NUR 2115 FUNDAMENTALS OF NURSING EXAM 2 STUDY GUIDE
Fundamentals of nursing exam 2 study guide
Rasmussen summer ‘19
Module 4 – clinical judgement and nursing process
The nursing process - is a systematic method that directs the nurse and patient,
as together they accomplish the following: (1) assess the patient to determine
the need for nursing care, (2) determine nursing diagnoses for actual and
potential health problems, (3) identify expected out- comes and plan care, (4)
implement the care, and (5) evaluate the results.
• Systematically collect patient data (assessing) • Clearly identify patient
strengths and actual and potential problems (diagnosing) • Develop a holistic
plan of individualized care that specifies the desired patient goals and related
outcomes and the nursing interventions most likely to assist the patient to meet
those expected outcomes (planning) • Execute the plan of care
(implementing).
An example of the nursing process in action:
Assessing
You are checking on a patient who had abdominal surgery yesterday and hear that
the patient has considerable pain: “It kept me up all night.” The patient has been
reluctant to ask for any pain medication, fearing effects of the drug. “I don’t want
to become a junkie.” The patient’s blood pressure and pulse rate are slightly
elevated.
Diagnosing
You analyze the data just described and write the nursing diagnosis: Unrelieved
pain related to a fear of taking pain-relieving medications. The patient agrees that
this is becoming a problem.
Outcome Identification and Planning
,NUR 2115 FUNDAMENTALS OF NURSING EXAM 2 STUDY GUIDE
You decide to work with the patient to achieve the outcome: By 3:00 pm, patient
reports sufficient relief of pain to enable him to rest and to get out of bed to go to
the bathroom. The patient wants to accomplish the outcome. You identify teaching
as the primary nursing intervention.
Implementing
After asking the patient about his experiences with pain- relieving medications,
you explain that although many of these drugs are addictive when abused, there is
no harm if they are taken as prescribed postoperatively. You also explain that it is
important for him to experience enough pain relief to be able to cough and deep
breath, ambulate, and do other things important to his recovery. You suggest that
the medication will be most effective if taken before his pain peaks and becomes
intense. You administer the prescribed medication for pain when the patient
indicates that he is willing to give it a try.
Evaluating
After enough time has elapsed for the medication to take effect, you check back
with the patient to evaluate whether he has obtained relief and met his outcome. If
the patient is satisfied and you both feel that comfort is no longer a problem, you
terminate the plan of care for this diagnosis. If the patient still feels pain or is
dissatisfied with the medication, each of the preceding steps of the nursing process
is re-evaluated, and necessary changes are made in the plan of care.
Nursing process continues…
Assessing is the systematic and continuous collection, analysis, validation, and
communication of patient data, or information.
Assessing - Preparing for data collection • Collecting data • Indentifying cues and
making inferences • Validating data • Clustering related data and indentifying
patterns • Reporting and recording data
Types of assessments
Nursing assessments include:
, NUR 2115 FUNDAMENTALS OF NURSING EXAM 2 STUDY GUIDE
comprehensive initial assessment
focused assessment
emergency assessment
time-lapsed assessment
Initial assessment
The initial assessment is performed shortly after the patient is admitted to a
health care agency or service.
Focused Assessment
In a focused assessment, the nurse gathers data about a specific problem that
has already been identified. Helpful questions include:
• What are your signs and symptoms? • When did they start? • Were you doing
anything different than usual when they started? • What makes your symptoms
better? Worse? • Are you taking any remedies (medical or natural) for your
symptoms?
Emergency Assessment
When a physiologic or psychological crisis presents, the nurse performs an
emergency assessment to identify life- threatening problems. A long-term care
facility resident who begins choking in the dining room, a bleeding patient
brought to the emergency department with a stab wound, an unresponsive
patient in the rehabilitation unit, and a factory worker threatening violence are
all candidates for an emergency assessment.
Time-lapsed Assessment
The time-lapsed assessment is scheduled to compare a patient’s current status
to the baseline data obtained earlier. Most patients in residential settings and
those receiving nursing care over longer periods of time, such as home- bound
patients with visiting nurses, are scheduled for periodic time-lapsed assessments
to reassess their health status and to make necessary revisions in the plan of
care. This assessment can be comprehensive or focused
Collecting DATA
There are two types of data: subjective and objective.
