GINERA

SUBJECT: NURSING FOUNDATION

TOPIC: ASSINGMENT
SUBTOPIC: UNIT 2 – NURSING PROCESS
(SOLVED PYQ)
SUBMITTED TO: MRS. SUHASINI MA’AM
CLASS 1 LACTURER
HOD OF FY BSC NURSING
GINERA, AHMEDABAD

SUBMITTED BY:
GROUP-2
ROLL NO. 9 TO 14
SUBMITTED ON: 17-07-2023
 MCQ (1 mark)
1. When considering the nursing process , the word
"observe" is to "assess" as the word "explore" is to
which of the following words ?
A. Plan
B. Analyze
C. Evaluate
D. Implement
Answer: B. Analyze

2. Which word best describes the role of the nurse

when using the nursing process to meet the needs of
the patient holistically?
A. Teacher
B. Advocate
C. Surrogate
D. Counselor
Answer: B. Advocate

3. A nurse teaches a patient to use visualization to cope

with chronic pain. Which step of the nursing process
is associated with this nursing intervention?
 A. Planning
B. Analysis
C. Evaluation
D. Implementation
Answer: D. Implementation
4. A pebble dropped into a pond causes ripples on the
surface of the water. Which part of the nursing
diagnosis is directly related to this concept?
A. Defining Characteristics
B. Outcome criteria
C. Etiology
D. Goal
Answer: C. Etiology
5. During which step of the nursing process does
determining which actions will be employed to meet
the needs of a patient occur?
A. Implementation
B. Assessment
C. Planning
D. Analysis
Answer: C. Planning
6. A nurse concludes that a patient's elevated
temperature, pulse and respirations are significant.
Which step of the nursing process is being used
when the nurse comes to this conclusion?
A.Implementation
B. Assessment
C. Evaluation
D.Analysis
Answer: D. Analysis
7. When the nurse considers the nursing process, the
word 'identify' is to 'recognize' as the word 'do' is to
which of the following words?
A.Plan
B. Analyze
C. Evaluate
D.Implement
Answer: D. Implement
8. A nurse is interviewing a patient. Which patient
statements are examples of objective data? Select all
that apply
A.'I am hungry '
 B. ' I feel very warm
C. ' I ate half my lunch . '
D.' I have a rash on my arm . "
E. ' I have the urge to urinate . '
F. ' I vomit every time I eat something . '
Answer:
A.' I ate half my lunch .
B. ' I have a rash on my arm . '
C. ' I vomit every time I eat something . '

9. The nurse assesses a patient and collects a variety of

data. Identify the human responses that are
subjective data. Select all that apply
A.Nausea
B. Jaundice
C. Dizziness
D.Diaphoresis
E. Hypotension
Answer:
A.Nausea
B. Dizziness
10. A nurse assesses that a patient has slurred
speech and a retained bolus of food in the mouth.
 The presence of which additional patient
assessments should be clustered with this group of
signs and symptoms? Select all that apply
A.Dyspepsia
B. Coughing
C. Drooling
D.Gurgling
E. Plaque
Answer: B. Coughing
11. A nurse concludes that a patient's elevated
temperature, pulse and respirations are significant .
Which step of the nursing process is being used
when the nurse comes to this conclusion?
A.Implementation
B. Assessment
C. Evaluation
D.Analysis
Answer: D. Analysis
12. Which statement is related to the concept that
is central to the nursing process.
A.It is dynamic rather than static.
 B. It focuses on the role of the nurse.
C. It moves from the simple to the complex.
D.It is based on the patient's medical problem.
Answer: A. It is dynamic rather than static.
13. A nurse collects information about a patient.
Which should the nurse do next?
A.Plan nursing interventions
B. Write patient - centered goals
C. Formulate nursing diagnosis
D.Determine significance of the data
Answer: D. Determine significance of the data

 Short answer (2marks)

1. define nursing diagnosis (2021)
Answer:
"Nursing diagnosis is defined as a clinical
judgment about individual , family or community
responses to actual and potential health / life
processes . Nursing diagnosis provides the basis for
 selection of nursing interventions to achieve
outcomes for which the nurse is accountable. "
-North American Nursing Diagnosis
Association (NANDA)
2. Define nursing process (2020)
Answer:
"The nursing process is a critical thinking
process that professional nurses use to apply the best
available evidence to caregiving and promoting human
functions and responses to health and illness."
-American Nurses Association, 2010
"Nursing process is a set of actions used to
determine, plan, implement and evaluate nursing care "
"Nursing process is a scientific problem -
solving model, uses the steps of assessment, nursing
diagnosis or problem identification planning,
implementation, and evaluation in a step - by - step
process to plan care for patients"
3. Method of physical assessment (2012/2018/2013)
Answer:
Physical Assessment
 The purpose of the nursing physical assessment
include the assessment of health status, the
identification of health problems, and the
establishment of a database for nursing
interventions.
 The nursing physical assessment involves the
examination of all body systems in a systematic
manner, commonly using a head - to - toe
format or body system - wise assessment. Four
basic methods are used to collect data during
the physical assessment are as following (For
details refer chapter of physical examination)
 Inspection: The process of performing
deliberate, purposeful observations in a
systematic manner.
 Palpation: Use of the sense of touch to assess
skin temperature, turgor, texture, and moisture
as well as vibrations within the body. It is
further of two types - light and deep palpation.
 Percussion: The act of striking one object
against another to produce specific sound to
identify presence of air, liquid or solid.
  Auscultation: The act of listening sounds with a
stethoscope produced within the body. It is
commonly used for assessment of
cardiovascular, respiratory and gastrointestinal
system.

