Nursing Process

Question 1

is a systematic and rational method of planning and
providing individualized nursing care to patient. (Berman et al., 2016, p. 181)

Answer 1

Nursing Process

Question 2

The Nursing Process include

Answer 2

assessing , diagnosing, planning, implementing and
evaluating.

Question 3

is the systematic and continuous collection, organization, validation and documentation of data.

Answer 3

Assessment

Question 4

is the process of interpreting and analysing assessment data to identify clients strengths and problems.

Answer 4

Diagnosis

Question 5

is the deliberate process of identifying nursing interventions to prevent, reduce or eliminate the client’s
nursing problem.

Answer 5

Planning

Question 6

is the action phase in which the nurse performs the nursing interventions and document the
care needed.

Answer 6

Implementation

Question 7

is the a planned, ongoing and purposeful activity to determine the client’s progress, the achievement
of the goals and the effectiveness of the nursing care plan.

Answer 7

Evaluation

Question 8

1. Collect data to identify the client’s health status.
2. Identify the client’s actual or potential nursing problems arising from the medical problem.
3. Create a Plan of Care that will meet the needs and solve the nursing problems.

Answer 8

Purposes of the Nursing Process

Question 9

1. Cyclic & Dynamic
2. Client-centeredness
3. Focus on problem solving and decision-making
4. Goal-oriented
5. Interpersonal process & collaborative
6. Use of critical thinking and clinical reasoning
7. Universal applicability

Answer 9

Characteristics of the Nursing Process:

Question 10

is collected via personal communication

Answer 10

subjective data

Question 11

is collected via observations

Answer 11

Objective data

Question 12

There are 4 Main Activities performed in assessment:

Answer 12

1.Collection of Data
2.Organization of Data
3.Validation of Data
4.Documentation of Data

Question 13

is the systematic and continuous collection, organization, validation and
documentation of data.

Answer 13

Assessment

Question 14

There are 4 types of assessment;

Answer 14

Initial, Problem-focused, Emergency and Time-lapsed
assessment.

Question 15

contains all the information about a client, it includes physical assessment, history,
physical examination, results of laboratory and diagnostic tests and other information
contributed by other health care professional.

Answer 15

database

Question 16

data are apparent only to the person affected and can be described or verified only by that
person.

Answer 16

Subjective

Question 17

are detectable by an observer and can be measured or tested against
an accepted standard.

Answer 17

Objective Data

Question 18

Sources of data include

Answer 18

client, support people, client records, health care professionals and
literatures.

Question 19

methods include observation, interview and physical examination.

Answer 19

Data Collection

Question 20

for organization of data depends on the health care institution but the most
commonly used frameworks include Body Systems Model, Maslow’s Hierarchy of Needs and
Developmental Theories.

Answer 20

Frameworks

Question 21

To complete the assessment process,

Answer 21

the nurse must record the collected data in the patient’s
record.

Question 22

TYPE OF ASSESSTMENT - TIME PERFORMED: INITIAL

Answer 22

Performed within a specified time
after admission to a HC Agency.

Question 23

TYPE OF ASSESSTMENT - TIME PERFORMED: PROBLEM FOCUSED

Answer 23

Ongoing process integrated within
nursing care.

Question 24

TYPE OF ASSESSTMENT - TIME PERFORMED: Emergency

Answer 24

During any physiological or
psychological crisis of the client.

Question 25

TYPE OF ASSESSTMENT - TIME PERFORMED: Time-lapsed

Answer 25

Several months after initial

assessment.

Question 26

TYPE OF ASSESSTMENT - PURPOSE: Time-lapsed

Answer 26

To compare the client’s current status
to baseline data previously obtained.

Question 27

TYPE OF ASSESSTMENT - PURPOSE: Emergency

Answer 27

To identify life-threatening problems.
To identify new or overlooked
problem.

Question 28

TYPE OF ASSESSTMENT - PURPOSE: Problem-
focused

Answer 28

To determine the status of a specific
problem identified in an earlier
assessment.

Question 29

TYPE OF ASSESSTMENT - PURPOSE: Initial

Answer 29

To establish a complete database for
problem identification, reference and
future comparison.

Question 30

TYPE OF ASSESSTMENT - EXAMPLE - INITIAL

Answer 30

Nursing admission
assessment.

Question 31

TYPE OF ASSESSTMENT - EXAMPLE - PROBLEM FOCUSED

Answer 31

Hourly assessment of client’s
fluid intake and urinary
output in an ICU.

Question 32

TYPE OF ASSESSTMENT - EXAMPLE -Emergency

Answer 32

Rapid assessment of ABC
after cardiac arrest.

Question 33

TYPE OF ASSESSTMENT - EXAMPLE -Time Lapsed

Answer 33

Reassessment of a client’s
functional health problem in
a home care or out patient
setting.

Question 34

is “ A clinical judgment concerning a human response to health conditions/life processes, or a
vulnerability for that response, by an individual, family, group or community”.

Answer 34

diagnosis

Question 35

To define, refine and promote a taxonomy of nursing diagnostic terminology for general use of professional
nurses.

Answer 35

PURPOSE OF NANDA INTERNATIONAL:

Question 36

There are 3 Main Activities performed in diagnosis:

Answer 36

1. Analyze the data
2. Identify health problems
3. Formulate diagnostic statement

Question 37

inadequate amount, quality, not sufficient, incomplete

Answer 37

1. Deficient-

Question 38

made worse, weakened, damage, reduced, deteriorated

Answer 38

Impaired-

Question 39

lesser in size, amount or degree

Answer 39

Decreased-

Question 40

not producing the desired effect

Answer 40

Ineffective-

Question 41

Identifies one or more probable causes of health problem, gives __________________________ therapy and
enables the nurse to individualize the client’s care.

Answer 41

direction to the required nursing

Question 42

client’s signs and symptoms

Answer 42

ACTUAL NDX-

Question 43

no subjective and objective data

Answer 43

RISK NDX-

Question 44

Components of NANDA Nursing Diagnosis: 3 Parts (Use for actual problem)

Answer 44

1. Problem
2. Etiology
3. Signs and Symptoms

Question 45

Components of NANDA Nursing Diagnosis: 2 Parts (Use for risk and syndrome)

Answer 45

1. Problem
2. Etiology

Question 46

Components of NANDA Nursing Diagnosis: 1 Part (Use for health promotion)

Answer 46

1. Problem

Question 47

There are 4 types of diagnosis-

Answer 47

Actual Diagnosis, health Promotion Diagnosis, Risk
Diagnosis and Syndrome Diagnosis.

Question 48

In formulating the ____________________, the nurse can use the 3 Parts, 2 Parts and 1 Part
Component.

Answer 48

nursing diagnosis

Question 49

is “ A clinical judgment concerning a human response to health conditions/life
processes, or a vulnerability for that response, by an individual, family, group or
community”.

Answer 49

Diagnosis