Fundamental Principles of Nursing Quiz

The Characteristics and Steps of the Nursing Process

• The nursing process involves establishing a database about the client's health status, concerns, and ability to manage healthcare needs.
• The nursing process has five characteristics: patient-centered, interpersonal, collaborative, dynamic and cyclical, and requires critical thinking.
• The nursing process is an adaptation of problem-solving and system theory and is separate from the process used by physicians.
• The nursing process involves decision-making in every phase and allows for individualization of the nurse's plan of care.
• The first step of the nursing process is assessing, which involves the systematic and continuous collection, organization, validation, and documentation of data.
• Nursing assessment is a continuous process carried out during all phases of the nursing process and is essential for accurate and complete data collection.
• The purposes of nursing assessment include validating a diagnosis, providing a basis for effective nursing care, promoting holistic nursing care, and collecting data for nursing research.
• The assessment process involves collecting subjective and objective data, validating data, organizing data, and documenting data.
• Subjective data are symptoms or covert data that are apparent only to the person affected and can be described or verified only by that person.
• Objective data are observable and measurable data, such as vital signs and laboratory results.
• The nursing process depends on accurate and complete data collection to determine the outcomes of nursing strategies and to evaluate goal achievement.
• Nurses can be highly creative in determining when and how to use data to make decisions, promoting open communication, mutual respect, and shared decision-making to achieve quality patient care.

Data Collection in Nursing Assessment

• Nursing assessment involves collecting data about a patient's health status and history.
• Data can be subjective (based on the patient's perspective) or objective (measurable through observation or testing).
• Constant data refers to unchanging information, while variable data can change frequently or rarely.
• Sources of data include the patient, family members, other healthcare professionals, records and reports, lab tests, and literature.
• The three primary methods of data collection are observation, interviewing, and physical examination.
• Observation involves using the senses to gather data in a deliberate, organized manner.
• Interviews are planned conversations with a specific purpose, such as gathering information or providing support.
• Physical examination uses techniques such as inspection, auscultation, palpation, and percussion to detect health problems.
• Validation is the process of verifying data accuracy and completeness.
• Organizing data involves using a written or computerized format to systematically organize assessment data.
• Accurate documentation is essential and should include all data collected about the patient's health status.
• Data should be recorded in a factual manner without interpretation or judgment.