4. Write any 4 position use in physical assessment

(2016)
Answer:
Here are four common positions used in physical
assessments:

1. Supine Position: The supine position is when the

patient lies flat on their back with their face upward.
This position allows for the examination of the front
of the body, including the chest, abdomen, and
lower extremities.

2. Prone Position: The prone position is when the

patient lies flat on their stomach with their face
downward. This position is often used to examine
the back, spine, and buttocks.
3. Sitting Position: The sitting position involves the
patient sitting upright on a chair or examination
table. This position allows for the assessment of vital
signs, lung function, and upper body mobility. It is
also useful for evaluating the head, neck, and upper
extremities.

4. Lateral Recumbent Position: The lateral

recumbent position, also known as the side-lying
position, is when the patient lies on their side with
their knees slightly bent. This position is often used
for examining the spine, hips, and lower extremities.
It also allows for the assessment of the
cardiovascular system, as well as the auscultation of
the lungs.

These positions provide healthcare professionals

with access to different areas of the body during
physical assessments, allowing for a comprehensive
evaluation of a patient's health status.
  Short note (5marks)
1. Methods of recording and reporting.(2020)
Answer:
Recording and reporting are essential aspects of nursing
practice, ensuring accurate and comprehensive
documentation of patient care. Here are some common
methods used in recording and reporting in nursing:

1. Written Documentation: This is the traditional method

of recording patient information using pen and paper or
typed entries. Nurses write down details of patient
assessments, interventions, medications administered,
vital signs, and any changes in the patient's condition.
Written documentation should be clear, concise, and
follow organizational guidelines and standards.

2. Electronic Health Records (EHRs): With the

widespread adoption of technology in healthcare,
electronic health records have become increasingly
common. EHRs allow nurses to input and access patient
information digitally. This method provides benefits such
as easy retrieval, legibility, and the ability to share
information across different healthcare settings.

3. Flowcharts and Diagrams: Flowcharts and diagrams

are visual tools that help nurses depict complex
processes or care pathways. They are often used to
document and communicate care plans, medication
administration routes, wound care procedures, or the
sequence of nursing interventions. These visual aids
improve clarity and promote consistency in practice.

4. Handover and Shift Reports: Nurses regularly hand

over patient care responsibilities to incoming shifts or
healthcare providers. Handover reports provide a
summary of the patient's condition, recent events,
ongoing care needs, and any changes in treatment plans.
These reports should be accurate, concise, and contain
important details to ensure continuity of care.
5. Verbal Communication: While written documentation
is crucial, verbal communication is equally important,
especially in urgent or critical situations. Nurses often
communicate directly with healthcare providers,
interdisciplinary teams, or during patient rounds. Verbal
reports should be clear, concise, and focused on essential
information to facilitate effective communication and
collaboration.

6. Incident Reports: Incident reports are used to

document any unexpected events, errors, or incidents
that occur during patient care. This includes falls,
medication errors, equipment malfunctions, or any
adverse events. Incident reports help identify potential
areas for improvement and serve as a tool for risk
management and quality improvement.

When recording and reporting in nursing, accuracy,

objectivity, and timeliness are vital. Nurses must adhere
to legal and ethical guidelines, maintain confidentiality,
and ensure that documentation reflects the patient's
condition and the care provided accurately. Effective
recording and reporting contribute to safe and high-
quality patient care, promote continuity of care, and
facilitate communication among healthcare providers.
2. Difference between medical diagnosis and a nursing
diagnosis. (2017,2011)
Answer:
Medical Diagnosis:
A medical diagnosis refers to the identification of a
disease, illness, or condition based on a patient's signs,
symptoms, medical history, physical examination, and
diagnostic tests. It is made by a physician or other
healthcare provider with expertise in diagnosing and
treating medical conditions. Medical diagnoses are
typically based on the underlying pathological processes
and are classified using standardized systems such as the
International Classification of Diseases (ICD). Medical
diagnoses guide the treatment and management of the
specific disease or condition.

Nursing Diagnosis:
On the other hand, a nursing diagnosis is a clinical
judgment made by a registered nurse (RN) about a
patient's response to a health problem. It focuses on the
patient's actual or potential physiological, psychological,
social, and spiritual responses to an illness or health
condition. Nursing diagnoses are standardized and
classified using standardized systems such as the NANDA
International (NANDA-I) nursing diagnosis taxonomy.
Nursing diagnoses help nurses identify and prioritize the
patient's unique needs, develop appropriate nursing
interventions, and evaluate the outcomes of nursing
care.

