THE NURSING

PROCESS

 Nurses use the problem-solving process

to identify human responses and to
plan, implement, and evaluate nursing
care.
When scientific problem solving is used
within the context of nursing, it is
known as the nursing process.
The nursing process contains five steps:
assessment, analysis/nursing
diagnosis, planning,
implementation, and evaluation.

 Because the nursing process incorporates

critical thinking used by nurses to meet
patients needs, items on nursing
examinations are designed to test the use
of this process.
Test items are not written haphazardly.
They are carefully designed to test your
knowledge of a specific concept, skill,
theory, or fact, from the perspective of
one of the five steps of the nursing
process.

 When reading an item, being able to

identify its place within the nursing
process should contribute to your ability to
recognize what the test item is asking.
To do this, you must focus on the critical
words within the item.

ASSESSMENT

 During assessment, data must be

accurately collected, verified, and
communicated.
Assessment items are designed to test
your knowledge of information, theories,
principles, and skills related to the
assessment of the patient.
This establishes the foundation on which
nurses base the subsequent steps in the
nursing process.

Assessment questions ask you to:

Obtain vital statistics

Perform a physical assessment
Collect specimens
Identify patient adaptations that are
objective or subjective
Identify patient adaptations that are verbal
or nonverbal

 Identify adaptations that are expected

(normal) or unexpected (abnormal)
Use various data collection methods
Identify sources of data
Verify critical findings
Identify commonalities and differences in
response to illness
Communicate information about
assessments to appropriate members of
the health team

 The critical words within a test item

that indicate that the item is focused
on assessment include these:
inspect, identify, verify, observe,
determine, notify, check, inform,
question, communicate, verbal and
nonverbal, signs and symptoms,
stressors, adaptations, sources,
perceptions, and assess

Most testing errors that occur on

assessment items occur because options
are selected that:
Collect insufficient data
Have data that are inaccurately collected
Use unscientific methods of data
collection
Rely on a secondary source rather than
the primary source, the patient
Contain irrelevant data

 Fail to verify data

Reflect bias or prejudice
Fail to accurately communicate data

COLLECTING DATA
Methods of Data
Collection

 Collecting data is the first part of

ASSESSMENT.
The nurse collects data through specific
methods of data collection, such as
performing a physical examination,
interviewing, and reviewing records.
A physical examination includes the
assessment techniques of inspection,
palpation, auscultation, and percussion.

 Also, it includes obtaining the vital

signs and recognizing acceptable and
unacceptable parameters of obtained
values.
Interviewing collects data using a
formal approach (e.g., obtaining a
health history) or an informal
approach (e.g., exploring feelings
while providing other nursing care).

 Review of records includes

consideration of reports such as the
results of laboratory tests, diagnostic
procedures, and assessments or
consultations by other members of the
health team.

 While making rounds, the nurse finds

a patient on the floor in the hall. What
should be the nurses initial
response?

(a) Inspect the patient for injury

(b) Transfer the patient back to bed
(c) Move the patient to the closest chair
(d) Report the incident to the nursing
supervisor

 This item tests your ability to recognize

that, in an emergency situation, the
nurse must first assess (inspect) the
condition of the patient.
This principle is basic to any emergency
response by a nurse.
Moving a patient before an assessment
could worsen an injury, this item
demonstrates how a basic concept
related to assessment can be tested.

 What should the nurse do to avoid patient

accidents?
a) Keep an over bed table in front of a sitting
patient
b) Determine the strength of a patient
before walking
c) Provide a cane for ambulation if the
patient is weak
d) Apply a vest restraint when a patient uses
a wheelchair

 This item tests your ability to recognize

the concept that the nurse must assess
a patient before implementing care.
The three distractors are all concerned
with implementing care.
This question also tests your ability to
recognize physical examination as a
method of collecting data about the
status of a patient.

Sources of Data
Data can be gathered not only by different
methods but also from different sources.
Sources of data available to the nurse
include those that are primary, secondary,
and tertiary.
There is only one primary source, the
patient.
The patient is the most valuable source of
information because the data collected are
the most current and specific to the patient.

 A secondary source produces

information from someplace other
than the patient.
A family member is a secondary
source who can contribute
information about the patients likes
and dislikes, ethnic and cultural
background, similarities and
differences in behavior, and
functioning before and during the
health problem.

 The patients medical record (chart) is

another example of a secondary
source.
It is a legal document containing
information that concerns the
patients physical, psychosocial,
religious, and economic history and
documents the patients physical and
emotional adaptations

 Controversy surrounds the labeling of

diagnostic test results in a chart as
being from either primary or
secondary sources.
Although the chart itself is a
secondary source, diagnostic test
results are direct objective
measurements of the patients status
and therefore are considered by
some health-care providers to be a

 The nurse must remember that the

information in a chart is history and
does not reflect the current status of
the patient because the patient is
dynamic and constantly changing.
Secondary sources are valuable for
gathering supplementary information
about a patient.

 A tertiary source provides

information from outside the specific
patients frame of reference.
Examples of tertiary sources include
textbooks, the nurses experience, and
accepted commonalities among
patients with similar adaptations.
The nurses or other health team
members responses to the patient are
tertiary sources of patient data.

