N204 exam 2(100% Correct answers)
The Nursing Process correct answersA dynamic, systematic clinical management tool that
functions as the primary means of directing the sequence, planning, implementation, and
evaluation of nursing care to achieve specific health goals.
What are the different steps in the nursing process? correct answersAssessment, diagnosis,
planning, implementing, and evaluation
What is the assessment phase? correct answersThe collection, analysis, and verification of data.
What information is collected in the assessment phase? correct answerscurrent and past
problems, the patient's perception of his or her health patterns, Relevant social, occupational,
medical and psychiatric history (ex. Previous hospitalizations, medical and psychiatric treatment,
medications, The patient's coping patterns and the level and availability of the patient's support
system
What is subjective data? correct answerspatient's perception of data & what patient or family
says about the data. Document: Patient states, "..."
What is objective data? correct answersdata directly observed or verified through physical exams
or tests. Document in specific measurable terms.
When caring for a patient what is number one priority? correct answersMost immediate, life
threatening problem
Diagnosis phase? correct answersA clinical judgment about individual, family or community
responses to actual or potential health problems/ life processes.
What do you do during the diagnosis phase? correct answersAnalyze collected data, identify
gaps, formulate nursing diagnosis.
What is a problem-focused ND? correct answersHuman response to health conditions/life
processes that can exist in an individual, family, or community.
How do you write a problem focused ND? correct answersInclude the Problem - label or
"diagnostic label", Cause - etiology or "related to" factor (R/T), and Evidence - signs &
symptoms - "as evidenced by" (AEB)
What is a risk and high risk ND? correct answersHuman response to health conditions/life
processes that may develop in a vulnerable individual, family, or community.
How do you write a risk and high risk ND? correct answersIncludes the words Risk for +
Problem and Cause r/t
What is a possible ND? correct answersDescribe a suspected problem requiring additional data
to confirm or rule out (r/o).
, How do you write a possible ND? correct answersIncludes the word Possible + Problem and
cause r/t
What is a health promotion ND? correct answersA clinical judgment of a person's, family's, or
community's motivation and desire to increase well-being and actualize human health potential
as expressed in the readiness to enhance specific health behaviors, such as nutrition and exercise.
How do you write a health promotion ND? correct answersIncludes the words, "Readiness for
enhanced" + Problem (NO R/T)
What is a syndrome ND? correct answersComprise a cluster of predicted problem-focused
(actual) or high-risk ND related to a certain event or situation.
How do you write a syndrome ND? correct answersProblem + the word syndrome. No r/t
What is a Risk for Complications ND? correct answersnurses monitor the patient's condition and
responses to help prevent or reduce complications related to the Medical Diagnosis (MD)
How do you write a risk for complications ND? correct answersInclude the abbreviation RC of +
physiologic condition (no r/t)
What do you do during the planning phase? correct answersNurses & patients mutually decide
on a plan of care (POC) and anticipated outcomes.
What is the planning phase based on? correct answersassessment data of patient needs, strengths,
and resources.
BMCT correct answersbehavior, measurable, condition, and time
What do you include during outcome statements? correct answersWho, behavior (what action
must the patient take), measurable (how well they are doing), condition (under what
circumstances), and time (by when)
What occurs during the implementation phase? correct answersTaking agreed-on action to alter a
patient's status/ symptoms.
What does the implementation phase consist of? correct answersEncouraging, supporting, and
validating the patient to achieve goals through integrated therapeutic nursing interventions and
communication strategies.
What occurs during the evaluation phase? correct answersNurse & patient mutually evaluate
attainment of expected outcomes & survey each step of the NP.
What are the components to nursing intervention? correct answersGiving direct physical or
indirect care, Providing support to patients/families, Teaching health or management of disorder,
The Nursing Process correct answersA dynamic, systematic clinical management tool that
functions as the primary means of directing the sequence, planning, implementation, and
evaluation of nursing care to achieve specific health goals.
What are the different steps in the nursing process? correct answersAssessment, diagnosis,
planning, implementing, and evaluation
What is the assessment phase? correct answersThe collection, analysis, and verification of data.
What information is collected in the assessment phase? correct answerscurrent and past
problems, the patient's perception of his or her health patterns, Relevant social, occupational,
medical and psychiatric history (ex. Previous hospitalizations, medical and psychiatric treatment,
medications, The patient's coping patterns and the level and availability of the patient's support
system
What is subjective data? correct answerspatient's perception of data & what patient or family
says about the data. Document: Patient states, "..."
What is objective data? correct answersdata directly observed or verified through physical exams
or tests. Document in specific measurable terms.
When caring for a patient what is number one priority? correct answersMost immediate, life
threatening problem
Diagnosis phase? correct answersA clinical judgment about individual, family or community
responses to actual or potential health problems/ life processes.
What do you do during the diagnosis phase? correct answersAnalyze collected data, identify
gaps, formulate nursing diagnosis.
What is a problem-focused ND? correct answersHuman response to health conditions/life
processes that can exist in an individual, family, or community.
How do you write a problem focused ND? correct answersInclude the Problem - label or
"diagnostic label", Cause - etiology or "related to" factor (R/T), and Evidence - signs &
symptoms - "as evidenced by" (AEB)
What is a risk and high risk ND? correct answersHuman response to health conditions/life
processes that may develop in a vulnerable individual, family, or community.
How do you write a risk and high risk ND? correct answersIncludes the words Risk for +
Problem and Cause r/t
What is a possible ND? correct answersDescribe a suspected problem requiring additional data
to confirm or rule out (r/o).
, How do you write a possible ND? correct answersIncludes the word Possible + Problem and
cause r/t
What is a health promotion ND? correct answersA clinical judgment of a person's, family's, or
community's motivation and desire to increase well-being and actualize human health potential
as expressed in the readiness to enhance specific health behaviors, such as nutrition and exercise.
How do you write a health promotion ND? correct answersIncludes the words, "Readiness for
enhanced" + Problem (NO R/T)
What is a syndrome ND? correct answersComprise a cluster of predicted problem-focused
(actual) or high-risk ND related to a certain event or situation.
How do you write a syndrome ND? correct answersProblem + the word syndrome. No r/t
What is a Risk for Complications ND? correct answersnurses monitor the patient's condition and
responses to help prevent or reduce complications related to the Medical Diagnosis (MD)
How do you write a risk for complications ND? correct answersInclude the abbreviation RC of +
physiologic condition (no r/t)
What do you do during the planning phase? correct answersNurses & patients mutually decide
on a plan of care (POC) and anticipated outcomes.
What is the planning phase based on? correct answersassessment data of patient needs, strengths,
and resources.
BMCT correct answersbehavior, measurable, condition, and time
What do you include during outcome statements? correct answersWho, behavior (what action
must the patient take), measurable (how well they are doing), condition (under what
circumstances), and time (by when)
What occurs during the implementation phase? correct answersTaking agreed-on action to alter a
patient's status/ symptoms.
What does the implementation phase consist of? correct answersEncouraging, supporting, and
validating the patient to achieve goals through integrated therapeutic nursing interventions and
communication strategies.
What occurs during the evaluation phase? correct answersNurse & patient mutually evaluate
attainment of expected outcomes & survey each step of the NP.
What are the components to nursing intervention? correct answersGiving direct physical or
indirect care, Providing support to patients/families, Teaching health or management of disorder,