 Here are a few key differences between medical

diagnosis and nursing diagnosis:

1. Purpose: The purpose of a medical diagnosis is to

identify and classify the disease or condition affecting the
patient. It guides the medical treatment plan. In contrast,
the purpose of a nursing diagnosis is to identify the
patient's response to the health problem and develop
individualized nursing interventions to address those
responses.

2. Scope: Medical diagnoses focus on the disease or

condition itself, its causes, pathophysiology, and medical
interventions. Nursing diagnoses consider the patient as
a whole, including physical, psychological, social, and
spiritual aspects, and focus on how the patient is
responding to the illness or condition.

3. Provider: Medical diagnoses are made by physicians or

other healthcare providers with diagnostic authority.
Nursing diagnoses are made by registered nurses based
on their assessment, clinical judgment, and knowledge of
nursing theory and practice.

4. Classification Systems: Medical diagnoses are

classified using systems such as the International
Classification of Diseases (ICD). Nursing diagnoses are
classified using systems such as NANDA International
(NANDA-I) nursing diagnosis taxonomy.
5. Treatment Focus: Medical diagnoses guide medical
treatments and interventions, such as medications,
surgeries, or other medical procedures. Nursing
diagnoses guide nursing interventions aimed at
promoting the patient's health, managing symptoms,
providing comfort, and facilitating the patient's overall
well-being.

It's important to note that medical diagnosis and nursing

diagnosis are complementary and interdependent. The
medical diagnosis provides the foundation for medical
treatment, while the nursing diagnosis focuses on the
patient's unique responses and guides the delivery of
nursing care to promote optimal health outcomes.
3. Write a short note on Nursing assessment (20122)
Answer:
Nursing assessment is a systematic and
comprehensive process of gathering patient
information to identify their healthcare needs,
establish a baseline for care, and develop an
 individualized nursing care plan. It involves the
collection, analysis, and interpretation of data
related to the patient's physical, psychological,
social, and spiritual health.

 Here are some key aspects of nursing assessment:

1. Purpose: The primary purpose of nursing

assessment is to gather data about the patient's
current health status, including their physical,
emotional, and social well-being. This information
helps nurses identify actual and potential health
problems, formulate nursing diagnoses, and develop
appropriate interventions to promote the patient's
well-being.

2. Components of Nursing Assessment:

a. Health History: Nurses collect a comprehensive

health history by interviewing the patient or their
family members. This includes information about the
patient's past medical history, current medications,
allergies, lifestyle habits, family history, and
psychosocial factors.

b. Physical Examination: Nurses perform a physical

examination to assess the patient's overall physical
health. This involves observing, palpating,
auscultating, and percussing various body systems to
identify abnormalities, assess vital signs, and gather
objective data.

c. Subjective Data: Nurses gather subjective data

through open-ended questioning, allowing the
patient to describe their symptoms, feelings,
concerns, and experiences. This information
provides insights into the patient's perception of
their health and guides nursing interventions.

d. Objective Data: Objective data is obtained

through direct observation, measurement, and
physical examination findings. It includes vital signs,
laboratory results, diagnostic test reports, wound
assessments, and other measurable data.
 e. Psychosocial Assessment: Nurses assess the
patient's mental and emotional well-being, including
their cognitive function, emotional state, social
support systems, coping mechanisms, and cultural
considerations. This helps identify factors that may
impact the patient's health and care.

3. Techniques and Tools: Nurses use various

techniques and tools during the assessment process.
This includes interviewing skills, observation
techniques, physical assessment tools (such as
stethoscope, blood pressure cuff, thermometer), and
screening questionnaires or assessment forms
specific to certain conditions or populations.

4. Documentation: Accurate and thorough

documentation of nursing assessment findings is
crucial. Nurses record their observations, subjective
and objective data, and interpret the data to
formulate nursing diagnoses. Documentation
ensures continuity of care, supports communication
among healthcare providers, and serves as legal and
professional records.
 5. Ongoing Assessment: Nursing assessment is an
ongoing process that continues throughout the
patient's care. Nurses reassess the patient regularly
to monitor changes in their condition, evaluate the
effectiveness of interventions, and update the
nursing care plan accordingly.

Nursing assessment forms the foundation for

nursing care planning, implementation, and
evaluation. It helps nurses develop a holistic
understanding of the patient's health status,
prioritize care needs, and collaborate with the
healthcare team to provide patient-centered care.
By gathering comprehensive and accurate data,
nursing assessment contributes to improved patient
outcomes and enhanced quality of care.

4. Enlist the Steps in nursing process.

Answer:
The nursing process is a systematic problem-solving
framework used by nurses to provide individualized
and holistic care to patients. It consists of several
steps that guide the nurse in assessing, diagnosing,
planning, implementing, and evaluating patient care.
Here are the five steps in the nursing process:

1. Assessment:
The assessment phase involves gathering
comprehensive and accurate information about the
patient's physical, psychological, social, and spiritual
health. The nurse collects data through interviews,
health history, physical examination, observation,
and review of medical records and diagnostic test
results. The information collected during the
assessment forms the basis for understanding the
patient's health needs and identifying any actual or
potential problems.