 The nurse asks a patients wife specific

questions about the patients health
complaints before admission. When
collecting this information, the nurse is
seeking information from a:
(a) Primary source
(b) Tertiary source
(c) Subjective source
(d) Secondary source

 This item tests your ability to

recognize that a family member is a
secondary source of information.
Secondary sources provide
information that is supplemental to
the information collected from the
patient.

Types of Data
The types of data collected when
assessing a patient can be objective
or subjective, verbal or nonverbal.
Objective data are measurable
assessments collected when the
nurse uses sight, touch, smell, or
hearing to acquire information.

 Examples of objective data include

an excoriated perineal area,
diaphoresis, ammonia odor of urine,
crackles, and vital signs.
Subjective data can be collected
only when the patient shares
feelings, perceptions, thoughts, and
sensations about a health problem or
concern.

 Examples of subjective data include

patient statements about pain,
shortness of breath, or feeling
depressed.

 The nurse is performing a physical

assessment of a newly admitted
patient. Which patient statement
communicates subjective data?
a) I have sores between my toes.
b) I dye my hair but it is really grey.
c) My left leg drags on the floor when I
walk.
d) My joints hurt when I get up in the
morning.

 This item tests your ability to

differentiate between subjective and
objective data.
The nurse should know the types of
data collected for the purposes of
future clustering and determining
their significance.
Any information that the patient
shares regarding feelings, thoughts,
and concerns is subjective.

 Any information that the nurse

verifies using the senses (e.g., vision,
hearing, smell, and touch) or via
some form of instrumentation (e.g.,
thermometer, pulse oximetry,
laboratory data) is objective.

 Communication can be verbal or

nonverbal.
Verbal data are collected via the
spoken or written word.
For example, statements made to the
nurse by the patient are verbal data.
Nonverbal data are collected via
transmission of a message without
words.

 Crying, a fearful facial expression,

the appearance of the patient, and
gestures are all examples of
nonverbal data.

 What is an example of nonverbal

communication?
a)
b)
c)
d)

A letter
Holding hands
Noise in the room
A telephone message

 This item tests your ability to

recognize that holding hands is a
form of nonverbal communication.
Nonverbal communication does not
use words.
Touch, gestures, posture, and facial
expressions are examples of
nonverbal communication.

VERIFY DATA
After data are collected, they must be
verified.
To verify data is to confirm
information by collecting additional
data, questioning orders, obtaining
judgments and/or conclusions from
other team members when
appropriate, and by collecting data
oneself rather than relying on
technology.

 Verifying data ensures authenticity

and accuracy.
For example, when a vital statistic is
outside the expected range, the
nurse must substantiate the results
first by collecting the data again and
then collecting additional data to
supplement the original information.

 The nurse takes the patients blood

pressure and records a diastolic
pressure of 120. What should the
nurse do FIRST?
a) Retake the blood pressure
b) Take the other vital signs
c) Notify the nurse in charge
d) Notify the physician

 This item tests your ability to identify

that you need to verify data when
they are unexpectedly outside the
acceptable range.
Your first action should be to wait a
minute and then retake the blood
pressure.
An error may have been made when
taking the blood pressure.

COMMUNICATE INFORMATION
ABOUT ASSESSMENTS
The last component of assessment
includes the nurses ability to
communicate information obtained
from assessment activities.
Sharing vital information about a
patient is essential if members of the
health team are to be alerted to the
most current status of the patient.

 Communication methods vary (e.g.,

progress notes, verbal notification,
flow sheets); however, they all share
the need to be accurate, concise,
thorough, current, organized, and
confidential.

 When assessing a patient with a fluid

volume deficit, which assessment should the
nurse document on the patients record?
a) Thready radial pulse and straw-colored
urine
b) Straw-colored urine and decreased skin
turgor
c) Urine specific gravity of 1.015 and thready
radial pulse
d) Decreased skin turgor and a urine specific
gravity of 1.035

 This item tests your ability to assess

for patient adaptations related to a
fluid volume deficit and document
these adaptations on the patients
record so that they can be
communicated to other health team
members.

Analysis/Nursing Diagnosis
Analysis, the second step of the nursing
process, is the most difficult component.
Analysis requires that data be validated
and clustered and that their significance
be determined.
To analyze data, you need a strong
foundation in scientific principles related
to nursing theory, social sciences, and
physical sciences.

 You need to know the commonalities

and differences in patients
responses to various stresses.
You need to use reasoning to apply
your knowledge and experience
when answering analysis items.

 After the initial analysis of data,

sometimes additional data need to be
collected and analyzed.
Only after all the data have been
analyzed should a nursing diagnosis
be made.
Analysis questions ask you to:
Validate interrelationship of data
Cluster data

 Identify clustered data as meaningful

Interpret validated and clustered
data
Identify when additional data are
needed to further validate clustered
data

 Identify nursing diagnoses

Communicate nursing diagnoses to
others
The critical words within a test item
that indicate that the item is focused
on analysis/nursing diagnosis include
these:

 valid, organize, categorize, cluster,

reexamine, pattern, formulate,
nursing diagnosis, reflect, relate,
problem, interpret, contribute,
relevant, decision, significant,
deduction, statement, and analysis.

 Testing errors occur on analysis items

when options are selected that:
Omit data
Cluster data prematurely
Make a nursing diagnosis before all
significant data have been clustered
Force the nursing diagnosis to fit the
signs and symptoms collected