©BRIGHTSTARS EXAM SOLUTIONS
11/16/2024 10:16 AM
Nursing 251 Final – NDSU Exam Study
Guide.
Nursing Process - answer✔Assessment
Diagnosis
Planning
Implementation
Evaluation
Assessment - answer✔Gathers information about the patient's condition
The systematic collection and verification of data
Purpose is to establish baseline data about the client
Seeing If there are changes from first assessment
Gives the nurse the necessary information about risk factors so care can be individualized
The data is analyzed to develop nursing diagnosis
Important for nurse to know disease conditions and the client's responses to illness and
treatment
Diagnosis - answer✔Identify the patient's problems
Planning - answer✔Set goals of care and desired outcomes and identify appropriate nursing
actions
Implementation - answer✔Perform the nursing actions identified in planning
Evaluation - answer✔Determine if goals and expected outcomes are achieved
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, ©BRIGHTSTARS EXAM SOLUTIONS
11/16/2024 10:16 AM
ANA Standard 1: Assessment - answer✔Nurses are responsible for collecting comprehensive
data that is pertinent to the patient's health and the situation
Getting all the information
Data needs to be documented or it didn't happen
First step in determining priorities to individualize care
The data must also be documented in a retrievable format
Assessment Components - answer✔§ Data collection methods (fist part in assessment)
Observation
ex. Is the patient engaged, facial reactions, 5 senses
Interview:
1. Pre-interaction phase
2. Orientation phase
3. Working phase
4. Termination phase
Examination
Medical record review
Pre-interaction phase - answer✔· Before meeting the client
o Review data
o Talk to other caregivers
o Anticipate concerns or issues that may arise
o Plan for adequate time
o Identify locations that foster comfort & privacy
Orientation phase - answer✔· The nurse and the client meet
· Get to know one another
· Set the tone
o Warmth
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11/16/2024 10:16 AM
o Empathetic
o Caring manner
· Clarifies the role of nurse/client
Working phase - answer✔· Nurse & client work together to:
o Solve problems
o Accomplish goals
· Therapeutic communication to facilitate interactions
· Uses appropriate self-disclosure & confrontation
Termination phase - answer✔· During the ending of the nurse/client relationship
o Reminds that termination is near
o Evaluates goal achievement with the client
o Separates from the client
o Transition from nurse to caregiver
Assessment Frameworks - answer✔Maslow's basic needs: nursing stay within the first two
needs most often
Physiological needs (base)
Ex: food, water, shelter, bp, pulse, O2 (ABC's = airway, breathing, circulation)
Safety/security needs
Love and belonging
Self-esteem
Self-actualization
Gordon's functional heath status
Nursing Diagnosis: used for care planning
Type of data - answer✔subjective: what they report and feel
objective: what you observe
Sources of data - answer✔Client
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, ©BRIGHTSTARS EXAM SOLUTIONS
11/16/2024 10:16 AM
Family and significant others
Health care team members
Medical records/other records
Literature review
Nurse's experience
Other Records
Data collection is based on - answer✔Assessment
Client review
Chart review
Health History - answer✔Biological
Expectations
Family history
Past medical history
Present medical history
Environmental
Spiritual
Review of systems (ROS)
Psychological
Reasons for seeking healthcare
ANA Standard 2: Diagnosis - answer✔The registered nurse analyzes the assessment data to
determine the diagnoses or issues.
ADVANTAGES OF NURSING DIAGNOSIS
Defines nursing domain: how we practice as a nurse
Facilitates communication: between shifts and other healthcare facilities
Helps prioritize the needs of the client: ABC's
Useful in documentation
4|Page
11/16/2024 10:16 AM
Nursing 251 Final – NDSU Exam Study
Guide.
Nursing Process - answer✔Assessment
Diagnosis
Planning
Implementation
Evaluation
Assessment - answer✔Gathers information about the patient's condition
The systematic collection and verification of data
Purpose is to establish baseline data about the client
Seeing If there are changes from first assessment
Gives the nurse the necessary information about risk factors so care can be individualized
The data is analyzed to develop nursing diagnosis
Important for nurse to know disease conditions and the client's responses to illness and
treatment
Diagnosis - answer✔Identify the patient's problems
Planning - answer✔Set goals of care and desired outcomes and identify appropriate nursing
actions
Implementation - answer✔Perform the nursing actions identified in planning
Evaluation - answer✔Determine if goals and expected outcomes are achieved
1|Page
, ©BRIGHTSTARS EXAM SOLUTIONS
11/16/2024 10:16 AM
ANA Standard 1: Assessment - answer✔Nurses are responsible for collecting comprehensive
data that is pertinent to the patient's health and the situation
Getting all the information
Data needs to be documented or it didn't happen
First step in determining priorities to individualize care
The data must also be documented in a retrievable format
Assessment Components - answer✔§ Data collection methods (fist part in assessment)
Observation
ex. Is the patient engaged, facial reactions, 5 senses
Interview:
1. Pre-interaction phase
2. Orientation phase
3. Working phase
4. Termination phase
Examination
Medical record review
Pre-interaction phase - answer✔· Before meeting the client
o Review data
o Talk to other caregivers
o Anticipate concerns or issues that may arise
o Plan for adequate time
o Identify locations that foster comfort & privacy
Orientation phase - answer✔· The nurse and the client meet
· Get to know one another
· Set the tone
o Warmth
2|Page
, ©BRIGHTSTARS EXAM SOLUTIONS
11/16/2024 10:16 AM
o Empathetic
o Caring manner
· Clarifies the role of nurse/client
Working phase - answer✔· Nurse & client work together to:
o Solve problems
o Accomplish goals
· Therapeutic communication to facilitate interactions
· Uses appropriate self-disclosure & confrontation
Termination phase - answer✔· During the ending of the nurse/client relationship
o Reminds that termination is near
o Evaluates goal achievement with the client
o Separates from the client
o Transition from nurse to caregiver
Assessment Frameworks - answer✔Maslow's basic needs: nursing stay within the first two
needs most often
Physiological needs (base)
Ex: food, water, shelter, bp, pulse, O2 (ABC's = airway, breathing, circulation)
Safety/security needs
Love and belonging
Self-esteem
Self-actualization
Gordon's functional heath status
Nursing Diagnosis: used for care planning
Type of data - answer✔subjective: what they report and feel
objective: what you observe
Sources of data - answer✔Client
3|Page
, ©BRIGHTSTARS EXAM SOLUTIONS
11/16/2024 10:16 AM
Family and significant others
Health care team members
Medical records/other records
Literature review
Nurse's experience
Other Records
Data collection is based on - answer✔Assessment
Client review
Chart review
Health History - answer✔Biological
Expectations
Family history
Past medical history
Present medical history
Environmental
Spiritual
Review of systems (ROS)
Psychological
Reasons for seeking healthcare
ANA Standard 2: Diagnosis - answer✔The registered nurse analyzes the assessment data to
determine the diagnoses or issues.
ADVANTAGES OF NURSING DIAGNOSIS
Defines nursing domain: how we practice as a nurse
Facilitates communication: between shifts and other healthcare facilities
Helps prioritize the needs of the client: ABC's
Useful in documentation
4|Page