2. Diagnosis:
In the diagnosis phase, the nurse analyzes and
interprets the data collected during the assessment
to identify nursing diagnoses. Nursing diagnoses are
clinical judgments about the patient's responses to
actual or potential health problems. These diagnoses
provide a framework for planning appropriate
nursing interventions. Nurses use standardized
nursing diagnosis taxonomies, such as NANDA
International (NANDA-I), to label and classify the
identified nursing diagnoses.

3. Planning:
The planning phase involves developing a
comprehensive care plan based on the identified
nursing diagnoses. The nurse collaborates with the
patient, their family, and other healthcare
professionals to establish goals and outcomes that
are realistic, measurable, and achievable. Nursing
interventions are then selected and documented to
address the identified problems and promote the
patient's well-being. The care plan should be
individualized and consider the patient's
preferences, values, and cultural beliefs.

4. Implementation:
During the implementation phase, the nurse carries
out the planned nursing interventions. This includes
providing direct patient care, administering
medications, assisting with activities of daily living,
educating the patient and their family, and
coordinating and collaborating with other healthcare
team members. The interventions are implemented
according to the established care plan and evidence-
based practice guidelines. The nurse ensures that
interventions are performed safely, effectively, and
with respect for the patient's dignity and autonomy.

5. Evaluation:
In the evaluation phase, the nurse assesses the
patient's response to the nursing interventions and
determines the effectiveness of the care provided.
The nurse compares the achieved outcomes with the
expected outcomes and identifies any deviations or
areas for improvement. Based on the evaluation,
modifications may be made to the care plan as
necessary. Evaluation is an ongoing process and
helps to guide subsequent cycles of the nursing
process.

It is important to note that the nursing process is

cyclical and dynamic. Nurses continually assess,
diagnose, plan, implement, and evaluate care as the
 patient's condition changes or new information
becomes available. The nursing process promotes
systematic and patient-centered care, enhances
communication and collaboration among healthcare
providers, and improves patient outcomes.

5. Explain ASSESMENT as first step of Nursing process.

Answer:
Assessment is the first step of the nursing process
and serves as the foundation for providing quality
and individualized patient care. It involves
systematically gathering information about the
patient's health status, needs, and preferences
through various data collection methods. The
assessment process allows nurses to gain a
comprehensive understanding of the patient,
identify health issues, and make informed clinical
judgments.

Here are key aspects of the assessment phase in the

nursing process:

1. Data Collection:
The nurse collects data using a variety of methods,
including interviews, health history, physical
examination, observation, and review of medical
records and diagnostic test results. Data can be
subjective (based on the patient's perception and
verbal expression) or objective (measurable and
observable findings). The nurse collects information
about the patient's current health status, medical
history, medications, allergies, lifestyle habits, social
support systems, and any specific concerns or
complaints.

2. Organizing and Documenting Data:

Once data is collected, the nurse organizes and
documents it in a systematic and structured manner.
This helps to ensure accuracy, consistency, and ease
of access for future reference. Common
documentation methods include electronic health
records (EHRs), standardized assessment forms, or
nursing notes. It is important to document both
subjective and objective data accurately and
objectively to provide a comprehensive overview of
the patient's health.
3. Data Analysis and Interpretation:
After collecting and organizing the data, the nurse
analyzes and interprets it to identify patterns,
trends, and potential health issues. This involves
critically thinking about the significance of the
collected data, recognizing normal and abnormal
findings, and identifying actual or potential nursing
diagnoses. The nurse uses clinical judgment and
evidence-based practice guidelines to analyze the
data and make informed decisions regarding the
patient's care needs.

4. Validating Data:
Data validation is an important step in the
assessment process. The nurse verifies the accuracy
and completeness of the collected data by cross-
checking information with the patient, other
healthcare providers, or additional resources. This
helps to ensure that the assessment findings are
reliable and valid.

5. Prioritizing Needs:
Based on the analysis of data, the nurse prioritizes
the patient's needs. This involves identifying the
most urgent and significant problems that require
immediate attention. Prioritization is essential for
effective care planning and ensures that resources
and interventions are allocated appropriately.

6. Communication and Collaboration:

Throughout the assessment process, effective
communication and collaboration with the patient,
their family, and other healthcare team members
are crucial. The nurse actively listens to the patient,
shows empathy, and establishes a trusting
relationship. Collaboration with other healthcare
professionals allows for a comprehensive
understanding of the patient's health and facilitates
coordinated care.

By conducting a thorough assessment, nurses gather

crucial information that guides subsequent steps in
the nursing process, such as diagnosing, planning,
implementing, and evaluating care. Assessment
provides the nurse with a holistic view of the
 patient's health, identifies individualized care needs,
and lays the groundwork for providing safe,
effective, and patient-centered care.

