection” is a risk diagnosis, indicating a potential problem that requires
preventive care.
14. In nursing care, which of the following outcomes is critical for evaluating the
effectiveness of a nursing diagnosis? a) Patient satisfaction
b) Improvement in medical condition
c) Achievement of nursing goals
d) Discharge from care
Answer: c
Rationale: Evaluating whether the patient has achieved the set nursing goals (e.g., symptom
relief, mobility improvement) is essential for determining the effectiveness of nursing care.
, 15. What is the primary role of critical thinking in nursing diagnosis? a) To ensure
nurses make the right medical diagnosis
b) To provide a method for evaluating patient outcomes
c) To ensure accurate and appropriate nursing diagnoses
d) To document care plans
Answer: c
Rationale: Critical thinking is essential for making accurate nursing diagnoses, as it involves
assessing, analyzing, and interpreting patient data.
16. Which of the following nursing diagnoses would likely involve collaboration with
other healthcare providers? a) Risk for falls
b) Imbalanced nutrition: Less than body requirements
c) Chronic pain related to arthritis
d) Impaired gas exchange
Answer: d
Rationale: Diagnoses like “impaired gas exchange” often require collaboration with respiratory
therapists, physicians, or other specialists for comprehensive care.
17. Which of the following elements is most important for creating a measurable patient
outcome? a) The patient’s symptoms
b) A specific time frame for achieving the outcome
c) The nurse’s opinion
d) The patient’s medical condition
Answer: b
Rationale: A measurable patient outcome should include a specific time frame for when the goal
will be achieved, ensuring that progress can be monitored.
18. What is the purpose of using a care plan in nursing? a) To provide a standard
treatment for all patients
b) To outline the patient’s medical diagnosis and treatment
c) To provide a framework for individualized, evidence-based patient care
d) To eliminate the need for physician input
,Answer: c
Rationale: Care plans provide individualized, evidence-based care tailored to each patient’s
specific nursing diagnosis and health needs.
19. In which scenario would a wellness diagnosis be most appropriate? a) A patient with
uncontrolled diabetes
b) A pregnant woman seeking advice on healthy nutrition
c) A patient recovering from surgery with pain
d) A patient experiencing a myocardial infarction
Answer: b
Rationale: A wellness diagnosis focuses on enhancing a patient’s health and well-being, such as
in the case of a pregnant woman seeking advice on nutrition.
20. Which of the following is essential for reassessing a patient’s nursing diagnosis? a)
Waiting for a physician to update the medical diagnosis
b) Reviewing the patient’s progress toward goals
c) Ensuring the nursing interventions were documented
d) Writing a new care plan
Answer: b
Rationale: Reassessing a nursing diagnosis involves reviewing the patient’s progress toward the
established goals and determining whether the interventions are effective.
Chapter 2: The Nursing Process: Assessment, Diagnosis, Planning,
Implementation, and Evaluation
Main Concepts:
1. The Nursing Process Overview:
o The nursing process is a systematic, patient-centered method used to ensure
quality care. It includes five steps: assessment, diagnosis, planning,
implementation, and evaluation (ADPIE).
o Each step is interconnected and requires critical thinking to address the patient's
holistic needs.
2. Assessment:
o The first step involves gathering patient data through observation, interviews,
physical exams, and diagnostic results.
, o Types of Data: Subjective (what the patient reports) and objective (what the
nurse observes/measures).
3. Diagnosis:
o Based on the data collected, the nurse identifies actual or potential health
problems, formulating nursing diagnoses using NANDA-I taxonomy.
4. Planning:
o Once a diagnosis is made, the nurse creates a plan of care, setting patient-centered
goals and expected outcomes. Goals must be Specific, Measurable, Achievable,
Relevant, and Time-bound (SMART).
5. Implementation:
o The nurse carries out the interventions detailed in the care plan, adjusting as
necessary based on the patient's condition.
o Nursing interventions can be independent (nurse-initiated), dependent (physician-
ordered), or collaborative (team-based).
6. Evaluation:
o The nurse evaluates the patient’s progress toward achieving the planned
outcomes. Reassessment may lead to modifications in the care plan if goals are
unmet.
Key Evidence-Based Practices:
Holistic and comprehensive assessment: Combining subjective and objective data
ensures that all aspects of the patient's health are addressed.
Critical thinking and collaboration: Both are essential in each step of the nursing
process to ensure the most accurate diagnosis and effective interventions.
Ongoing reassessment: This ensures that interventions remain effective and that goals
are adjusted according to the patient’s changing status.
Patient Outcomes:
Successful implementation of the nursing process should lead to:
o Accurate identification of health problems.
o Measurable improvement in patient conditions.
o Achievement of patient-centered goals.
o Enhanced patient satisfaction with care.
Case Studies/Patient Scenarios:
Scenario 1: A 45-year-old patient is admitted with chronic obstructive pulmonary disease
(COPD). The nurse performs a comprehensive assessment, identifying subjective data
, (patient reports shortness of breath) and objective data (SpO2 of 89%, wheezing on
auscultation). Develop a care plan addressing the nursing diagnosis of "Ineffective airway
clearance related to bronchoconstriction."
Scenario 2: An elderly patient recovering from surgery has difficulty moving due to
postoperative pain. The nurse diagnoses "Impaired physical mobility related to
postoperative pain as evidenced by patient reports of pain when attempting to ambulate."
Create a plan of care focusing on pain management and mobilization.
Sample Test Bank for Chapter 2:
Multiple-Choice Questions:
1. What is the first step of the nursing process?
a) Diagnosis
b) Assessment
c) Implementation
d) Planning
Answer: b
Rationale: Assessment is the first step of the nursing process, where the nurse gathers
subjective and objective data to understand the patient's health status.
2. Which of the following is an example of subjective data?
a) The patient’s blood pressure is 150/90 mmHg
b) The patient reports feeling dizzy
c) The patient’s heart rate is 85 beats per minute
d) The nurse observes a wound on the patient's leg
Answer: b
Rationale: Subjective data refers to what the patient reports, such as feeling dizzy, while
objective data includes measurable or observable facts.
3. A nursing diagnosis is formulated based on which of the following?
a) Nursing interventions
b) Medical diagnosis
c) Assessment data
d) Patient preferences