Fundamentals of nursing exam 2 study guide
Rasmussen summer ‘19
Module 4 – clinical judgement and nursing process
The nursing process - is a systematic method that directs the nurse and patient,
as together they accomplish the following: (1) assess the patient to determine
the need for nursing care, (2) determine nursing diagnoses for actual and
potential health problems, (3) identify expected out- comes and plan care, (4)
implement the care, and (5) evaluate the results.
• Systematically collect patient data (assessing) • Clearly identify patient
strengths and actual and potential problems (diagnosing) • Develop a holistic
plan of individualized care that specifies the desired patient goals and related
outcomes and the nursing interventions most likely to assist the patient to meet
those expected outcomes (planning) • Execute the plan of care
(implementing).
An example of the nursing process in action:
Assessing
You are checking on a patient who had abdominal surgery yesterday and hear that
the patient has considerable pain: “It kept me up all night.” The patient has been
reluctant to ask for any pain medication, fearing effects of the drug. “I don’t want
to become a junkie.” The patient’s blood pressure and pulse rate are slightly
elevated.
Diagnosing
You analyze the data just described and write the nursing diagnosis: Unrelieved
pain related to a fear of taking pain-relieving medications. The patient agrees that
this is becoming a problem.
Outcome Identification and Planning
,NUR 2115 FUNDAMENTALS OF NURSING EXAM 2 STUDY GUIDE
You decide to work with the patient to achieve the outcome: By 3:00 pm, patient
reports sufficient relief of pain to enable him to rest and to get out of bed to go to
the bathroom. The patient wants to accomplish the outcome. You identify teaching
as the primary nursing intervention.
Implementing
After asking the patient about his experiences with pain- relieving medications,
you explain that although many of these drugs are addictive when abused, there is
no harm if they are taken as prescribed postoperatively. You also explain that it is
important for him to experience enough pain relief to be able to cough and deep
breath, ambulate, and do other things important to his recovery. You suggest that
the medication will be most effective if taken before his pain peaks and becomes
intense. You administer the prescribed medication for pain when the patient
indicates that he is willing to give it a try.
Evaluating
After enough time has elapsed for the medication to take effect, you check back
with the patient to evaluate whether he has obtained relief and met his outcome. If
the patient is satisfied and you both feel that comfort is no longer a problem, you
terminate the plan of care for this diagnosis. If the patient still feels pain or is
dissatisfied with the medication, each of the preceding steps of the nursing process
is re-evaluated, and necessary changes are made in the plan of care.
Nursing process continues…
Assessing is the systematic and continuous collection, analysis, validation, and
communication of patient data, or information.
Assessing - Preparing for data collection • Collecting data • Indentifying cues and
making inferences • Validating data • Clustering related data and indentifying
patterns • Reporting and recording data
Types of assessments
Nursing assessments include:
, NUR 2115 FUNDAMENTALS OF NURSING EXAM 2 STUDY GUIDE
comprehensive initial assessment
focused assessment
emergency assessment
time-lapsed assessment
Initial assessment
The initial assessment is performed shortly after the patient is admitted to a
health care agency or service.
Focused Assessment
In a focused assessment, the nurse gathers data about a specific problem that
has already been identified. Helpful questions include:
• What are your signs and symptoms? • When did they start? • Were you doing
anything different than usual when they started? • What makes your symptoms
better? Worse? • Are you taking any remedies (medical or natural) for your
symptoms?
Emergency Assessment
When a physiologic or psychological crisis presents, the nurse performs an
emergency assessment to identify life- threatening problems. A long-term care
facility resident who begins choking in the dining room, a bleeding patient
brought to the emergency department with a stab wound, an unresponsive
patient in the rehabilitation unit, and a factory worker threatening violence are
all candidates for an emergency assessment.
Time-lapsed Assessment
The time-lapsed assessment is scheduled to compare a patient’s current status
to the baseline data obtained earlier. Most patients in residential settings and
those receiving nursing care over longer periods of time, such as home- bound
patients with visiting nurses, are scheduled for periodic time-lapsed assessments
to reassess their health status and to make necessary revisions in the plan of
care. This assessment can be comprehensive or focused
Collecting DATA
There are two types of data: subjective and objective.
