The Nursing Process

What is the first step in the nursing process?

• Assessment

• Planning

• Implementation

• Evaluation

Answer explanation

The first step in the nursing process is Assessment. This involves collecting comprehensive data about the patient's health status, which is essential for making informed decisions in subsequent steps.

Which type of data is collected through observation?

• Subjective Data

• Objective Data

Answer explanation

Objective data is collected through observation and is measurable and factual. In contrast, subjective data is based on personal opinions and feelings. Therefore, the correct answer is Objective Data.

The purpose of setting SMART goals in the planning phase of the nursing process is to:

• ensure goals are specific, measurable, achievable, relevant, and time-bound

• provide a general guideline for patient care

• allow flexibility in patient care plans

• focus solely on long-term outcomes

Answer explanation

The purpose of setting SMART goals is to ensure they are specific, measurable, achievable, relevant, and time-bound, which enhances clarity and effectiveness in patient care planning.

Identify a problem to form a (NANDA approved) nursing diagnosis. What are the two types of problems identified?

• Actual and Potential

• Chronic and Acute

• Primary and Secondary

• Simple and Complex

Answer explanation

In nursing, problems are categorized as Actual (existing issues) and Potential (risks for future issues). This distinction is crucial for effective diagnosis and care planning, making 'Actual and Potential' the correct choice.

The role of evaluation in the nursing process is to:

• assess patient needs

• implement nursing interventions

• determine the effectiveness of care

• plan nursing strategies

Answer explanation

The evaluation phase in the nursing process focuses on determining the effectiveness of care provided to patients, ensuring that interventions meet their needs and lead to desired outcomes.

12.76 PN:

While the nurse is irrigating an 86-year-old patient's ear to remove cerumen, the client comments that he is getting dizzy. Which nursing actions are appropriate? Select all that apply.

• Stop the procedure immediately

• Warm the irrigant and resume the proceure

• Monitor for increased intracranial pressure

• Notify the provider immediately

• Explore the canal with a cotton applicator

Answer explanation

Stopping the procedure immediately is crucial to prevent further dizziness. Warming the irrigant can help if the procedure resumes, as cold solutions can cause vertigo. Other options are not appropriate in this situation.

What is the primary purpose of the assessment phase in the nursing process?

• To set long-term goals for patient care

• To evaluate the effectiveness of care

• To implement nursing interventions

• To gather comprehensive data about the patient's health status

Answer explanation

The primary purpose of the assessment phase in the nursing process is to gather comprehensive data about the patient's health status, which is essential for planning effective care.

Which of the following is a characteristic of a well-written nursing diagnosis?

• It is based on assumptions

• It focuses solely on medical conditions

• It is specific and based on patient data

• It is vague and general

Answer explanation

A well-written nursing diagnosis is specific and based on patient data, ensuring it accurately reflects the patient's needs and conditions. This allows for effective care planning and interventions.

During which phase of the nursing process are nursing interventions carried out?

• Assessment

• Evaluation

• Diagnosis

• Implementation

Answer explanation

Nursing interventions are carried out during the Implementation phase of the nursing process. This phase involves executing the planned interventions to achieve the desired patient outcomes.

What is the primary focus of the diagnosis phase in the nursing process?

• To gather patient data

• To identify patient problems and needs

• To evaluate patient outcomes

• To implement care plans