6. explain the types and sources of Data Collection

Answer:
In nursing, data collection involves gathering
information about a patient's health status, needs,
and preferences. There are various types and
sources of data collection methods utilized to obtain
comprehensive and accurate information. Here are
some common types and sources of data collection
in nursing:

1. Subjective Data:
Subjective data refers to information that is reported
by the patient, their family members, or caregivers.
This type of data is based on the patient's
perceptions, feelings, and verbal expressions.
Examples of subjective data include symptoms, pain
descriptions, emotions, beliefs, and preferences.
Subjective data is typically obtained through
interviews, conversations, and open-ended
questions, allowing the patient to express their
experiences and perspectives.

2. Objective Data:
Objective data refers to measurable and observable
findings obtained through clinical observations,
physical examinations, and diagnostic tests. It
includes vital signs (such as blood pressure, heart
rate, and temperature), laboratory results, physical
assessment findings (such as skin color, breathing
sounds, or range of motion), and imaging studies.
Objective data is important for obtaining a
comprehensive and evidence-based view of the
patient's health status.

3. Health History:
A health history is a systematic collection of
information about a patient's past and current
health. It includes details about medical conditions,
surgeries, allergies, medications, immunization
history, family medical history, lifestyle habits, and
social factors. Health history is typically obtained
through interviews with the patient, family
members, or review of medical records.

4. Physical Examination:
Physical examination involves a systematic
assessment of the patient's body systems to gather
objective data. It includes techniques such as
inspection, palpation, percussion, and auscultation
to identify abnormalities, assess organ function, and
gather relevant physical findings. Physical
examination findings help nurses determine the
patient's overall health status and identify potential
health issues.

5. Diagnostic Tests and Procedures:

Diagnostic tests and procedures are ordered to
gather specific information about a patient's health.
These may include blood tests, imaging studies (such
as X-rays or CT scans), electrocardiograms (ECGs),
biopsies, or other specialized tests. The results of
these tests provide objective data and assist in
diagnosing and monitoring the patient's condition.
6. Health Records and Documentation:
Health records, including electronic health records
(EHRs) and paper-based records, serve as valuable
sources of data. These records contain essential
information about the patient's medical history,
previous treatments, laboratory results, diagnostic
reports, medications, and progress notes. Nurses
review health records to gather comprehensive and
up-to-date information about the patient.

7. Reports and Communication:

Communication with other healthcare professionals,
including physicians, specialists, and interdisciplinary
team members, provides valuable information about
the patient. Reports from these individuals, including
progress notes, handover reports, and consultations,
contribute to the overall data collection process.

8. Patient and Family Interviews:

Engaging in open and meaningful conversations with
the patient and their family members provides
valuable insights into the patient's experiences,
preferences, and concerns. These interviews help
 gather subjective data, understand the patient's
psychosocial well-being, and support person-
centered care.

By utilizing various types and sources of data

collection, nurses obtain a holistic view of the
patient's health and develop individualized care
plans. It is important for nurses to gather data from
multiple sources, validate information when
necessary, and maintain accurate documentation to
ensure high-quality and patient-centered care.
7. Describe various methods of data Collection.
Answer:
In nursing, there are several methods of data
collection used to gather information about a
patient's health status, needs, and preferences.
These methods vary in their approach and can be
tailored to suit the specific situation and the nature
of the data being collected. Here are some common
methods of data collection in nursing:

1. Interviews:
Interviews involve direct communication with the
patient, their family members, or caregivers. Nurses
use open-ended and closed-ended questions to
gather information about the patient's symptoms,
medical history, lifestyle habits, psychosocial factors,
and preferences. Interviews allow for a
comprehensive understanding of the patient's
experiences and perspectives.

2. Questionnaires and Surveys:

Questionnaires and surveys involve structured sets
of questions that patients or individuals complete
independently. These tools are designed to collect
standardized information and can be paper-based or
electronically administered. Questionnaires and
surveys are useful for gathering specific information
about a patient's symptoms, functional status,
quality of life, or satisfaction with care.

3. Observations:
Observations involve the systematic and objective
examination of a patient's physical appearance,
behavior, and environment. Nurses observe vital
signs, physical assessment findings, pain behaviors,
mobility, hygiene, and other observable factors.
Observations provide valuable objective data that
contributes to the overall assessment of the patient.

4. Physical Examination:
Physical examination involves a systematic
assessment of the patient's body systems,
performed by a nurse or healthcare provider. It
includes techniques such as inspection, palpation,
percussion, and auscultation to gather objective data
about the patient's physical health. Physical
examination findings help identify abnormalities,
determine organ function, and contribute to
diagnosis and care planning.

5. Diagnostic Tests and Procedures:

Diagnostic tests and procedures, ordered by
healthcare providers, provide objective data about a
patient's health status. These may include blood
tests, imaging studies, electrocardiograms (ECGs),
biopsies, or specialized tests. Nurses collect data by
reviewing and interpreting the results of these tests
to inform nursing care.

6. Review of Health Records:

Reviewing health records, including electronic health
records (EHRs) and paper-based records, provides a
comprehensive overview of the patient's medical
history, previous treatments, laboratory results,
diagnostic reports, medications, and progress notes.
Nurses collect data by examining the patient's health
records to gain insight into their health status and
care needs.

