Assessment
What is the first step in the nursing process?
Assessment is the first step in the nursing process.
What organization provides the standardized list of nursing diagnoses?
NANDA-I (North American Nursing Diagnosis Association International)
What does SMART stand for when writing goals?
SMART = Specific, Measurable, Attainable, Realistic, Timely.
What does “implementation” mean in the nursing process?
Implementation = putting the care plan into action.
What question do you ask when evaluating a care plan?
Main question = “Were the goals met, partially met, or not met?”
Give one example of objective vs subjective data.
Objective data = measurable (e.g., temperature 38.5°C); Subjective data = what the patient says (e.g., “I have a headache”).
What are the three components of an actual nursing diagnosis?
Three parts of an actual nursing diagnosis: Problem, Etiology (related to), Symptoms (as evidenced by) → PES format.
Write a SMART goal for a patient experiencing impaired mobility.
Example: Patient will walk 20 feet with walker and standby assist within 3 days.
Give an example of an independent nursing intervention for anxiety.
Example: Encourage relaxation breathing or provide calm environment for anxiety.
What are the possible outcomes after evaluating whether a goal has been met?
Three possible outcomes: Goal met, Goal partially met, Goal not met.
What are the two main parts of a nursing assessment?
Two parts of a nursing assessment: data collection and data analysis/validation.
Create a sample “problem–etiology–symptom” (PES) statement for acute pain.
Acute Pain related to surgical incision as evidenced by pain rating 8/10 and guarding behavior.
Distinguish between a short-term and a long-term goal.
Short-term goals = hours to days; Long-term goals = weeks to months.
Why is documentation an important part of implementation?
Documentation ensures continuity of care, accountability, and legal protection
If a patient has not met a goal, what should the nurse do?
If not met → reassess, revise interventions, adjust goals.
Name three sources of patient data besides the patient.
Three other data sources: family members, healthcare providers, medical records, diagnostic tests, literature.
What is the difference between a risk diagnosis and an actual diagnosis?
Actual diagnosis = problem exists now with signs/symptoms; Risk diagnosis = potential problem with risk factors but no symptoms yet.
What’s the difference between independent, dependent, and collaborative nursing interventions?
Independent = nurse-initiated (teaching, repositioning).
Dependent = require provider order (medications).
Collaborative = involve interdisciplinary team (PT, dietitian)
Differentiate between direct care and indirect care interventions.
Direct care = hands-on (medication administration, wound care); Indirect care = away from the patient (documentation, care conferences).
How is evaluation an ongoing process rather than a final step?
Evaluation is continuous and ongoing because patient conditions change.
What’s the difference between a medical diagnosis and a nursing assessment finding?
A medical diagnosis identifies a disease/condition; a nursing diagnosis identifies patient responses/needs
Why is it important to avoid using medical diagnoses when writing a nursing diagnosis?
Avoid using medical diagnoses because nursing diagnoses must reflect patient-centered responses, not medical conditions.
Why is prioritization (Maslow’s hierarchy, ABCs) important in planning?
Prioritization ensures that life-threatening and high-need issues are addressed first (e.g., ABCs, Maslow’s hierarchy).
How does evidence-based practice influence nursing interventions?
Evidence-based practice ensures interventions are supported by research and best practice guidelines.
Why is patient feedback important in evaluating care?
Patient feedback provides insight into care effectiveness and ensures client-centered adjustments.