Nursing Process ADPIE

This step of the nursing process includes the systematic collection of all subjective and objective data about the client in which the nurse focuses holistically on the client- physical, psychological, emotional, sociocultural, and spiritual.

• Assessment

• Planning

• Implementation

• Diagnosis

2. Which of the following is the subjective data?

• Patient verbalized feeling of pain

• The temperature is 38.5 degree celcius

• Wheezing lung sound present

• Heart rate is 100 beats per min

3. Impaired skin integrity (pressure injury) related to bedridden as evidenced by present of wound laceration. Which part of the above nursing diagnosis statement indicates etiology?

• Impaired skin integrity

• Bedridden

• Pressure ulcer

• Wound laceration

4. When planning nursing care for a client, objectives should be SMART. Specific, measurable, action-oriented, realistic, and timely. Which example best describes an outcome that is measurable?

• The client will ambulate to the end of the hallway within 2 days

• The client will verbalize feelings about her diagnosis

• The client will have control of his back pain

• The client's family will agree to the methods of treatment

The following are the types of nursing diagnosis except

• Actual

• Risk

• Health promotion

• Safety

• Possible