7. Focus Groups or Patient Consultations:

Focus groups or patient consultations involve
gathering a group of patients or individuals with
similar health conditions to discuss their
experiences, needs, and preferences. These group
discussions or consultations provide valuable
qualitative data, allowing nurses to gain a deeper
understanding of the patient's perspectives and
identify common issues or themes.
 8. Literature Review:
Literature review involves conducting a thorough
review of relevant research studies, articles, or
published literature on a specific topic or condition.
Nurses collect data by examining existing evidence-
based practice guidelines, scholarly publications, and
research findings. Literature reviews contribute to
the development of evidence-based nursing care
and inform decision-making.

It is important for nurses to select the most

appropriate method of data collection based on the
specific context and the information being sought.
Combining multiple methods can provide a
comprehensive and holistic understanding of the
patient's health status and care needs.

8. Explain the steps of Nursing Care plan for a client

with suitable example.
Answer:
Developing a nursing care plan involves a systematic
approach to provide individualized care to a client. It
consists of several steps that guide nurses in
identifying the client's needs, formulating nursing
diagnoses, establishing goals, planning interventions,
and evaluating the outcomes of care. Here are the
steps of a nursing care plan along with a suitable
example:

1. Assessment:
Assess the client's health status by collecting data
through interviews, physical examinations, and
review of medical records. For example, a nurse
assesses a client with diabetes who presents with
high blood sugar levels, polyuria (excessive
urination), and increased thirst. The nurse collects
data about the client's medical history, current
medications, dietary habits, and glucose monitoring
results.

2. Diagnosis:
Analyze and interpret the collected data to identify
nursing diagnoses. Nursing diagnoses are clinical
judgments about the client's responses to actual or
potential health problems. In the example of the
client with diabetes, the nurse identifies the nursing
diagnosis of "Risk for Unstable Blood Glucose Level
related to inadequate knowledge about diabetes
management."

3. Planning:
Establish goals and outcomes in collaboration with
the client. Goals are broad statements that describe
the desired change or outcome, while outcomes are
specific, measurable, realistic, and time-bound. For
the client with diabetes, a goal could be "Maintain
stable blood glucose levels within the target range."
An outcome could be "Client will demonstrate
proper self-monitoring of blood glucose levels using
a glucometer within one week."

4. Interventions:
Plan and implement nursing interventions to address
the identified nursing diagnoses and achieve the
desired outcomes. Interventions are specific actions
or activities that the nurse performs to help the
client. In the example, interventions could include
"Educate the client about the importance of regular
blood glucose monitoring" and "Teach the client
about dietary modifications and portion control to
manage blood sugar levels."

5. Evaluation:
Evaluate the client's response to the nursing
interventions and determine the achievement of
desired outcomes. This involves comparing the
client's progress with the established goals and
outcomes. For the client with diabetes, the nurse
evaluates if the client is effectively monitoring their
blood glucose levels and making appropriate dietary
modifications. If the outcomes are met, the care plan
may be continued or modified based on the client's
evolving needs. If the outcomes are not achieved,
the care plan may need to be reassessed and
revised.

It is important to note that the nursing care plan is

dynamic and should be regularly reviewed, revised,
and updated based on the client's changing needs
and responses to care. The involvement and
collaboration of the client in the care planning
process are essential for patient-centered care. The
 nursing care plan serves as a guide for the nurse and
other healthcare team members, ensuring that care
is individualized, evidence-based, and focused on
achieving optimal client outcomes.

9. Define nursing diagnosis and discuss the types of

nursing diagnosis with example.
Answer:
Nursing diagnosis is a clinical judgment made by
nurses to identify the client's actual or potential
health problems or responses to a health condition.
It provides the foundation for planning and
implementing nursing interventions to address these
problems and promote the client's well-being.
Nursing diagnoses are classified and labeled using
standardized taxonomies such as NANDA
International (NANDA-I).

 There are three types of nursing diagnoses:

1. Actual Nursing Diagnosis:

An actual nursing diagnosis describes a client's
current health problem or condition that is
supported by signs and symptoms, objective data, or
diagnostic test results. It reflects a problem that the
client is currently experiencing. Examples of actual
nursing diagnoses include:

- Acute Pain related to surgical incision as evidenced

by the client's self-report of pain, guarding behavior,
and increased heart rate.

- Impaired Mobility related to joint stiffness and

muscle weakness as evidenced by limited range of
motion, difficulty walking, and use of assistive
devices.

2. Risk Nursing Diagnosis:

A risk nursing diagnosis identifies potential health
problems or complications that a client is at risk for
developing. It is used when there are risk factors
present that make the client vulnerable to a specific
health issue. Examples of risk nursing diagnoses
include:
- Risk for Falls related to unsteady gait,
environmental hazards, and use of medications that
cause dizziness.

- Risk for Impaired Skin Integrity related to

immobility, poor nutrition, and urinary incontinence.

3. Health Promotion Nursing Diagnosis:

A health promotion nursing diagnosis focuses on
promoting the client's optimal health and preventing
the development of potential health problems. It
recognizes the client's readiness and willingness to
enhance their well-being. Examples of health
promotion nursing diagnoses include:

- Readiness for Enhanced Nutrition related to the

client's expressed desire to improve eating habits
and learn about healthy food choices.

