Nursing Test 1 2026 |
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Rationales
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, Steps of the Nursing Process 1. Assessment
2.Diagnosis
3. Planning
4. implementation
5. Evalulation
Components of a health hx biographical data, chief complaint, hx of present illness, past hx, family hx, lifestyle,
and social data.
Assessment Collecting, organizing, and validating data; documenting the pt assessment data;
the purpose is to establish a database about the patients response to health
concerns or illness and their ability to manage their needs.
Nursing Dx Analyzing and synthesizing data. The purpose is to identify a clients strengths and
health problems that can be prevented or resolved by collaborative and nursing
interventions.
Planning Determining how to prevent, reduce, or resolve the identified priority client
problems; determine how to support the client's strengths; determine how to
implement the nursing interventions in an organized, individualized, and goal
directed manner. The purpose is to develop individualized plans of care that
specifies a client's goals or desired outcomes that are related to the priority nursing
interventions.
Implementation carrying out or delegating and documenting the planned nursing interventions. The
purpose is to assist the client to meet their desired goals or outcomes, to promote
wellness, to prevent illness and disease, to restore health, and to facilitate the client
with coping with altered functioning.
Evaluation Measuring the degree to which the clients goals or outcomes have been met or
have NOT been met. The purpose is to determine whether to modify, terminate, or
continue the client's plan of care.
Subjective Data Symptoms; the client's perception about their health problems. This information is
only apparent to the client. Examples include pain, nausea, anxiety, itching.
Objective data Signs; observations or measurements made by the collector. Examples include
vitals, wound size, vomiting, diarrhea, rash, edema.
Types of Nursing Dx Actual, risk, wellness, health promotion, and syndrome
PES Components of a nursing Dx; 1. Problem, 2. Etiology (R/T), 3. signs/symptoms
(AEB)
SMART The guidelines for writing goals or outcomes; Specific, Measurable, Attainable,
Relevant, Time limited.
Types of nursing interventions Independent, dependent, collaborative
Independent intervention Nurse initiated; I/O, Teaching, Vitals, Emotional support, Assessments, Turn, cough
and deep breathing.