Lecture 2

Question 1

A nurse reviews vital signs, asks about pain, clarifies medication use, and documents findings. Which phase of the nursing process is occurring, and why?

Answer 1

Assessment — the nurse is collecting, validating, organizing, and documenting data without making decisions or taking action yet.

Question 2

A patient says, “I feel dizzy when I stand up.” What type of data is this, and why?

Answer 2

Subjective data — it is based on the patient’s personal experience and cannot be directly measured by the nurse.

Question 3

A patient reports taking their medication daily, but pharmacy records show missed refills. What should the nurse do next?

Answer 3

Validate the data by clarifying with the patient and investigating the discrepancy before proceeding.

Question 4

Why must nurses consider the source of assessment information?

Answer 4

Because information may be incomplete or inaccurate, and reliable data is essential for safe clinical decisions.

Question 5

Why is asking about natural or herbal products an important part of assessment?

Answer 5

Because supplements and natural products can interact with prescribed medications and affect patient responses.

Question 6

What is the primary goal of the assessment phase?

Answer 6

To gather and analyze information in order to understand the patient’s health status and needs.

Question 7

A patient suddenly appears pale and diaphoretic. What is the nurse’s immediate priority within the nursing process?

Answer 7

Assessment — new or unexpected changes require immediate data collection.

Question 8

What key questions does assessment aim to answer about patient care?

Answer 8

Who, what, when, where, why, and how.

Question 9

When does assessment occur in the nursing process?

Answer 9

Continuously — before, during, and after care.

Question 10

Explain the assessment phase in one sentence.

Answer 10

Assessment is the ongoing process of collecting, validating, organizing, and documenting subjective and objective patient data to understand health needs.

Question 11

You enter the room of a 72-year-old patient admitted with shortness of breath. What is your first nursing action and why?

Answer 11

My first action is to perform a focused assessment by collecting both subjective and objective data to understand the patient’s current condition.

Question 12

What subjective assessment data would you collect from this patient?

Answer 12

I would ask about shortness of breath, fatigue, activity tolerance, sleep position, onset of symptoms, and any swelling or discomfort the patient is experiencing.

Question 13

What objective data is most important to assess in this patient?

Answer 13

I would assess respiratory rate, oxygen saturation, heart rate, lung sounds, presence of edema, and overall work of breathing.

Question 14

You note an oxygen saturation of 89% on room air. What does this finding mean within the assessment phase?

Answer 14

This is objective assessment data indicating reduced oxygenation and requires further monitoring and validation.

Question 15

Why is it important to organize assessment data rather than view each finding separately?

Answer 15

Organizing data allows me to identify patterns and relationships between symptoms, which supports accurate clinical reasoning.

Question 16

The patient reports taking medications regularly, but pharmacy records show delayed refills. What is your next assessment step?

Answer 16

I would validate the information by clarifying medication adherence with the patient and reviewing additional sources as needed.

Question 17

Why do you ask specifically about over-the-counter and herbal products during assessment?

Answer 17

Because supplements and over-the-counter products can interact with prescribed medications and affect the patient’s condition.

Question 18

The patient sleeps on two pillows at night. Why is this important assessment information?

Answer 18

This provides insight into breathing comfort and possible changes in respiratory or fluid status.

Question 19

You notice bilateral ankle edema. What should you do with this information at this stage?

Answer 19

I document the finding, assess its severity and onset, and consider it as part of the overall assessment without making a diagnosis yet.

Question 20

When should reassessment occur for this patient?

Answer 20

Reassessment should occur continuously, especially if the patient’s condition changes or after interventions are implemented.

Question 21

How would you summarize your assessment findings to another nurse or instructor?

Answer 21

I assessed a 72-year-old patient with shortness of breath and fatigue, noting increased respiratory rate, low oxygen saturation, bilateral edema, crackles, and reported difficulty with exertion.

Question 22

Why is it inappropriate to identify a nursing diagnosis during the initial assessment?

Answer 22

Because assessment focuses on collecting and validating data; diagnoses are made only after sufficient information has been gathered and analyzed.