- Readiness for Enhanced Parenting related to the

client's interest in learning effective parenting
techniques and providing a nurturing environment
for their child.
 It is important to note that nursing diagnoses are
distinct from medical diagnoses. Medical diagnoses
focus on identifying diseases or medical conditions,
whereas nursing diagnoses focus on the client's
responses to these conditions and their holistic well-
being.

Nursing diagnoses provide a framework for

individualizing care, developing care plans, and
determining appropriate nursing interventions. They
help nurses prioritize the client's needs, guide
decision-making, and evaluate the outcomes of care.

10. Define Nursing Process. Explain the purposes

and importance of Nursing process.
Answer:
The nursing process is a systematic problem-solving
framework that guides nurses in providing individualized
and holistic care to patients. It consists of five
interrelated steps: assessment, diagnosis, planning,
implementation, and evaluation. The nursing process is a
dynamic and ongoing process that helps nurses identify
and address the unique needs of each patient.

 The purposes of the nursing process are as follows:

1. Holistic Assessment: The nursing process allows

nurses to conduct a comprehensive assessment of the
patient's physical, psychological, social, and spiritual
dimensions. It helps nurses gather relevant data to
understand the patient's health status, identify potential
health problems, and recognize factors that may impact
the care provided.

2. Individualized Care: By following the nursing process,

nurses can develop individualized care plans based on
the specific needs and preferences of each patient. It
promotes patient-centered care and ensures that
interventions are tailored to address the unique concerns
and circumstances of the patient.
3. Clinical Decision-Making: The nursing process
provides a structured approach to clinical decision-
making. It helps nurses critically analyze and interpret
data, make sound clinical judgments, and prioritize
nursing diagnoses and interventions. The nursing process
supports evidence-based practice, allowing nurses to
integrate research findings, clinical expertise, and patient
preferences into their decision-making.

4. Continuity of Care: The nursing process promotes

continuity of care by facilitating effective communication
and collaboration among healthcare providers. It ensures
that relevant information is shared accurately and timely,
allowing for seamless transitions in care settings and
providing consistent and coordinated care.

5. Outcome Evaluation: Through the nursing process,

nurses evaluate the outcomes of care interventions. They
assess whether the goals and expected outcomes have
been achieved, and if not, they revise the care plan as
needed. Evaluation helps nurses determine the
effectiveness of nursing interventions, make adjustments
to the plan of care, and improve patient outcomes.

 The importance of the nursing process can be

summarized as follows:

1. Improved Patient Outcomes: By using a systematic

approach to care, the nursing process helps nurses
provide evidence-based and individualized care, leading
to improved patient outcomes and quality of care.

2. Efficient and Effective Care: The nursing process

enhances efficiency and effectiveness by guiding nurses
to focus on relevant information, prioritize care needs,
and utilize available resources appropriately. It helps
minimize errors and optimize the use of nursing
resources.

3. Professional Accountability: Following the nursing

process promotes professional accountability. Nurses are
responsible for their practice, and the nursing process
helps ensure that they provide safe, ethical, and
competent care to their patients.

4. Enhanced Communication and Collaboration: The

nursing process fosters effective communication and
collaboration among healthcare team members. It
facilitates the sharing of relevant information, promotes
interdisciplinary teamwork, and supports a holistic
approach to patient care.

5. Patient Empowerment and Involvement: The nursing

process encourages patient involvement in their care. It
promotes shared decision-making, active participation,
and patient education, empowering patients to take
charge of their health and well-being.

In summary, the nursing process is a systematic approach

that guides nurses in delivering individualized, holistic,
and evidence-based care. It promotes efficient and
effective care, improves patient outcomes, enhances
communication and collaboration, and ensures
professional accountability. By following the nursing
process, nurses can provide high-quality care that meets
the unique needs of each patient.

11. Define nursing Intervention and discuss the

types of Nursing Intervention.
Answer:
Nursing intervention refers to the actions and activities
that nurses perform to promote, maintain, or restore the
health and well-being of patients. These interventions
are based on nursing diagnoses and are designed to
achieve specific goals and outcomes in the nursing care
plan. Nursing interventions encompass a wide range of
actions, including direct patient care, education,
counseling, coordination, and advocacy.

 Here are the types of nursing interventions:

1. Independent Nursing Interventions:

Independent nursing interventions are actions that
nurses can initiate and carry out without the need for a
physician's order or supervision. These interventions are
within the scope of nursing practice and are based on the
nurse's knowledge, clinical judgment, and expertise.
Examples of independent nursing interventions include:

- Providing comfort measures such as positioning,

administering pain relief interventions, and providing
emotional support.
- Assisting with activities of daily living (ADLs) such as
bathing, grooming, and feeding.
- Educating patients about self-care, medication
management, and lifestyle modifications.
- Promoting mobility and preventing complications
associated with immobility.
- Implementing infection control measures, including
proper hand hygiene and isolation precautions.

