NSG 3480 Exam 2 Study Guide | 2026 Update with complete
solutions.
Nursing Process Overview (Terms 1–5)
1. Nursing process
• Systematic clinical process used to deliver patient-centered care
• Framework for critical thinking and clinical judgment
• Cyclical, not linear – constantly reassessing
2. ADPIE
• Assessment
• Diagnosis
• Outcome identification
• Planning
• Implementation
• Evaluation
3. Critical thinking
• Purposeful, informed, outcome-oriented reasoning
• Requires questioning assumptions and analyzing data
• Essential for safe nursing practice
4. Clinical judgment
• Interpretation of assessment data to make clinical decisions
• Observation → Recognition → Action → Evaluation
• Develops with experience and reflection
5. Evidence-based practice (EBP)
• Integrating best research + clinical expertise + patient values
• Uses current, peer-reviewed evidence
• Improves patient outcomes and safety
,Assessment (Terms 6–17)
6. Subjective data
• Patient's verbal description (symptoms, feelings, perceptions)
• Cannot be measured or observed by others
• Example: "I feel dizzy" or "I have sharp pain in my chest"
7. Objective data
• Measurable, observable data
• Collected by nurse through physical exam, labs, vitals
• Example: BP 140/90, temp 101.2°F, wound drainage present
8. Primary source
• The patient – always the best source of information
• Provides first-hand account of symptoms and history
• If patient unable, use medical record or family
9. Secondary source
• Family members, caregivers
• Medical records, transfer reports
• Other healthcare providers (MD, PT, social work)
10. Mental status examination (MSE)
• Assessment of appearance, behavior, cognition, mood
• Includes orientation: person, place, time, situation
• Screens for delirium, dementia, depression
11. Health history
• Past medical history (PMH)
• Family history, social history (smoking, alcohol, living situation)
• Medications, allergies, immunizations
• Reason for seeking care (chief complaint)
12. Psychosocial exam
, • Emotional and mental health status
• Social support system (family, friends, community)
• Cultural, spiritual, and financial considerations
13. Physical exam
• Head-to-toe or focused assessment
• Uses four techniques: inspection, palpation, percussion, auscultation
• Performed systematically to avoid missing findings
14. Inspection
• First step of physical exam – visual observation
• Observe skin color, symmetry, movement, breathing effort
• Requires good lighting and exposure
15. Auscultation
• Listening to heart, lung, bowel sounds with stethoscope
• Performed after inspection, before palpation for abdomen
• Note rate, rhythm, pitch, intensity
16. Validation of data
• Confirming subjective data with objective findings
• Checking inconsistencies or missing information
• Example: Patient says "no pain" but grimaces and guards
17. Data clustering
• Grouping related assessment data to identify patterns/problems
• Helps formulate nursing diagnoses
• Example : Fever + cough + crackles = possible respiratory infection
Diagnosis (Terms 18–30)
18. Nursing diagnosis
, • Clinical judgment about patient's response to health problems
• Different from medical diagnosis (focuses on patient response)
• Provides direction for nursing interventions
19. Problem (diagnostic label)
• Name of the nursing diagnosis (from NANDA-I list)
• Describes the patient's response clearly
• Example: Acute Pain, Impaired Gas Exchange, Anxiety
20. Related factors (etiology)
• Cause or contributing factor of the problem
• Guides the choice of interventions
• Example: Acute Pain related to surgical incision
21. Defining characteristics
• Signs and symptoms that support the diagnosis
• Includes both subjective and objective data
• Example: Acute Pain – patient reports pain 8/10, grimacing, guarding
22. PES format
• P = Problem (diagnostic label)
• E = Etiology (related factors)
• S = Signs/Symptoms (defining characteristics)
• Example: Acute Pain (P) related to surgical incision (E) as evidenced by patient
report of 8/10 pain and grimacing (S)
23. Actual nursing diagnosis
• Patient currently has signs/symptoms
• Requires immediate intervention
• Example: Impaired Gas Exchange, Decreased Cardiac Output
24. Risk nursing diagnosis
• Patient is vulnerable to developing a problem
• No signs/symptoms yet, but high likelihood
• Example: Risk for Falls, Risk for Infection
25. Health promotion diagnosis
solutions.
