RNSG 1413 Exam 2 -Power Point, Objective, & Learning
Guide Review UPDATED ACTUAL Questions and
CORRECT Answers
The nursing process is: *a systematic problem solving approach (critical thinking)
*used to identify, prevent, & treat health problems, & promote wellness
*provide a structure for organizing info (data)
*to direct critical thinking
*to make sound nursing decisions (clinical judgment)
*to individualize nursing care
NCJMM Nursing Clinical Judgement Measurement Model
recognize cues, analyze cues, prioritize hypotheses, generate solutions, take action,
evaluate outcomes
step 1 of nursing process & 2 stages of it Assessment
stage 1 = collection & verification of data (cues)
stage 2 = analysis of data
Types of Assessment -the patient-centered interview during a nursing health history.
-a physical examination.
-the periodic assessments you make during rounding or administering care.
types of patient data subjective (what the pt. tells you)
objective (what the nurse observes/ measures)
Sources of Patient Data ● Primary Source
○ Patient
● Secondary Sources
○ Family and significant others
■ Primary if patient is unable
○ Health care team
○ Medical records
○ Other records and the scientific literature
○ Nurse's experience
Motivational Interviewing (MI) collaborative conversation style that promotes positive health behavior change
and strengthens an individual's motivation and commitment to change. MI uses
the OARS mnemonic (Open-ended questions, Affirmation, Reflective listening, and
Summarizing)
What are the different types of effective communication Verbal communication.
needed in health care? Non-verbal communication (or body language).
Written communication.
Formal communication.
,Parts of the patient-centered interview ● The nurse-patient relationship
● Understanding the patient's story
● Interview preparation
● Phases of an interview
○ Orientation & setting an agenda
○ working phase
○ termination
○ Immediate Reporting and documentation of assessment data
orientation phase of a pt-centered interview perform introductions with the patient, establish a rapport, establish boundaries,
and explain patient confidentiality.
working phase of a pt.-centered interview the nurse elicits the client's comments about major biographic data, reasons for
seeking care, history of present health concern, past health history, family history,
review of body systems for current health problems, lifestyle and health practices,
and developmental level.
termination phase of a pt-centered interview the nurse informs the patient that the interview is ending. As the interview ends,
the nurse and the patient will review the data gathered, highlighting key points and
ensuring all information is accurate.
Interview Techniques Observation
Open-ended questions
Leading questions
Back channeling
Probing
Direct closed-ended questions
, components of nursing health history biographical information,
reason for seeking health care(patient's statement is not diagnostic, it is perception),
patient expectations,
present illness or health concerns,
health history,
family history,
psychosocial history(stress coping, parent's support system), spiritual health,
review of systems(subject data),
diagnostic & labs,
observation of patient behavior
a cue is info you obtain through use of senses
an inference is your judgement or interpretation of cues
validating the data from a pt-centered interview *ensures collection of complete database
*leads to 2nd step of nursing process
data validation means checking the accuracy and quality of source data before using, importing or
otherwise processing data.
data clustering in the diagnostic reasoning process grouping related cues together to help identify patterns that will assist with the
indentification of a nursing diagnosis. signs and symptoms.
defining characteristics in the diagnostic reasoning are a format to facilitate the description of signs and symptoms of a response to an
process identified health problem which helps nurses diagnose what they need to intervene
2nd Step of Nursing Process nursing diagnosis (analyze cues & prioritize hypotheses)
*applying clinical judgement to cues & data we collected
Types of Diagnoses *Medical diagnosis (from HCP)
*Nursing Diagnosis (the nurse's clinical judgement about the pt. response to actual
or potential health conditions or needs)
*Collaborative problems (such as seizures, bleeding)
nursing diagnosis come from North American Nursing Diagnosis Association International (NANDA-I)
-currently over 244 diagnostic labels
-purposes of standard formal diagnostic statement (provides what nurse's scope of
practice is without HP orders)
-types of NANDA-I nursing diagnoses:
*risk-focused
*risk
*health promotion
Steps for Nursing Diagnostic Process 1- organize the data
2- cluster the data (what is normal/abnormal)
3- interpret the data & analyze cues
4- • Make initial inferences
• Validate the nursing diagnoses
• Does it fit the NANDA-I definition?
• Are the defining characteristics in the assessment?
