©SIRJOEL EXAM SOLUTIONS 2024/2025
ALL RIGHTS RESERVED.
Nur 230 Exam 1 Study Guide.
Nursing process - Answers✔Assessment, diagnosis, planning, implementation, evaluation
(ADPIE)
Assessment - Answers✔Collect data subjective and objective, it is an ongoing processes not a
one time thing
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
Subjective data - Answers✔What the patients says about their self during history taking, or
what a close family member or friend say, cultural/spiritual , mental status ,
Objective data - Answers✔Observations made during physical examination, general survey,
vital signs, head-to-toe assessment
Comprehensive "admission assessment" - Answers✔Health history and physical exam, enables
complete picture of patients health status
Episodic/focused "shift assessment" - Answers✔A comprehensive asses that focuses more on a
specific things
Emergency assessment - Answers✔Not going to take the time to do comprehensive
Follow-up assessment - Answers✔What changed, better/worse, what coping strategies used
physical examination - Answers✔Inspection, palpitation, percussion, auscultation
Diagnosis - Answers✔Compare findings that are normal and abnormal, and developmental
events, interpret data, identify cluster of clues, make hypotheses and test it, derive diagnosis,
validate and document diagnosis
Outcome identification - Answers✔Identify expected outcomes, individualize for patient,
culturally appropriate, realistic and measurable and have a time frame
Planning - Answers✔Establish priorities, develop outcomes, set timelines for outcomes, identify
interventions, integrate evidence based trends/research, document plan of care, development
outcomes, identity interventions, document plan of care
1|Page
, ©SIRJOEL EXAM SOLUTIONS 2024/2025
ALL RIGHTS RESERVED.
First level priority problem - Answers✔Are emergent, life-threatening, or immediate (ABCV)
airway, breathing cardiac/cardiovascular probs, vital sign concerns
Second level priority problem - Answers✔Next in urgency, prompting you to forestall further
deterioration (mental changes, acute pain, urinary elimination, abnormal lab value, risk of
infection
Third level problems - Answers✔Important to patients health, but can be addressed later or
after more urgent steps taken care of, more long term, response to treatment expected to take
more time
Collaborative problems - Answers✔Approach to treatment involves multiple disciplines nurse's
diagnosis the onset and monitor the changes in status
Implementation - Answers✔Safe and timely manner, evidence-based interventions,
collaboration, use community resources, coordinate care delivery , promote health and health
education, document care and any modifications
Evaluation - Answers✔Compare established outcomes with actual outcomes, identify any
roadblocks, modify pan, document evaluation of plan of care
Evidenced based practice - Answers✔Patients deserve to be treated with most current and best
practice techniques
Systematic approach to practice that emphasizes the use of best evidence in combination with
clinicians experience as wel as the patients preferences and values
Evidence based clinical decision making - Answers✔Evidence from research and evidence-based
theories, physical examination and assessment of patient, clinical expertise, patient preferences
and values
Complete data base - Answers✔Total health, complete health history/ full physical
examination, current and past health state and forms a baseline so changes can be measured,
ex primary care setting
Focused/problem centered data base - Answers✔Limited or short term, collect a mini database
or smaller in scope and more targeted, mainly for one problem one body system
Follow up data base - Answers✔Short term/ chronic problems, problems should be evaluated
at regular and appropriate intervals
What has changed, worse/better, coping strategies used
Emergency data base - Answers✔Rapid collection of crucial information complied concurrently
with lifesaving measures, diagnosis must be swift and sure, what did you take Dan how much of
it is was
2|Page
ALL RIGHTS RESERVED.
Nur 230 Exam 1 Study Guide.
Nursing process - Answers✔Assessment, diagnosis, planning, implementation, evaluation
(ADPIE)
Assessment - Answers✔Collect data subjective and objective, it is an ongoing processes not a
one time thing
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
Subjective data - Answers✔What the patients says about their self during history taking, or
what a close family member or friend say, cultural/spiritual , mental status ,
Objective data - Answers✔Observations made during physical examination, general survey,
vital signs, head-to-toe assessment
Comprehensive "admission assessment" - Answers✔Health history and physical exam, enables
complete picture of patients health status
Episodic/focused "shift assessment" - Answers✔A comprehensive asses that focuses more on a
specific things
Emergency assessment - Answers✔Not going to take the time to do comprehensive
Follow-up assessment - Answers✔What changed, better/worse, what coping strategies used
physical examination - Answers✔Inspection, palpitation, percussion, auscultation
Diagnosis - Answers✔Compare findings that are normal and abnormal, and developmental
events, interpret data, identify cluster of clues, make hypotheses and test it, derive diagnosis,
validate and document diagnosis
Outcome identification - Answers✔Identify expected outcomes, individualize for patient,
culturally appropriate, realistic and measurable and have a time frame
Planning - Answers✔Establish priorities, develop outcomes, set timelines for outcomes, identify
interventions, integrate evidence based trends/research, document plan of care, development
outcomes, identity interventions, document plan of care
1|Page
, ©SIRJOEL EXAM SOLUTIONS 2024/2025
ALL RIGHTS RESERVED.
First level priority problem - Answers✔Are emergent, life-threatening, or immediate (ABCV)
airway, breathing cardiac/cardiovascular probs, vital sign concerns
Second level priority problem - Answers✔Next in urgency, prompting you to forestall further
deterioration (mental changes, acute pain, urinary elimination, abnormal lab value, risk of
infection
Third level problems - Answers✔Important to patients health, but can be addressed later or
after more urgent steps taken care of, more long term, response to treatment expected to take
more time
Collaborative problems - Answers✔Approach to treatment involves multiple disciplines nurse's
diagnosis the onset and monitor the changes in status
Implementation - Answers✔Safe and timely manner, evidence-based interventions,
collaboration, use community resources, coordinate care delivery , promote health and health
education, document care and any modifications
Evaluation - Answers✔Compare established outcomes with actual outcomes, identify any
roadblocks, modify pan, document evaluation of plan of care
Evidenced based practice - Answers✔Patients deserve to be treated with most current and best
practice techniques
Systematic approach to practice that emphasizes the use of best evidence in combination with
clinicians experience as wel as the patients preferences and values
Evidence based clinical decision making - Answers✔Evidence from research and evidence-based
theories, physical examination and assessment of patient, clinical expertise, patient preferences
and values
Complete data base - Answers✔Total health, complete health history/ full physical
examination, current and past health state and forms a baseline so changes can be measured,
ex primary care setting
Focused/problem centered data base - Answers✔Limited or short term, collect a mini database
or smaller in scope and more targeted, mainly for one problem one body system
Follow up data base - Answers✔Short term/ chronic problems, problems should be evaluated
at regular and appropriate intervals
What has changed, worse/better, coping strategies used
Emergency data base - Answers✔Rapid collection of crucial information complied concurrently
with lifesaving measures, diagnosis must be swift and sure, what did you take Dan how much of
it is was
2|Page