Question 23

You are assessing a patient and obtain a blood pressure of 150/96, heart rate of 88 bpm, and oxygen saturation of 91%. What type of data is this, and why?

Answer 23

This is objective data because it is measurable, observable, and does not rely on the patient’s perception.

Question 24

During a physical assessment, you observe bilateral ankle edema and hear crackles in the lung bases. How should this information be classified and used?

Answer 24

These are objective findings that should be documented clearly and used to support clinical reasoning and further assessment.

Question 25

A patient states they are in pain, but you note grimacing, guarding, and limited movement. Which findings are objective, and how do they contribute to assessment?

Answer 25

Grimacing, guarding, and limited movement are objective data because they are observable signs that support the patient’s reported symptoms.

Question 26

An X-ray confirms a femoral neck fracture. How does this result fit into the assessment phase of the nursing process?

Answer 26

This is objective diagnostic data that provides concrete evidence of the patient’s condition and informs safe planning of care.

Question 27

When documenting assessment findings, why should nurses prioritize objective data whenever possible?

Answer 27

Objective data improves accuracy and clarity because it is concrete, measurable, and verifiable by other healthcare providers.

Question 28

What is the assessment phase of the nursing process?

Answer 28

Assessment is the first step of the nursing process where the nurse collects, validates, organizes, and documents subjective and objective data to understand the patient’s health status.

Question 29

How do you complete a nursing assessment?

Answer 29

I complete an assessment by compiling a health history, performing a physical examination, and reviewing diagnostic tests and laboratory results.

Question 30

Who can provide information during the assessment phase?

Answer 30

Information can be obtained from the client, family or significant others, and members of the healthcare team.

Question 31

What information are you specifically assessing?

Answer 31

I assess the client’s past health history, current health status, and determinants of health such as social supports and access to care.

Question 32

Why is observing nonverbal cues important during assessment?

Answer 32

Nonverbal cues help me determine whether what I observe matches what the patient reports, which supports accurate assessment.

Question 33

Why should nurses avoid using opinion-based language in documentation?

Answer 33

Opinion-based language can be subjective and unclear; objective documentation ensures accuracy and consistency across the healthcare team.

Question 34

How would you objectively document that a patient is sleeping?

Answer 34

I would document observable findings, such as the patient lying in bed with eyes closed and respirations even and unlaboured.

Question 35

Why is assessment considered an ongoing process?

Answer 35

Assessment is ongoing because the patient’s condition can change, and new information may require reassessment.

Question 36

What is the nurse’s priority during assessment?

Answer 36

The priority is to gather accurate, complete information to support safe clinical decisions.

Question 37

A nurse completes a head-to-toe assessment and notes abnormal lung sounds but normal vital signs. What should the nurse do next, and why?

Answer 37

Further assess the area of concern and review related data (such as oxygen saturation and labs), because assessment requires looking at the whole clinical picture, not a single finding.

Question 38

Why is a head-to-toe assessment important even when the patient presents with one specific complaint?

Answer 38

Because it establishes a baseline and helps identify additional or related problems that may not be immediately obvious.

Question 39

A lab report shows abnormal CBC values, but the patient appears clinically stable. How should the nurse interpret this information?

Answer 39

The nurse should correlate the lab findings with physical assessment and patient symptoms before drawing conclusions.

Question 40

During a physical assessment, when should the nurse use inspection, palpation, percussion, and auscultation?

Answer 40

These techniques are used together to gather comprehensive objective data during a head-to-toe or focused physical assessment.

Question 41

Why is it unsafe to focus on only one abnormal finding during assessment?

Answer 41

Because isolated data can be misleading; safe clinical decisions require integrating physical findings, vital signs, labs, and patient responses.

Question 42

A nurse reviews assessment data showing shortness of breath, low oxygen saturation, and anxiety. What is the nurse doing in the diagnosis phase?

Answer 42

Analyzing assessment data to identify the patient’s health problem and response to illness using critical thinking.

Question 43

Why is a nursing diagnosis different from a medical diagnosis?

