Chapter 1

Question 1

Subjective data

Answer 1

what the client tells you

Question 2

Objective

Answer 2

what you observe

Question 3

Database

Answer 3

Patient’s record and laboratory studies

Question 4

Steps of Nursing Process

Answer 4

ADOPIE

Question 5

Assessment

Answer 5

-Collect Data
Review of the clinical record
Health history
Physical examination
Functional assessment
Risk assessment
Review of the literature
- Use evidence-based assessment techniques
- Documentation relevant data

Question 6

Diagnosis

Answer 6

-Compare clinical findings with normal & abnormal variation & developmental events.
-Interpret data
identify clusters of clues
make hypotheses
Test hypotheses
derive diagnoses
-Validate diagnosis
- Document diagnoses

Question 7

Outcome

Answer 7

-Identify expected outcome
-Individualize to the person
-culturally appropriate
- Realistic & measurable
-Include a timeline

Question 8

Planning

Answer 8

-Establish priorities
- Develop outcomes
-Set timelines for outcomes
-Identify interventions
-integrate evidence-based trends & research
-Document plan of care

Question 9

Implementation

Answer 9

-Implement in a safe & timely manner
-Use evidence-based interventions
- Collaborate with colleagues
-Use community resources
-Coordinate care delivery
-Provide health teaching & health promotion
-Document implementation & any modification

Question 10

Evaluation

Answer 10

-Progress toward outcomes
-Conduct systematic, ongoing, criterion-based evaluation
-Include patient & significant others
-Use ongoing assessment to revise diagnoses, outcomes, plan
-Disseminate results to patient & family