Unit 1 Nursing 120 Exam (Lectures 1-8)
Questions with Latest Update
Describe the five phases of the nursing process - Answer-The five phases of the
nursing process are assessment, diagnosis, planning/outcome identification,
implementation, and evaluation. They can be represented by the acronym ADPIE for
easy recall. The assessment step is where you collect all of your data on the patient,
both objective and subjective. Objective data is data that can be measured by at least
one other like minded individual, meaning another nurse, or an instructor. Examples of
objective data include temperature, color, symmetry, bruises, vital signs, wounds, and
sounds the body makes. Subjective data is data that is dependent on what someone
else feels, perceives, and/or believes, meaning that it might be right but it might be
wrong. Examples of subjective data are a limp, the chart, and information told to you by
the patient or the patient's family members. Diagnosis means the nursing diagnosis,
which is very different from a medical diagnosis. A medical diagnosis tells what is
medically wrong with a patient. A nursing diagnosis takes this medical diagnosis into
consideration, but is really a nurses judgement on how the patient will react to the
medical diagnosis, or, more so, how the diagnosis will affect the patient and their life as
a whole. Planning and outcome identification is when the nurse comes up with a big
goal and mini goals on where she/he and the patient agree the patient wants to and
should be, and comes up with a sort of plan of action for how to get the patient there.
Simply put, it is when the nurse decides how to treat the patient dependent upon the
nursing diagnosis. Implementation is simply the step during which the nurse begins to
implement and do the things they decided to do. And lastly there is evaluation which is
when the nurse re-examines and evaluates the patient to see if goals were met and if
the course of treatment they decided
Describe the assessment phase - Answer-The assessment phase is when the nurse
gathers a bunch of different pieces of data on the patient to get a more thorough
understanding of them and their condition. There are two different kinds of data that can
be collected in an assessment, objective data and subjective data. Objective data is
observable data that can be measured by you, and by another like minded individual,
such as another nurse, peer, or instructor. Examples of objective data include vital
signs, temperature, color/complexion, bruises, wounds, conditions, and sounds the
body makes. The other kind of data that can be collected is subjective data. This is the
kind of data that someone "says", so it might be right, but it might be wrong. Examples
of this kind of data include what the patient tells you, what the patient's family told you,
what other nurses or health care professionals told you, the chart, and a limp.
REMEMBER THAT A NURSE'S ASSESSMENT OF A PATIENT IS CONTINUOUS.
Identify the components of a nursing diagnosis - Answer-There are three parts to a
nursing diagnosis, although only all three parts will included if it is an actual diagnosis,
meaning it is a true thing that the patient is currently experiencing. Only two parts will
appear in the diagnosis if the diagnosis is an at risk diagnosis. This means that the
, patient is not actually experiencing the nursing diagnosis, but it is something that could
potentially occur, such as a person who is at risk for impaired skin integrity. The first
part of the diagnosis is just the diagnosis, also referred to as the label. The next part of
the diagnosis is the R/T (related to) also referred to as the etiology, which is the origin or
cause of the nursing diagnosis. The third part that is typically only included in the
diagnosis if it is an actual diagnosis is the AEB (as evidence by), also known as the
signs and symptoms. These are the signs and symptoms that the patient is
experiencing and/or displaying that led you to your nursing diagnosis. An example of a
complete nursing diagnosis is: Impaired physical mobility R/T pain and discomfort
following surgery AEB no ambulation since surgery, limited ROM in right hip, and
statements of pain of 10/10. NOTE THAT THE R/T CAN NOT BE THE MEDICAL
DIAGNOSIS.
Contrast a nursing diagnosis with a medical diagnosis - Answer-A medical diagnosis is
a diagnosis of what is medically wrong with the patient, or what the patient is in for and
why they are being treated. These can only be given by medical professionals such as
physicians, physician's assistants, and nurse practitioners. A nursing diagnosis is a
clinical judgement by the nurse of how this medical diagnosis will affect the patient's life.
It takes the medical diagnosis into account and into consideration, but does not actually
state what is medically wrong with a person as nurses are not in a high enough position
to diagnose in this way. Medical diagnoses stay the same for as long as that medical
condition exists within the patient, but nursing diagnoses constantly change ad adapt
based on how the patient is feeling or reacting to treatment that was chosen.
Describe the process of developing a nursing diagnosis - Answer-The nurse must first
complete assessment of the patient and collect as much information as possible on
them. He/she must then examine the signs and symptoms that the patient is presenting
as these will now become the defining characteristics of the nursing diagnosis. The
nurse then clusters these signs and symptoms/defining characteristics together to make
a cue. A cue is a group of defining characteristic that point the nurse in the direction of
the proper nursing diagnosis. Based off of all of this information, the nurse then decides
upon the best diagnosis, or diagnoses. There are often more that one, but at this point
in time we will only be required to identify one per patient. If there is more than one
diagnosis, then the nurse must prioritize these diagnoses from the one of highest
importance to lowest importance to know which one she should address first. The
patient should be included in this decision so you know what is the most important to
them to fix.
Discuss the purpose and benefits of outcome identification - Answer-Outcome
identification is important because both you and the patient need to know what it is that
you are aiming for, or what you are trying to do. It gives something for the patient to look
forward to and aim for. Many times when given something to strive for, people take it as
a challenge and try as hard as they can to reach and surpass that goal. Outcome
identification helps you and your patient set whatever goals are desired and work
toward something, instead of just randomly attempting to do something. It sets an
intellectual plan of action for you to follow instead of just doing whatever you or the