Answer 43

A nursing diagnosis focuses on the patient’s **response** to a health condition, while a medical diagnosis identifies the disease or pathology.

Question 44

How does a nursing diagnosis support safe and effective nursing care?

Answer 44

It provides a clear, standardized description of the patient’s problem that guides nursing interventions and expected outcomes.

Question 45

What role does assessment data play in forming a nursing diagnosis?

Answer 45

Assessment data reveals patterns and key findings that are synthesized to determine the most accurate nursing diagnosis.

Question 46

Why are standardized nursing languages such as NANDA and NIC important?

Answer 46

They promote clear communication, consistency, and continuity of care across the healthcare team.

Question 47

Problem-focused

Answer 47

Decreased cardiac output

Question 48

Risk

Answer 48

Risk for impaired oral mucous membrane integrity

Question 49

Health promotion

Answer 49

Readiness for enhanced family processes

Question 50

Syndrome

Answer 50

Ineffective peripheral tissue perfusion

Question 51

A nurse writes the goal, “Nurse will administer oxygen as ordered.” Why is this not an appropriate planning goal, and how should it be corrected?

Answer 51

It describes a nursing action, not a patient outcome. Planning goals must focus on the patient’s response, such as “Patient will maintain oxygen saturation ≥ 92%.”

Question 52

A patient with severe shortness of breath, anxiety, and a knowledge deficit is admitted. Which problem should be addressed first during planning, and why?

Answer 52

Shortness of breath should be prioritized because ABCs and physiological needs come before psychosocial or educational needs.

Question 53

Why is it important that planning goals are measurable?

Answer 53

Measurable goals allow the nurse to evaluate effectiveness and determine whether the plan should be continued, modified, or discontinued.

Question 54

A nurse plans a daily exercise program for a patient who reports limited time and fatigue. Which planning principle is being overlooked?

Answer 54

Attainability and feasibility—goals must be realistic and fit the patient’s lifestyle to support adherence.

Question 55

A nurse sets the goal, “Patient will demonstrate proper wound care technique before discharge.” Which SMART components are present, and which could be improved?

Answer 55

The goal is specific and relevant, but could be improved by adding a measurable criterion and a clear time frame (e.g., by end of teaching session).

Question 56

Implementation

Answer 56

Implementation is when the nurse puts the care plan into action.

Question 57

What happens during implementation?

Answer 57

* The nurse carries out nursing interventions * Provides care to meet the patient’s needs * Documents what was done and how the patient responded

Question 58

What guides implementation?

Answer 58

Interventions are evidence-based, meaning they are guided by: * Pharmacology – giving medications safely * Pathology & anatomy – understanding what’s going wrong in the body * Lab & diagnostic results – adjusting care based on results * Interpersonal communication – working with patients and families * Teaching & learning principles – educating patients effectively

Question 59

Why is reassessing the client an essential part of implementation before carrying out an intervention?

Answer 59

Because the patient’s condition may have changed, and reassessment ensures the planned intervention is still safe, appropriate, and necessary.

Question 60

A nurse administers medication and forgets to document it. Why is this considered incomplete implementation?

Answer 60

Because care is not legally or professionally complete until it is documented; undocumented care is treated as if it did not occur.

Question 61

What is the key difference between direct and indirect nursing interventions during implementation?

Answer 61

Direct interventions involve hands-on patient care, while indirect interventions support care through coordination, communication, and planning without direct patient contact.

Question 62

When delegating care during implementation, what responsibility does the nurse retain?

Answer 62

The nurse remains accountable for ensuring the delegated task is appropriate, completed correctly, and followed by necessary assessment or documentation.

Question 63

Why is client engagement emphasized during the implementation phase?

Answer 63

Because involving the patient improves adherence, understanding, and effectiveness of interventions, leading to better outcomes.

Question 64

You assess a patient who says, “I feel really bad and uncomfortable.” How should this be documented correctly?

Answer 64

Document objective data and quoted subjective data, such as: “Patient states, ‘I feel really bad and uncomfortable.’ Patient grimacing, guarding abdomen, pain rated 7/10.”