Nursing Process Overview (Terms 1–5)
1. Nursing process
• Systematic clinical process used to deliver patient-centered care
• Framework for critical thinking and clinical judgment
• Cyclical, not linear – constantly reassessing
2. ADPIE
• Assessment
• Diagnosis
• Outcome identification
• Planning
• Implementation
• Evaluation
3. Critical thinking
• Purposeful, informed, outcome-oriented reasoning
• Requires questioning assumptions and analyzing data
• Essential for safe nursing practice
4. Clinical judgment
• Interpretation of assessment data to make clinical decisions
• Observation → Recognition → Action → Evaluation
• Develops with experience and reflection
5. Evidence-based practice (EBP)
• Integrating best research + clinical expertise + patient values
• Uses current, peer-reviewed evidence
• Improves patient outcomes and safety
,Assessment (Terms 6–17)
6. Subjective data
• Patient's verbal description (symptoms, feelings, perceptions)
• Cannot be measured or observed by others
• Example: "I feel dizzy" or "I have sharp pain in my chest"
7. Objective data
• Measurable, observable data
• Collected by nurse through physical exam, labs, vitals
• Example: BP 140/90, temp 101.2°F, wound drainage present
8. Primary source
• The patient – always the best source of information
• Provides first-hand account of symptoms and history
• If patient unable, use medical record or family
9. Secondary source
• Family members, caregivers
• Medical records, transfer reports
• Other healthcare providers (MD, PT, social work)
10. Mental status examination (MSE)
• Assessment of appearance, behavior, cognition, mood
• Includes orientation: person, place, time, situation
• Screens for delirium, dementia, depression
11. Health history
• Past medical history (PMH)
• Family history, social history (smoking, alcohol, living situation)
• Medications, allergies, immunizations
• Reason for seeking care (chief complaint)
12. Psychosocial exam
, • Emotional and mental health status
• Social support system (family, friends, community)
• Cultural, spiritual, and financial considerations
13. Physical exam
• Head-to-toe or focused assessment
• Uses four techniques: inspection, palpation, percussion, auscultation
• Performed systematically to avoid missing findings
14. Inspection
• First step of physical exam – visual observation
• Observe skin color, symmetry, movement, breathing effort
• Requires good lighting and exposure
15. Auscultation
• Listening to heart, lung, bowel sounds with stethoscope
• Performed after inspection, before palpation for abdomen
• Note rate, rhythm, pitch, intensity
16. Validation of data
• Confirming subjective data with objective findings
• Checking inconsistencies or missing information
• Example: Patient says "no pain" but grimaces and guards
17. Data clustering
• Grouping related assessment data to identify patterns/problems
• Helps formulate nursing diagnoses
• Example : Fever + cough + crackles = possible respiratory infection
Diagnosis (Terms 18–30)
18. Nursing diagnosis
, • Clinical judgment about patient's response to health problems
• Different from medical diagnosis (focuses on patient response)
• Provides direction for nursing interventions
19. Problem (diagnostic label)
• Name of the nursing diagnosis (from NANDA-I list)
• Describes the patient's response clearly
• Example: Acute Pain, Impaired Gas Exchange, Anxiety
20. Related factors (etiology)
• Cause or contributing factor of the problem
• Guides the choice of interventions
• Example: Acute Pain related to surgical incision
21. Defining characteristics
• Signs and symptoms that support the diagnosis
• Includes both subjective and objective data
• Example: Acute Pain – patient reports pain 8/10, grimacing, guarding
22. PES format
• P = Problem (diagnostic label)
• E = Etiology (related factors)
• S = Signs/Symptoms (defining characteristics)
• Example: Acute Pain (P) related to surgical incision (E) as evidenced by patient
report of 8/10 pain and grimacing (S)
23. Actual nursing diagnosis
• Patient currently has signs/symptoms
• Requires immediate intervention
• Example: Impaired Gas Exchange, Decreased Cardiac Output
24. Risk nursing diagnosis
• Patient is vulnerable to developing a problem
• No signs/symptoms yet, but high likelihood
• Example: Risk for Falls, Risk for Infection
25. Health promotion diagnosis
