Nursing Process UPDATED ACTUAL Questions and
CORRECT Answers
Define the nursing process a systematic problem solving approach toward providing individualized nursing
care.
What is NANDA-I North American Nursing
Diagnosis Association International
What are the characteristics of the nursing process? 1-framework for care to indiv, families, & communities 2-orderly & systematic 3-
interdependent 4-provides specific care for the indiv, fam, & comm 5- client
centered 6-appropriate for use throughout lifespan 7-used in ALL settings
What are the steps of the nursing process? ADPIE A=assessment D=diagnosis P=planning I=implementation E=evaluation
How does the nurse obtain assessment info? 1- initial (or admission assessment) 2- focused assessment 3- emergency
assesment
How does the nurse obtain assessment info? past medical hx - family hx - reason for admission - current meds - previous
hospitalizations & surgeries - psychosocial assessment - nutrition - complete
physical assessment
focused assessment Collects data about a problem that has already been identified. This type of
assessment determines whether
the problem still exists, or any changes.
focused assessment questions ‐ What are your symptoms?
‐ When did they start?
‐ What activity were you doing ?
‐ What makes it better or worse?
‐ What are you doing to relieve the symptom?
Emergency assessment Performed to identify a life‐threatening problem (choking, stab wound, heart
attack).
subjective data Information verbalized or stated by the client.
objective data ‐ Observable and measurable information.
‐ Remember to include your senses: smell, hearing, touch and sight.
sign An objective finding perceived by the examiner ex. (fever, rash, etc.)
symptom Subjective findings verbalized or stated by the client ex. ("I have a headache" " I
feel sick in my stomach.")
signs are objective
, symptoms are subjective
2 sources of data primary & 2ndary
primary source of data ‐Information obtained from the patient (only)
secondary sources of data ‐ Family members
‐ Significant others
‐ Past & current health records, laboratory tests,diagnostic procedures,
consultations from other healthcare professionals.
collect the data then BLANK the data VALIDATE
‐Confirm and verify the information.
‐ Keep it free from errors, bias, or misinterpretation.
Data is 1,2,3 collected, validated, then clustered
clustering of data often contains defining characteristics which are specific assessment findings that support a
nursing diagnosis.
during the clustering of data what is used critical thinking is used to analyze and synthesize the information that is
collected. The data is then put into specific clusters that describe a specific client
problem.
identify sources of data for obtaining information from subjective & objective, primary & secondary, people, healthcare professionals,
the client medical chart, test & lab results etc
identify how you develop a nursing diagnosis As you cluster data, you begin to consider various diagnoses that may relate to
the client. You must remember that if certain defining characteristics do not exist
for a specific diagnosis, then you must not use the diagnosis.
identify how you develop a nursing diagnosis (what is first 1. Complete thorough assessment of the patient.
/ next etc) 2.Highlight or underline relevant symptoms (defining
characteristics).
3. Make a list of symptoms.
4. Cluster and interpret the symptoms.
5. Analyze and interpret the symptoms.
6. Select a nursing diagnosis based on the definition
found in the nursing diagnosis manual by Doenges,
Moorhouse and Murr.
7. Remember to prioritize the identified problems.
what is the difference between a medical and nursing dx A medical diagnosis describes a disease process. A nursing diagnosis describes an
individual, family or
group response to an actual or potential problem.
medical dx ‐Identification of a disease condition based on specific
findings such as diagnostic tests and procedures.
‐ Remains the same as long as the disease is present.
CORRECT Answers
Define the nursing process a systematic problem solving approach toward providing individualized nursing
care.
What is NANDA-I North American Nursing
Diagnosis Association International
What are the characteristics of the nursing process? 1-framework for care to indiv, families, & communities 2-orderly & systematic 3-
interdependent 4-provides specific care for the indiv, fam, & comm 5- client
centered 6-appropriate for use throughout lifespan 7-used in ALL settings
What are the steps of the nursing process? ADPIE A=assessment D=diagnosis P=planning I=implementation E=evaluation
How does the nurse obtain assessment info? 1- initial (or admission assessment) 2- focused assessment 3- emergency
assesment
How does the nurse obtain assessment info? past medical hx - family hx - reason for admission - current meds - previous
hospitalizations & surgeries - psychosocial assessment - nutrition - complete
physical assessment
focused assessment Collects data about a problem that has already been identified. This type of
assessment determines whether
the problem still exists, or any changes.
focused assessment questions ‐ What are your symptoms?
‐ When did they start?
‐ What activity were you doing ?
‐ What makes it better or worse?
‐ What are you doing to relieve the symptom?
Emergency assessment Performed to identify a life‐threatening problem (choking, stab wound, heart
attack).
subjective data Information verbalized or stated by the client.
objective data ‐ Observable and measurable information.
‐ Remember to include your senses: smell, hearing, touch and sight.
sign An objective finding perceived by the examiner ex. (fever, rash, etc.)
symptom Subjective findings verbalized or stated by the client ex. ("I have a headache" " I
feel sick in my stomach.")
signs are objective
, symptoms are subjective
2 sources of data primary & 2ndary
primary source of data ‐Information obtained from the patient (only)
secondary sources of data ‐ Family members
‐ Significant others
‐ Past & current health records, laboratory tests,diagnostic procedures,
consultations from other healthcare professionals.
collect the data then BLANK the data VALIDATE
‐Confirm and verify the information.
‐ Keep it free from errors, bias, or misinterpretation.
Data is 1,2,3 collected, validated, then clustered
clustering of data often contains defining characteristics which are specific assessment findings that support a
nursing diagnosis.
during the clustering of data what is used critical thinking is used to analyze and synthesize the information that is
collected. The data is then put into specific clusters that describe a specific client
problem.
identify sources of data for obtaining information from subjective & objective, primary & secondary, people, healthcare professionals,
the client medical chart, test & lab results etc
identify how you develop a nursing diagnosis As you cluster data, you begin to consider various diagnoses that may relate to
the client. You must remember that if certain defining characteristics do not exist
for a specific diagnosis, then you must not use the diagnosis.
identify how you develop a nursing diagnosis (what is first 1. Complete thorough assessment of the patient.
/ next etc) 2.Highlight or underline relevant symptoms (defining
characteristics).
3. Make a list of symptoms.
4. Cluster and interpret the symptoms.
5. Analyze and interpret the symptoms.
6. Select a nursing diagnosis based on the definition
found in the nursing diagnosis manual by Doenges,
Moorhouse and Murr.
7. Remember to prioritize the identified problems.
what is the difference between a medical and nursing dx A medical diagnosis describes a disease process. A nursing diagnosis describes an
individual, family or
group response to an actual or potential problem.
medical dx ‐Identification of a disease condition based on specific
findings such as diagnostic tests and procedures.
‐ Remains the same as long as the disease is present.