Question 65

Why is it unsafe to document “patient appears comfortable” in the health record?

Answer 65

Because it is subjective and interpretive. Documentation must describe what is observed, not assumptions (e.g., “patient resting with eyes closed, respirations even at 16/min”).

Question 66

A nurse performs wound care but forgets to chart it. From a legal standpoint, what is the implication?

Answer 66

If it is not documented, it is considered not done, placing the nurse and patient at risk.

Question 67

Which four elements must be present in proper nursing documentation after an intervention?

Answer 67

What was done, When it was done, How the patient responded, Any follow-up needed

Question 68

A patient refuses a prescribed intervention. What is the most appropriate documentation approach?

Answer 68

Document the refusal objectively, including patient statement, education provided, and provider notification (e.g., “Patient declined repositioning despite education on skin integrity; provider notified”).

Question 69

Scenario: A patient admitted with pneumonia becomes increasingly short of breath over your shift. SpO₂ drops from 95% to 89% on room air. Oxygen is applied and SpO₂ improves to 94%. Question: What key elements must be included in your documentation to support safe care and continuity?

Answer 69

Answer: Change in condition (SpO₂ trend), intervention (oxygen applied with amount), patient response, and any provider notification.

Question 70

Scenario: A patient tells you they fell at home but has injuries that don’t match the explanation. Question: From a documentation and advocacy perspective, how should this be charted?

Answer 70

Answer: Objectively document the patient’s statement verbatim, the observed injuries, and inconsistencies without interpretation or accusation.

Question 71

Scenario: You educate a patient on the administration of insulin. The patient nods, but later gives the injection incorrectly. Question: What should your documentation include to demonstrate professional accountability?

Answer 71

Answer: Teaching provided, patient response, evidence of understanding (or lack of), correction given, and plan for further education.

Question 72

Scenario: A patient refuses a prescribed intervention, stating they are “too tired.” Question: What documentation best supports legal and professional standards?

Answer 72

Answer: Patient refusal in their own words, education provided, patient’s understanding, and follow-up actions or notifications.

Question 73

Scenario: During a busy shift, you perform wound care but delay charting until the end of the shift. Question: What is the primary risk of delayed or incomplete documentation?

Answer 73

Answer: Inability to prove care was provided, increased risk to patient safety, and lack of continuity for the next provider.

Question 74

You are assessing a patient admitted with pneumonia. SpO₂ is 91% on room air, respiratory rate is 24/min, and the patient says, “It’s getting harder to breathe.” What would you do next?

Answer 74

Expected verbal response (model): “I would prioritize airway and breathing by positioning the patient in high Fowler’s and applying supplemental oxygen. I would reassess oxygen saturation and work of breathing, then notify the provider if there is no improvement.”

Question 75

Your patient has the following findings: RR 22/min SpO₂ 94% on room air Pain 6/10 with coughing Temperature 38.5°C What would you address first and why?

Answer 75

Expected verbal response: “I would address the fever first because elevated temperature increases metabolic and oxygen demand. Airway and breathing are currently stable, so reducing fever helps prevent respiratory compromise.”

Question 76

You applied oxygen via nasal cannula at 2 L/min 20 minutes ago. Current SpO₂ is 95%, RR is 18/min, and the patient appears less anxious. What would you do next?

Answer 76

Expected verbal response: “I would evaluate the effectiveness of the intervention by documenting the improved oxygen saturation and respiratory rate, continue monitoring, and ensure oxygen is maintained as ordered.”

Question 77

During reassessment, you notice the patient’s SpO₂ has decreased from 95% to 90% despite oxygen therapy. What would you do next?

Answer 77

Expected verbal response: “I would reassess the patient’s airway and breathing, ensure oxygen delivery is functioning properly, increase oxygen as per protocol, and notify the provider due to worsening respiratory status.”

Question 78

You completed oxygen therapy, repositioned the patient, and reassessed respiratory status. What would you document?

Answer 78

Expected verbal response: “I would document the time and type of intervention, oxygen delivery method and flow rate, objective reassessment findings such as SpO₂ and respiratory rate, and the patient’s response.”