2350 Exam 2

NURS 2350 – Exam 2 Study Guide

Module 3: Nursing Process, Clinical Judgment & Care Planning

I. The Five Steps of the Nursing Process (Know Cold)

Order matters. Exams love order errors.

1. Assessment

   • Collect comprehensive data

   • Subjective + objective

2. Diagnosis (Analysis)

   • Interpret data

   • Identify nursing problems (NANDA)

3. Planning / Outcomes

   • Set priorities

   • Write SMART outcomes

   • Select interventions

4. Implementation

   • Carry out interventions

5. Evaluation

   • Determine if outcomes were met

   • Revise care as needed

Key idea:
The nursing process is cyclical, not linear. You can jump back to assessment at any time.

II. Assessment: Subjective vs Objective Data

Two Components of Assessment

Subjective Data

• What the patient says

• Symptoms, perceptions, feelings

• Pain, nausea, dizziness, anxiety

• Cannot be directly measured

Objective Data

• What the nurse observes or measures

• Vital signs, labs, physical exam findings

• Behaviors you see, hear, touch

📌 Exam trap:
Patient statements are always subjective — even if they sound factual.

III. Categories of a Patient Health History

Know these conceptually, not just as a list.

1. Biographical Information

   • Demographics, contact info

2. Chief Concern

   • Reason for seeking care (in patient’s words)

3. Present Health History

   • Current illness, treatments, perception of health

4. Past Health History

   • Hospitalizations, surgeries

   • Medications (Rx, OTC, herbal)

   • Allergies + reactions

   • Lifestyle habits

5. Family History

   • Genetic risks

   • Family structure/support

6. Review of Systems (ROS)

   • Head-to-toe subjective review

7. Functional Health Patterns (Gordon)

   • Sleep, coping, nutrition, values, health behaviors

📌 Big idea:
ROS = body systems
Functional patterns = how the patient lives

IV. Therapeutic Communication & Patient-Centered Assessment

Why It Matters

• Builds trust

• Improves data accuracy

• Enhances clinical judgment

Key Techniques

• Open-ended questions

• Active listening

• Clarification, not assumptions

• Nonjudgmental tone

📌 Exam insight:
If a question asks why therapeutic communication matters →
The answer is better assessment data and safer clinical decisions, not just “rapport.”

V. Data Collection, Interpretation & Validation

Methods of Data Collection

• Patient interview

• Physical examination

• EHR review

• Interdisciplinary consultation

Data Interpretation (Clinical Judgment Core)

• Recognize cues

• Cluster related data

• Compare to norms

• Identify patterns

• Make inferences

Validation

• Compare subjective + objective

• Reassess unclear findings

• Confirm with measurements

• Consult team members

📌 Key phrase to recognize on exams:
“Verify,” “validate,” “clarify” = reassess before diagnosing

VI. Nursing Diagnoses (Problem-Oriented Thinking)

Problem-Focused Diagnosis (3 Parts)

1. Diagnostic Label

2. Related Factor (“related to”)

3. Defining Characteristics (“as evidenced by”)

Example:
Impaired Physical Mobility
related to muscle weakness
as evidenced by unsteady gait

Risk Diagnosis

• Two parts only

• No signs/symptoms yet

Example:
Risk for Infection related to surgical incision

Prioritization Principles

• Patient condition changes → priorities change

• Physiological > safety > psychosocial

• Use clinical judgment, not memorization

VII. SMART Outcome Statements (Exam Favorite)

Outcomes must be:

• Specific

• Measurable

• Attainable

• Relevant

• Time-limited

Good Outcome:
Patient will ambulate 50 feet with walker by end of shift

Bad Outcome:
Patient will improve mobility

📌 Test clue:
If you can’t measure it → it’s not an outcome.

VIII. Nursing Interventions (Know the Types)

By Authority

• Independent – nurse-initiated

• Dependent – provider order required

By Interaction

• Direct – patient contact

• Indirect – away from patient (charting, collaboration)

📌 Trick:
Teaching is independent + direct.

IX. Goals, Outcomes & Evaluation (They’re Linked)

Diagnosis → Outcomes → Interventions → Evaluation

• Goals = broad intention

• Outcomes = measurable proof

• Evaluation = did it work?

Evaluation Results

• Outcome met

• Partially met

• Not met

If not met → revise the plan, not blame the patient.

X. Evaluation Process (Ongoing, Not Final)

• Evaluate after every intervention

• Compare before vs after data

• Use objective + subjective measures

• Modify care as needed

📌 Exam insight:
Evaluation ≠ task completion
Evaluation = patient response

XI. Nursing Process & NCSBN Clinical Judgment Model

This is HUGE for exams.

📌 Bottom line:
Clinical judgment is the nursing process in action.

How to Study This for Exam Day

1. Practice identifying:

   • Subjective vs objective

   • Correct diagnosis format

   • SMART vs non-SMART outcomes

2. Read questions slowly

3. Ask: Which step of the nursing process am I in?

4. Choose answers that protect safety and use assessment first

Great — thanks for dropping the actual Module 3 Learning Guide. This lets us do what matters most for Exam 2: answer it exactly the way your instructor expects, using Potter + Giddens language and NCLEX logic.

Below is a completed, exam-ready answer key / study guide for NURS 2350 – Module 3, written in clear nursing language you can reuse on exams, quizzes, and clinical paperwork. Everything aligns directly with your uploaded learning guide .

