NUR 139 EXAM 2026 WITH ACTUAL
CORRECT QUESTIONS AND VERIFIED
DETAILED ANSWERS |CURRENTLY
TESTING QUESTIONS AND
SOLUTIONS|ALREADY GRADED
A+|NEWEST |BRAND NEW VERSION|JUST
RELEASED!!
The Nursing Process is...
A systematic method that directs the nurse and client to accomplish the following
Assess
the client to determine the need for nursing care
Diagnosis
Determine nursing diagnoses for actual and potential health problems
Implementation
Implement the care
Planning
formulating outcome/goal statements and determining nursing interventions
Evaluating
evaluating progress toward goal (making revisions when needed)
Characteristics of the nursing process
systematic
dynamic
1|Page
,interpersonal
outcome oriented
universally applicable
Step 1: Assessment
The purpose is to assess the client to create a plan of care that address the most important
problem. The primary source of client data is the patient.
Types of Nursing Assessments include
-Initial
-Focused
-Emergency
-Time-Lapsed
Initial Assessment
Is performed shortly after the patient is admitted to a HC facility or service. The purpose of this
assessment is to establish a complete database for problem identification and care planning.
Focused Assessment
The nurse gathers data about a specific problem that has already been identified. Purpose is to
identify new or overlooked problems
Emergency assessment
when a patient with a physiologic or psychological crisis, the nurse performs this to identify life-
threatening problems.
Time-Lapsed assessment
is scheduled to compare a patient's current status to the baseline data obtained earlier. Purpose
is to reassess the patient's health status and to make necessary revisions in their care plan
Subjective data
2|Page
,information perceived only by the affected person; this data cannot be perceived/verified by
another person. EX: feeling nervous, nauseated or chilly
Objective data
observable and measurable data that can be seen, heard, felt or measured by someone other
than the person experiencing them. EX: elevated temp reading, skin that is moist, refusal to look
at/eat food
Possible sources of client data
The patient
The family/sig others
Patient record
Other nurses/physicians
Methods of collecting data
Observation
Nursing History
Patient Interview
Physical Assessment
Problems related to data collection
Inappropriate organization of the database
Omission of pertinent data
Inclusion of irrelevant or duplicate data, erroneous or misinterpreted data
Failure to establish rapport and partnership
Recording an interpretation of data rather than observed behavior
Failure to update the database
Nursing diagnosis
A nursing statement approved by NANDA-I
3|Page
, medical diagnosis vs nursing diagnosis
A medical diagnosis deals with disease or medical condition. A nursing diagnosis deals with
human response to actual or potential health problems and life processes.
Actual vs Risk Diagnosis
Actual: experiencing the disease/problem
Risk: has signs/symptoms that could LEAD to disease/problems
Structuring a nursing diagnosis- ACTUAL (3parts)
P: Problem (from NANDA list) "Related to (R/T)"
E: Etiology "as evidenced by (AEB)"
S: Signs and Symptoms (evidence that the problem exists)
Structuring a nursing diagnosis-RISK (2parts)
P: Problem (from NANDA List) "related to, r/t"
E: Etiology
Prioritizing Nursing Diagnoses: Maslow's Hierarchy of Needs
1. Physiological (airway, circulation, nutrition, elimination)
2. Safety (falls)
3. Love & belonging
4. Self-esteem
5. Self actualization
Prioritize based on Maslow:
A.___Consipation
B.___Imbalanced Nutrition
C.___Powerlessness
D.___Risk for Falls
E.___Bathing:Self-care Deficit
F.___Social Isolation
4|Page
CORRECT QUESTIONS AND VERIFIED
DETAILED ANSWERS |CURRENTLY
TESTING QUESTIONS AND
SOLUTIONS|ALREADY GRADED
A+|NEWEST |BRAND NEW VERSION|JUST
RELEASED!!
The Nursing Process is...
A systematic method that directs the nurse and client to accomplish the following
Assess
the client to determine the need for nursing care
Diagnosis
Determine nursing diagnoses for actual and potential health problems
Implementation
Implement the care
Planning
formulating outcome/goal statements and determining nursing interventions
Evaluating
evaluating progress toward goal (making revisions when needed)
Characteristics of the nursing process
systematic
dynamic
1|Page
,interpersonal
outcome oriented
universally applicable
Step 1: Assessment
The purpose is to assess the client to create a plan of care that address the most important
problem. The primary source of client data is the patient.
Types of Nursing Assessments include
-Initial
-Focused
-Emergency
-Time-Lapsed
Initial Assessment
Is performed shortly after the patient is admitted to a HC facility or service. The purpose of this
assessment is to establish a complete database for problem identification and care planning.
Focused Assessment
The nurse gathers data about a specific problem that has already been identified. Purpose is to
identify new or overlooked problems
Emergency assessment
when a patient with a physiologic or psychological crisis, the nurse performs this to identify life-
threatening problems.
Time-Lapsed assessment
is scheduled to compare a patient's current status to the baseline data obtained earlier. Purpose
is to reassess the patient's health status and to make necessary revisions in their care plan
Subjective data
2|Page
,information perceived only by the affected person; this data cannot be perceived/verified by
another person. EX: feeling nervous, nauseated or chilly
Objective data
observable and measurable data that can be seen, heard, felt or measured by someone other
than the person experiencing them. EX: elevated temp reading, skin that is moist, refusal to look
at/eat food
Possible sources of client data
The patient
The family/sig others
Patient record
Other nurses/physicians
Methods of collecting data
Observation
Nursing History
Patient Interview
Physical Assessment
Problems related to data collection
Inappropriate organization of the database
Omission of pertinent data
Inclusion of irrelevant or duplicate data, erroneous or misinterpreted data
Failure to establish rapport and partnership
Recording an interpretation of data rather than observed behavior
Failure to update the database
Nursing diagnosis
A nursing statement approved by NANDA-I
3|Page
, medical diagnosis vs nursing diagnosis
A medical diagnosis deals with disease or medical condition. A nursing diagnosis deals with
human response to actual or potential health problems and life processes.
Actual vs Risk Diagnosis
Actual: experiencing the disease/problem
Risk: has signs/symptoms that could LEAD to disease/problems
Structuring a nursing diagnosis- ACTUAL (3parts)
P: Problem (from NANDA list) "Related to (R/T)"
E: Etiology "as evidenced by (AEB)"
S: Signs and Symptoms (evidence that the problem exists)
Structuring a nursing diagnosis-RISK (2parts)
P: Problem (from NANDA List) "related to, r/t"
E: Etiology
Prioritizing Nursing Diagnoses: Maslow's Hierarchy of Needs
1. Physiological (airway, circulation, nutrition, elimination)
2. Safety (falls)
3. Love & belonging
4. Self-esteem
5. Self actualization
Prioritize based on Maslow:
A.___Consipation
B.___Imbalanced Nutrition
C.___Powerlessness
D.___Risk for Falls
E.___Bathing:Self-care Deficit
F.___Social Isolation
4|Page
