Nursing Process 2 — Questions and Answers
Question 1: A nurse is performing an initial assessment on a newly admitted client. The client reports chronic back pain and mentions they have been taking ibuprofen daily for 6 months. Which follow-up assessment is most important?
- Ask the client about their activity level and exercise habits
- Assess the client's stool color and frequency for signs of GI bleeding (Correct answer)
- Inquire about the client's diet and nutritional status
- Ask whether the client has tried physical therapy
Correct answer: Assess the client's stool color and frequency for signs of GI bleeding
Long-term daily NSAID use (such as ibuprofen) is associated with gastrointestinal irritation, peptic ulcers, and GI bleeding. Assessing stool color and frequency is most important to detect signs of GI complications.
Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen are among the most commonly used analgesics, but long-term daily use carries significant risks — most notably gastrointestinal complications. NSAIDs inhibit prostaglandin synthesis, which normally protects the gastric mucosa by stimulating mucus secretion and maintaining mucosal blood flow. With chronic NSAID use, this protective mechanism is compromised, leading to gastric erosion, peptic ulcer disease, and potentially GI bleeding. Gastrointestinal bleeding may manifest as: dark, tarry stools (melena) indicating upper GI bleeding, bright red blood in stool (hematochezia) for lower GI bleeding, coffee-ground emesis for slow upper GI bleeding, or abdominal pain and hemodynamic changes in severe cases. Asking about stool color and frequency is the most clinically important assessment. Other NSAID-related risks include renal impairment (particularly with prolonged use and dehydration), cardiovascular risk (increased with chronic use), and elevated liver enzymes. Complete assessment should also include renal function (BUN, creatinine) and blood pressure monitoring. Activity, diet, and alternative treatments are relevant to chronic pain management but do not address the most urgent safety concern related to the client's specific medication use pattern. The nurse should also ask whether the client is taking a proton pump inhibitor (PPI) or H2 blocker for GI protection, which is recommended with chronic NSAID use.
Question 2: A nurse is developing a care plan for a client with diabetes who has a non-healing wound on the left foot. Which nursing diagnosis is most appropriate?
- Risk for infection related to hyperglycemia and impaired wound healing (Correct answer)
- Disturbed body image related to visible wound on the foot
- Deficient knowledge related to diabetes management
- Ineffective health maintenance related to non-compliance with medication
Correct answer: Risk for infection related to hyperglycemia and impaired wound healing
A non-healing wound in a diabetic client poses the highest risk for infection due to hyperglycemia-impaired immune function and poor circulation. Risk for infection is the highest priority nursing diagnosis.
Diabetic foot wounds are a major clinical concern because diabetes impairs multiple wound-healing mechanisms simultaneously. Hyperglycemia inhibits neutrophil and macrophage function (reducing immune response), impairs fibroblast proliferation and collagen synthesis (slowing tissue repair), and contributes to peripheral neuropathy (loss of protective sensation) and peripheral arterial disease (reduced oxygen and nutrient delivery to wound). A non-healing diabetic foot wound is at very high risk of infection, which can progress rapidly to osteomyelitis (bone infection), gangrene, and amputation. Therefore, 'Risk for infection related to hyperglycemia and impaired wound healing' is the highest priority nursing diagnosis. Interventions include: monitoring blood glucose levels and maintaining glycemic control (HbA1c target per provider), daily wound assessment (size, depth, exudate, surrounding tissue, presence of undermining or tunneling), wound care per orders, offloading pressure from the wound, assessing peripheral pulses and sensation, educating the client on foot care, and ensuring referral to wound care specialist and possibly vascular surgery. Disturbed body image and deficient knowledge are relevant psychosocial and educational diagnoses but are not the highest priority. 'Non-compliance' as a diagnosis is outdated terminology and should be replaced with 'Non-adherence' or 'Deficient knowledge' to avoid stigma.
Question 3: A nurse has implemented a plan of care for a client with fluid volume excess. The client's weight has increased by 2 kg over the past 24 hours and breath sounds show new bilateral crackles. In which step of the nursing process is the nurse currently engaged?
- Assessment
- Planning
- Implementation
- Evaluation (Correct answer)
Correct answer: Evaluation
Evaluating the outcomes of implemented nursing interventions — in this case, determining that weight has increased and crackles have developed — is the Evaluation step of the nursing process.
The nursing process is a systematic, five-step framework: Assessment, Diagnosis, Planning, Implementation, and Evaluation (ADPIE). Each step serves a distinct purpose in providing scientific, individualized nursing care. Evaluation is the fifth step, in which the nurse measures the client's response to nursing interventions and determines whether the established goals and expected outcomes have been met, partially met, or not met. This requires reassessing the client (collecting new data) and comparing findings to the goals set during Planning. In this scenario, the nurse is evaluating the care plan for fluid volume excess. The findings — 2 kg weight gain and new bilateral crackles — indicate that the client's condition is worsening despite interventions, meaning the outcome has not been achieved. This should prompt the nurse to reassess (back to Assessment), revise the nursing diagnosis if needed, update the plan (increase diuretics, fluid restriction, dietary sodium modification), and re-implement with adjustments. The nursing process is cyclical, not linear — evaluation leads back into assessment and planning as client needs change. The nurse must also evaluate whether interventions were performed correctly and whether the expected outcomes were realistic for this client's condition and timeline.