NURS 2350 – Module 3 Learning Guide (COMPLETED STUDY GUIDE)

Five Steps of the Nursing Process (Correct Order)

1. Assessment

2. Nursing Diagnosis

3. Outcomes / Planning

4. Implementation

5. Evaluation

Assessment – Step 1 of the Nursing Process

Two Types of Assessments & When Used

Comprehensive Assessment

• Complete health history + physical exam

• Used on admission, first visit, or new patient encounter

Focused (Problem-Oriented) Assessment

• Limited to a specific issue or system

• Used for follow-ups, ongoing problems, or acute changes

Case Study: Subjective vs Objective Data

Interview Process – 3 Phases

1. Introduction Phase

   • Establish rapport

   • Explain purpose of interview

   • Ensure privacy and comfort

2. Working Phase

   • Collect subjective and objective data

   • Ask open-ended questions

   • Clarify and validate information

3. Termination Phase

   • Summarize key points

   • Verify accuracy

   • Explain next steps

Components of a Nursing Health History

• Biographical information

• Chief concern

• Present health history

• Past health history

• Family history

• Review of systems (ROS)

• Functional health patterns

Review of Systems (ROS) vs Physical Exam

ROS

• Subjective

• Head-to-toe questioning

• Identifies symptoms and changes

Physical Exam

• Objective

• Inspection, palpation, percussion, auscultation

• Confirms or refutes ROS findings

Concept Map

A concept map is a visual tool that organizes patient data, nursing diagnoses, interventions, and outcomes.
It helps nurses:

• See relationships between problems

• Prioritize care

• Improve clinical judgment

• Plan holistic, patient-centered care

Nursing Diagnosis – Step 2

Three Types of Nursing Diagnoses

Problem-Focused

• Actual patient problem

• Has defining characteristics

Risk Diagnosis

• Potential problem

• No symptoms yet

Wellness Diagnosis

• Readiness to improve health

Problem-Focused vs Risk Diagnosis

• Problem-Focused → problem exists now

• Risk → problem may develop if no intervention occurs

Medical Diagnosis vs Nursing Diagnosis

Medical Diagnosis

• Identifies disease or pathology

• Example: Asthma, Diabetes, Hypertension

Nursing Diagnosis

• Identifies patient response to health condition

• Example: Ineffective Breathing Pattern, Risk for Infection

Key Diagnostic Terms

• Data Clustering: Grouping related assessment findings

• Finding Patterns: Identifying relationships among clusters

• Data Interpretation: Drawing conclusions from clustered data

Components of a Problem-Focused Diagnosis (3 Parts)

1. Diagnostic Label – name of the problem

2. Related Factor – cause or contributing factor

3. Defining Characteristics – signs and symptoms

Rationale:
Each part guides intervention selection and outcome planning.

Components of an At-Risk Diagnosis (2 Parts)

1. Diagnostic label

2. Risk factors

No “As Evidenced By” because the problem has not occurred yet.

Prioritizing Nursing Diagnoses

Nurses consider:

• Patient safety

• Severity of condition

• Physiological needs first

• Patient preferences

• Changes in patient condition

Priorities change as patient status changes.

Diagnostic Error

Occurs due to:

• Incomplete assessment

• Failure to validate data

• Incorrect data interpretation

• Jumping to conclusions

Prevention

• Reassess

• Validate findings

• Compare subjective and objective data

• Use clinical judgment

True / False – Nursing Diagnosis

• Identifies patient response → True

• Multiple problems in one diagnosis → False

• Based on subjective & objective data → False

• Identifies patient problem, not intervention → True

• May include response to disease or treatment → True

• Avoid legally inadvisable statements → True

• Single symptom sufficient → False

Planning & Outcomes – Step 3

SMART Goals

• Specific

• Measurable

• Attainable

• Relevant

• Time-limited

Outcomes Identification – Nurse Asks

1. What do I want the patient to achieve?

2. Is it measurable?

3. Is it realistic?

4. What timeframe is appropriate?

Interprofessional Collaboration

Team-based approach involving nurses, providers, therapists, pharmacists, and others.

Nurse’s Role

• Coordinate care

• Communicate patient needs

• Advocate for patient safety

• Implement and evaluate care

Dependent vs Independent Interventions

Dependent

• Require provider order

Independent

• Nurse-initiated

Correct Placement

Dependent

• Administering Tylenol

• Requesting crutches

• Inserting Foley catheter

Independent

• Admission assessment

• Repositioning patient

• Assisting ambulation

• Teaching medications

• Discharge instructions

• Glucometer education

Implementation – Step 4

Environmental Factors That Promote Healing

• Lighting

• Noise control

• Temperature

• Cleanliness

• Safety

Direct vs Indirect Care

Direct Care

• Performed with patient

• Example: IV insertion, wound care

Indirect Care

• Performed away from patient

• Example: Documentation, care coordination

Patient Adherence

Patient’s ability to follow treatment plan.

Importance

• Essential for achieving outcomes

• Influenced by education, culture, support, understanding

Evaluation – Step 5

Evaluation determines whether outcomes were:

• Met

• Partially met

• Not met

Evaluation statements:

• Are measurable

• Are written in past tense

Correct statement:

Clinical Judgment & Critical Thinking Require

• Analysis

• Reflection

Care Plan Revision (Javier Case Study)

• Care plan is revised, not discontinued

• Original diagnosis was appropriate

• Timeframe was unrealistic

• Interventions needed adjustment

• Revised plan + enema → outcome met

Why Documentation Matters

• Demonstrates quality care

• Supports continuity of care

• Provides legal protection

• Shows effectiveness of nursing interventions

Bottom Line for Exam 2

If you can:

• Identify the nursing process step

• Distinguish subjective vs objective

• Write SMART outcomes

• Choose correct intervention types

• Evaluate correctly (past tense, measurable)

You are well above the class average for this exam.