5- prioritize the problem (Maslow's, safety, unstable)
6- formulate the Diagnostic Statement
Guide Review UPDATED ACTUAL Questions and
CORRECT Answers
The nursing process is: *a systematic problem solving approach (critical thinking)
*used to identify, prevent, & treat health problems, & promote wellness
*provide a structure for organizing info (data)
*to direct critical thinking
*to make sound nursing decisions (clinical judgment)
*to individualize nursing care
NCJMM Nursing Clinical Judgement Measurement Model
recognize cues, analyze cues, prioritize hypotheses, generate solutions, take action,
evaluate outcomes
step 1 of nursing process & 2 stages of it Assessment
stage 1 = collection & verification of data (cues)
stage 2 = analysis of data
Types of Assessment -the patient-centered interview during a nursing health history.
-a physical examination.
-the periodic assessments you make during rounding or administering care.
types of patient data subjective (what the pt. tells you)
objective (what the nurse observes/ measures)
Sources of Patient Data ● Primary Source
○ Patient
● Secondary Sources
○ Family and significant others
■ Primary if patient is unable
○ Health care team
○ Medical records
○ Other records and the scientific literature
○ Nurse's experience
Motivational Interviewing (MI) collaborative conversation style that promotes positive health behavior change
and strengthens an individual's motivation and commitment to change. MI uses
the OARS mnemonic (Open-ended questions, Affirmation, Reflective listening, and
Summarizing)
What are the different types of effective communication Verbal communication.
needed in health care? Non-verbal communication (or body language).
Written communication.
Formal communication.
,Parts of the patient-centered interview ● The nurse-patient relationship
● Understanding the patient's story
● Interview preparation
● Phases of an interview
○ Orientation & setting an agenda
○ working phase
○ termination
○ Immediate Reporting and documentation of assessment data
orientation phase of a pt-centered interview perform introductions with the patient, establish a rapport, establish boundaries,
and explain patient confidentiality.
working phase of a pt.-centered interview the nurse elicits the client's comments about major biographic data, reasons for
seeking care, history of present health concern, past health history, family history,
review of body systems for current health problems, lifestyle and health practices,
and developmental level.
termination phase of a pt-centered interview the nurse informs the patient that the interview is ending. As the interview ends,
the nurse and the patient will review the data gathered, highlighting key points and
ensuring all information is accurate.
Interview Techniques Observation
Open-ended questions
Leading questions
Back channeling
Probing
Direct closed-ended questions
, components of nursing health history biographical information,
reason for seeking health care(patient's statement is not diagnostic, it is perception),
patient expectations,
present illness or health concerns,
health history,
family history,
psychosocial history(stress coping, parent's support system), spiritual health,
review of systems(subject data),
diagnostic & labs,
observation of patient behavior
a cue is info you obtain through use of senses
an inference is your judgement or interpretation of cues
validating the data from a pt-centered interview *ensures collection of complete database
*leads to 2nd step of nursing process
data validation means checking the accuracy and quality of source data before using, importing or
otherwise processing data.
data clustering in the diagnostic reasoning process grouping related cues together to help identify patterns that will assist with the
indentification of a nursing diagnosis. signs and symptoms.
defining characteristics in the diagnostic reasoning are a format to facilitate the description of signs and symptoms of a response to an
process identified health problem which helps nurses diagnose what they need to intervene
2nd Step of Nursing Process nursing diagnosis (analyze cues & prioritize hypotheses)
*applying clinical judgement to cues & data we collected
Types of Diagnoses *Medical diagnosis (from HCP)
*Nursing Diagnosis (the nurse's clinical judgement about the pt. response to actual
or potential health conditions or needs)
*Collaborative problems (such as seizures, bleeding)
nursing diagnosis come from North American Nursing Diagnosis Association International (NANDA-I)
-currently over 244 diagnostic labels
-purposes of standard formal diagnostic statement (provides what nurse's scope of
practice is without HP orders)
-types of NANDA-I nursing diagnoses:
*risk-focused
*risk
*health promotion
Steps for Nursing Diagnostic Process 1- organize the data
2- cluster the data (what is normal/abnormal)
3- interpret the data & analyze cues
4- • Make initial inferences
• Validate the nursing diagnoses
• Does it fit the NANDA-I definition?
• Are the defining characteristics in the assessment?
5- prioritize the problem (Maslow's, safety, unstable)
6- formulate the Diagnostic Statement
