1. A nurse is collecting data on a patient who is being admitted into hospice care. The nurse collects data from both the patient and the family so that a
... [Show More] clear picture of the patient status is obtained. The nurse is currently involved in which step of the nursing process?
a. Assessment
b. Implementation
c. Evaluation
d. Diagnosing
ANS: A
Assessment is the deliberate and systematic collection of data about a patient. The data will reveal a patients current and past health status, functional status, and present and past coping patterns. A nursing diagnosis is a clinical judgment about individual, family, or community responses to actual and potential health problems or life processes that the nurse is licensed and competent to treat. Implementation is the performance of nursing interventions necessary for achieving the goals and expected outcomes of nursing care. Evaluation is crucial to deciding whether, after interventions have been delivered, a patients condition or well-being improves.
PTS:1DIF:Cognitive Level: Applying (Application) REF:124OBJescribe each step of the nursing process.
TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care
2. The nurse is admitting a patient to the unit and asks the patient about the health history. The nurse is engaged in which component of the nursing process?
a. Evaluation
b. Diagnosis
c. Assessment
d. Planning
ANS: C
The nurse is in the assessment phase. An assessment database includes a patients comprehensive health history, which includes information about a patients physical and developmental status, emotional health, social practices and resources, goals, values, lifestyle, and expectations about the health care system. The database also includes physical examination findings and a summary of results from laboratory and diagnostic testing. A nursing diagnosis is a clinical judgment about individual, family, or community responses to actual and potential health problems or life processes that the nurse is licensed and competent to treat. Evaluation is crucial to deciding whether, after interventions have been delivered, a patients condition or well-being improves.
Planning involves setting priorities, identifying patient-centered goals and expected outcomes, and prescribing nursing interventions.
PTS:1DIF:Cognitive Level: Applying (Application)
REF: 124 OBJ: Discuss approaches to data collection in nursing assessment. TOP: Nursing Process: Assessment MSC: NCLEX: Management of Care [Show Less]