2. Dependent Nursing Interventions:

Dependent nursing interventions are actions that require
a physician's order or supervision to be carried out.
Nurses implement these interventions based on
healthcare provider prescriptions or treatment protocols.
Examples of dependent nursing interventions include:

- Administering medications, intravenous (IV) fluids, or

blood products as prescribed.
- Performing wound care, including dressing changes and
wound irrigation.
- Assisting with invasive procedures, such as inserting
urinary catheters or nasogastric tubes.
- Carrying out treatments, such as physical therapy,
respiratory therapy, or occupational therapy.
- Conducting diagnostic tests, such as blood draws or
electrocardiograms (ECGs).

3. Collaborative Nursing Interventions:

Collaborative nursing interventions involve working
together with other healthcare professionals to provide
comprehensive and coordinated care. These
interventions require effective communication and
teamwork among healthcare team members. Examples
of collaborative nursing interventions include:

- Consulting with a pharmacist to review and optimize

medication regimens.
- Collaborating with physical therapists to develop a
rehabilitation plan for a patient.
- Coordinating with social workers to arrange for
community resources or support services.
- Communicating and collaborating with physicians and
specialists to manage and monitor the patient's
condition.
- Participating in interdisciplinary team meetings to
develop and review the care plan.

4. Educational and Preventive Interventions:

Educational and preventive interventions focus on
promoting health, preventing illness, and teaching
patients and their families about self-care and healthy
behaviors. These interventions aim to empower patients
to actively participate in their care and make informed
decisions about their health. Examples of educational
and preventive nursing interventions include:

- Conducting health education sessions on topics such as

nutrition, exercise, stress management, or disease
prevention.
- Providing counseling and guidance on lifestyle
modifications and risk reduction strategies.
- Teaching patients and their families about medication
management, including proper administration and
potential side effects.
- Conducting prenatal classes to educate expectant
parents about pregnancy, childbirth, and newborn care.
- Facilitating support groups or educational programs for
patients with chronic conditions or specific healthcare
needs.
Nursing interventions play a crucial role in promoting
positive patient outcomes, managing health conditions,
and improving the overall well-being of patients. By
implementing appropriate interventions based on
nursing diagnoses, nurses contribute to the delivery of
safe, effective, and patient-centered care.

12. Explain the steps of Evaluation in Nursing

process.
Answer:
The evaluation step in the nursing process is a critical
component that involves assessing the effectiveness
of nursing interventions and determining if the
desired outcomes have been achieved. Evaluation
allows nurses to measure the progress made
towards the goals of care and make adjustments to
the plan as necessary. Here are the steps involved in
the evaluation phase of the nursing process:

1. Reassess the Patient:

To begin the evaluation process, the nurse
reassesses the patient's health status using the same
data collection methods employed during the initial
assessment. This reassessment helps gather current
and relevant data to compare with the baseline and
determine changes in the patient's condition.

2. Compare Actual Outcomes with Expected

Outcomes:
Next, the nurse compares the actual outcomes
achieved by the patient with the expected outcomes
established during the planning phase of the nursing
process. Expected outcomes are specific,
measurable, and time-bound statements that
describe the desired changes in the patient's health
status. By comparing the actual outcomes with the
expected outcomes, the nurse can assess the
effectiveness of the nursing interventions.

3. Analyze Variances:
If there are variances between the actual and
expected outcomes, the nurse analyzes the reasons
for these variances. Variances can be positive (better
than expected), negative (worse than expected), or
no change. The nurse identifies the factors that
contributed to the variances, such as unforeseen
complications, patient non-compliance, or
ineffective interventions.

4. Determine the Effectiveness of Nursing

Interventions:
The nurse evaluates the effectiveness of the nursing
interventions in relation to the achieved outcomes.
This evaluation involves considering the impact of
the interventions on the patient's health status and
the extent to which they contributed to the desired
outcomes. It helps determine whether the nursing
interventions were appropriate, timely, and effective
in addressing the identified nursing diagnoses.

5. Modify the Care Plan:

Based on the evaluation findings, the nurse may
modify the care plan as needed. If the expected
outcomes were achieved, the nurse may continue
with the current plan of care. However, if the
outcomes were not achieved or if there were
variances, the nurse revises the care plan by
identifying alternative interventions, setting new
goals, or modifying existing interventions to better
meet the patient's needs.

6. Document the Evaluation Findings:

It is essential to document the evaluation findings
accurately and thoroughly. The nurse records the
achieved outcomes, any variances, the effectiveness
of the interventions, and the modifications made to
the care plan. Documentation ensures continuity of
care, supports communication among healthcare
providers, and provides a legal and professional
record of the care provided.

7. Communicate and Collaborate:

The nurse communicates the evaluation findings to
the healthcare team members involved in the
patient's care. This collaborative communication
allows for discussion, shared decision-making, and
coordination of efforts to provide consistent and
coordinated care.

The evaluation phase is an ongoing process that

occurs throughout the nursing care continuum. It
helps nurses continuously monitor and improve the
quality of care, assess the effectiveness of nursing
interventions, and promote optimal patient
outcomes. By evaluating the outcomes of care,
nurses can make informed decisions, provide
evidence-based care, and tailor interventions to
meet the changing needs of the patient.