QUESTIONS AND ANSWERS | NURSING
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,five steps of the nursing process 1- assessment
2- diagnosis
3- planning
4- implementation
5- evaluation
assessment phase of the nursing process gather information about patient's condition
collection of both subjective and objective data
admission assessment comprehensive
"head to toe"
when arriving into medical unit
focus assessment more specific
looking at one area
speciality visit
emergency assessment rapid assessment
ABCs (airway, breathing, circulation)
subjective data symptoms
statement from cilents
cannot be measured
obtained through interviewing
objective data signs
observable/measurable
primary source of data patient
both subjective and objective
most reliable
secondary source of data family members/significant others
past/current health records
which of the following items of subjective cilent data would be cilent feels nauseated
documented in the medical record by the nurse?
3 multiple choice options
, what stage of the nursing process is the foundation for the assessment stage
nursing diagnosis?
diagnosis phase of the nursing process derives meaning from your assessment finding
provides basis for selection of nursing interventions
what is a nursing diagnosis based on? based on SIGNS and SYMPTOMS
3 types of nursing diagnosis actual nursing diagnosis
risk nursing diagnosis
wellness diagnosis
actual nursing diagnosis 3 part statement
diagnostic label R/T related factors AEB defining characteristics
AEB as evidenced by
example of actual nursing diagnosis ineffective airway clearance r/t tracheobronchial narrowing AEB tachycardia, tachypena,
hypoxia, adventitious breath sounds, cyanosis
risk nursing diagnosis has potential to occur
2 part statement
diagnostic label R/T risk factors
example of risk nursing diagnosis risk for acute confusion related to dehydration
planning phase of nursing diagnosis determine urgency of identified problems (ABCs)
priotize cilent needs
determine the OUTCOMES for the cilent
determine interventions needed for cilent
outcomes cilents response to interventions
SMART goals