Nursing Process Exam

Objective data refers to information that is factual, unbiased, and can be observed or measured. It is based on concrete evidence and does not depend on personal opinions or interpretations. This type of data is typically obtained through direct observation, measurements, or experiments. It is considered reliable and can be used to make objective conclusions or decisions. In contrast, subjective data is based on personal opinions, feelings, or interpretations, and it can vary from person to person. Therefore, the correct answer is objective data.

Emergency assessment is the correct answer because it involves a rapid and thorough evaluation of the patient's condition to identify any life-threatening problems such as choking, stab wounds, or heart attacks. This assessment is performed immediately upon arrival to prioritize and initiate appropriate interventions. It helps the healthcare provider quickly determine the severity of the situation and take immediate action to stabilize the patient's condition. The other options, initial assessment, focus assessment, and final assessment, may be performed at different stages of care but may not specifically focus on identifying life-threatening problems.

In this stage, evaluation is the correct answer because it involves determining if the patient has achieved the expected outcomes. It is the process of assessing the patient's progress and comparing it to the desired outcomes. This step helps healthcare professionals determine the effectiveness of the implemented interventions and make any necessary adjustments to the patient's care plan.

Assessment is the correct answer because it involves the systematic collection of subjective and objective data about the client. This step focuses on gathering information about the client's physical, psychological, emotional, sociocultural, and spiritual aspects. It is an essential part of the nursing process as it helps the nurse to understand the client's needs and create an individualized care plan.

The correct answer is subjective data because the question is asking about the type of information that is verbalized or stated by the client. Subjective data refers to information that is based on personal opinions, feelings, or experiences, and is often provided by the client themselves. Objective data, on the other hand, refers to factual and measurable information that can be observed or measured by others. Therefore, subjective data is the most appropriate answer in this context.

Implementation is the correct answer because it refers to the step in the nursing process where the nurse carries out the interventions that have been planned in order to achieve the goals established in the care plan. This step occurs after the care plan has been developed and includes actions such as administering medications, providing treatments, and educating the patient.

The nursing process is a systematic problem-solving approach used in providing individualized nursing care. It involves assessing the patient's needs, diagnosing the problems, planning and implementing interventions, and evaluating the outcomes. This approach helps nurses to effectively and efficiently address the unique needs of each patient and provide appropriate care. The nursing care plan is a part of the nursing process, but it is not the overall approach itself. The nurses practice act refers to the legal regulations and guidelines that govern the practice of nursing, which is not directly related to the systematic problem-solving approach.

A focus assessment is a type of assessment that collects data about a specific problem that has already been identified. It is used to determine if the problem still exists or if there have been any changes. This type of assessment is more targeted and focused on a specific issue or concern, compared to other types of assessments such as initial, emergency, or final assessments.

The correct answer is the North American Nursing Diagnosis Association International. This association was established with the purpose of developing, refining, and promoting the taxonomy of nursing diagnostic terminology used by nurses. It focuses on advancing the field of nursing through standardized language and classification systems for nursing diagnoses.

The initial assessment is a comprehensive evaluation of a patient's medical history, family history, reason for admission, current medications, previous hospitalization, surgeries, psycho-social assessment, nutrition, and a complete physical assessment. It is conducted at the beginning of a patient's hospitalization or medical encounter to gather important information about the patient's health status and to establish a baseline for future assessments and interventions. This assessment helps healthcare providers to identify any immediate health concerns, develop an appropriate care plan, and ensure the patient's overall well-being.

The three parts of a nursing diagnosis (PES) are problem, signs and symptoms, and etiology. The problem refers to the actual health issue or condition that the patient is experiencing. Signs and symptoms are the observable and subjective manifestations of the problem that the patient is presenting. Etiology, on the other hand, refers to the underlying cause or contributing factors that are responsible for the development of the problem. These three components are essential in formulating a comprehensive nursing diagnosis, which helps guide the nursing interventions and care planning for the patient.

In the planning step of the nursing process, the nurse prioritizes the diagnosis in order of importance and determines the nursing interventions that need to be implemented to achieve the goals of the care plan. This involves creating a plan of action to address the identified health issues and develop strategies to promote the patient's well-being. The nurse considers the patient's individual needs, resources, and preferences to create an effective care plan.

In the nursing process, the step of PES refers to the formulation of a nursing diagnosis. This involves analyzing the assessment data collected from the patient to identify the actual or potential health problems and their underlying causes. The nursing diagnosis helps in developing a plan of care and determining appropriate interventions and outcomes for the patient. Therefore, the correct answer is diagnosis.

The correct answer is Actual, Risk, Health promotion, and Wellness. These are the four types of nursing diagnosis. Actual nursing diagnosis refers to an existing health problem that requires nursing interventions. Risk nursing diagnosis identifies potential health problems that a patient may develop. Health promotion nursing diagnosis focuses on improving the patient's overall well-being and preventing future health issues. Wellness nursing diagnosis is used when a patient has a high level of wellness and seeks to maintain or enhance it.