Question 4: A nurse is planning care and setting priorities for four clients. Using the nursing process, which client should be seen first?
- A client with hypertension requesting education on a low-sodium diet
- A client post-op day 2 after cholecystectomy reporting incision pain of 5/10
- A client with new onset confusion and a blood pressure of 80/50 mmHg (Correct answer)
- A client with type 2 diabetes who needs their morning insulin administered
Correct answer: A client with new onset confusion and a blood pressure of 80/50 mmHg
A client with new onset confusion and a blood pressure of 80/50 mmHg is showing signs of possible shock — this is the highest priority because it represents an immediate threat to life (circulation compromise).
Prioritization using the nursing process requires the nurse to rapidly assess all available data and identify which client presents the most urgent physiological need. The ABCs (Airway, Breathing, Circulation) framework combined with recognition of acute deterioration guides this decision. New onset confusion combined with hypotension (80/50 mmHg) are classic signs of shock — a state of inadequate tissue perfusion. The brain is highly sensitive to hypoperfusion, and acute mental status change combined with low blood pressure may indicate septic shock, hemorrhagic shock, cardiogenic shock, or other acute emergencies. This client requires immediate assessment, vital signs, IV access, notification of the provider, and preparation for emergent interventions. The client requiring insulin is time-sensitive for metabolic reasons (hypoglycemia risk from skipped morning meal, hyperglycemia risks), but this is a scheduled task that can be addressed after the emergent client is stabilized. Post-operative pain of 5/10 is moderate and requires assessment and intervention but is not immediately life-threatening. Diet education is an elective activity. The nurse should use rapid prioritization techniques like the Urgent vs. Non-urgent framework, Maslow's hierarchy, and ABC to systematically assign priority. Communicating priorities to the charge nurse and delegating appropriate tasks ensures all clients receive timely care.
Question 5: A nurse formulates the nursing diagnosis: 'Impaired skin integrity related to immobility as evidenced by a 2 cm x 2 cm Stage 2 pressure injury on the sacrum.' Which part represents the 'etiology' component?
- Impaired skin integrity
- Immobility (Correct answer)
- A 2 cm x 2 cm Stage 2 pressure injury on the sacrum
- Related to
Correct answer: Immobility
In the PES (Problem-Etiology-Signs/Symptoms) nursing diagnosis format, the etiology is the related factor or cause — in this case, 'immobility' is the factor contributing to the skin integrity impairment.
The three-part (PES) nursing diagnosis format consists of: Problem (the nursing diagnosis label — identifies what is happening), Etiology (related factor — identifies the cause or contributing factor, linked by 'related to'), and Signs/Symptoms (defining characteristics — the evidence that supports the diagnosis, linked by 'as evidenced by'). In the given diagnosis: 'Impaired skin integrity' = Problem; 'immobility' = Etiology; 'a 2 cm x 2 cm Stage 2 pressure injury on the sacrum' = Signs/Symptoms. The etiology is critically important because nursing interventions are directed at the etiology, not just the problem label. If the cause is immobility, the intervention plan would include repositioning every 2 hours, use of specialty mattresses, skin protection measures, and a mobility program — all targeting immobility as the causative factor. Nursing diagnoses differ from medical diagnoses: medical diagnoses identify disease pathology (e.g., 'Type 2 diabetes mellitus'), while nursing diagnoses identify the client's response to illness or health conditions and are within the nursing scope to treat. The PES format was developed by NANDA International and provides a consistent framework for communicating nursing clinical judgments.
Question 6: A nurse is collecting data on a newly admitted client. The client reports feeling anxious and states their heart is racing. The nurse observes the client is diaphoretic and notes a heart rate of 118 bpm. Which data are objective?
- The client's report of feeling anxious and heart racing
- The heart rate of 118 bpm and visible diaphoresis (Correct answer)
- All data collected during a nursing assessment
- Only data obtained through laboratory analysis
Correct answer: The heart rate of 118 bpm and visible diaphoresis
Objective data (signs) are measurable and observable by the nurse: a heart rate of 118 bpm (measured) and diaphoresis (observed). Subjective data (symptoms) are what the client reports: feeling anxious and heart racing.
In the Assessment phase of the nursing process, the nurse collects two types of data: subjective and objective. Understanding the distinction is fundamental to accurate nursing assessment and documentation. Subjective data (symptoms) is information that only the client can describe — it is experienced by the client and cannot be directly observed or measured by the nurse. Examples include pain level, nausea, fatigue, fear, and the sensation of heart racing. These are documented using quotation marks and the client's own words: 'Client states, "My heart feels like it's pounding and I feel very anxious."' Objective data (signs) is information that the nurse can directly observe, measure, palpate, auscultate, or obtain through diagnostic testing — it is verifiable and not dependent on client report. Examples include vital signs, physical examination findings (diaphoresis, pallor, edema), laboratory values, and diagnostic imaging results. Heart rate of 118 bpm is measured; diaphoresis is visually observed. Both types of data are essential for accurate clinical assessment. A complete picture of the client's health status requires integrating what the client reports (symptoms) with what the nurse observes and measures (signs). Discrepancies between subjective and objective data can be clinically significant and should prompt further investigation.
Nursing Process 2
A nurse is performing an initial assessment on a newly admitted client.
The client reports chronic back pain and mentions they have been taking ibuprofen daily for 6 months.
Which follow-up assessment is most important?