Post RN BSN Advanced Concepts in Nursing I – Unit I Nursing Process and Nursing Diagnoses Solved Answers

Printing and copying of this article are not allowed. Please read it online at POST RN BSN Nursing Resources.

Post RN BSN Advanced Concepts in Nursing I – Unit I Nursing Process and Nursing Diagnoses Solved Answers

Posted by POST RN BSN Resources · Original syllabus post: April 12, 2019 · Category: Post RN BSN Nursing Course Syllabus

Post RN BSN Nursing – Advanced Concepts in Nursing I (ACN-I), Course No. 701 – Part 1 of 12. Expanded exam-style model answers for Unit I of the LUMHS Post RN BSN syllabus: the nursing process, its components and benefits, the format of a nursing diagnosis and of a nursing care plan, and the process step by step with examples. Use them as a study guide and write in your own words in the exam hall.

Please note: The syllabus lists topics only. These are exam-style questions and model answers prepared from those topics; they are not an official LUMHS paper or answer key. Patient examples are made up for learning. Nursing diagnosis wording follows NANDA International usage; check the current edition and your institution’s format.

📚 Course syllabus: Advanced Concepts in Nursing I (ACN-I, Course No. 701), LUMHS Post RN BSN – read the full course syllabus here.

In this article

1. Unit I – Nursing Process and Nursing Diagnoses

Nursing Process and Nursing Diagnosis Solved Answers | Post RN BSN ACN-I

Unit I: Nursing Process and Nursing Diagnoses

Course syllabus · Model exam answers

B.Sc NURSING (POST-RN), FIRST YEAR, SEMESTER-I

ADVANCED CONCEPTS IN NURSING I (ACN-I) – COURSE NO. 701

UNIT I: NURSING PROCESS AND NURSING DIAGNOSES

Credit hours: 6Source: course syllabus

Evaluation: Internal 20%, External (final) 80%

Syllabus topics: Nursing process; components of the nursing process; benefits of the nursing process; format of a nursing care plan; format of a nursing diagnosis; the process itself.

Note: the syllabus lists only six headings for this unit, so the questions below are expanded to cover assessment, diagnosis, planning, implementation, evaluation and documentation in the depth a Post RN student is expected to know. Your institution may prefer a particular care-plan format; follow it in clinical work.

Q-1. Define nursing process. Describe its historical development and characteristics.

The nursing process is a systematic, scientific, problem-solving method used by nurses to assess a client’s health needs, identify problems, plan, give and evaluate individualized care. It is a framework that organizes nursing thinking and action.

Historical development

Period	Development
1955	Lydia Hall described nursing care as a process
1959–1961	Johnson, Orlando and Wiedenbach described three or four step processes (assessment, planning, implementation, evaluation)
1967	Yura and Walsh described four phases and 1970s authors added diagnosis as a separate step
1973	The American Nurses Association adopted standards of practice based on the nursing process
Today	Five steps (ADPIE) are taught worldwide; many programmes add outcome identification as part of planning

Characteristics

• Systematic: follows an organized order of steps.
• Dynamic and cyclical: steps overlap and repeat.
• Client-centred: individual needs and participation.
• Goal-directed (outcome-oriented).
• Interpersonal and collaborative: client, family and health team.
• Based on critical thinking and decision making.
• Universal: can be used in any setting and for any age.
• Flexible, and adaptable to the situation (including emergencies).

Q-2. Describe the components (steps) of the nursing process.

The nursing process (ADPIE).

Step	Purpose	Main activities	Product
1. Assessment	Collect and organize data about the client	Interview, observation, physical examination, review of records; validate and document data	Database
2. Diagnosis	Interpret data and name client problems	Analyze and cluster data, identify strengths and problems, state nursing diagnoses and collaborative problems	Nursing diagnosis list
3. Planning	Decide how to prevent, reduce or resolve problems	Set priorities, write goals and expected outcomes, select interventions, write nursing orders	Nursing care plan
4. Implementation	Put the plan into action	Reassess, perform and delegate interventions, teach, coordinate, document	Interventions and records
5. Evaluation	Decide if goals were met	Compare outcomes with data, analyze reasons, continue, modify or stop the plan	Evaluation statement

Some authors add a sixth stage, outcome identification, between diagnosis and planning.

Q-3. What are the benefits of the nursing process?

To the client	To the nurse	To the profession and health system
Individualized, continuous and safe care; participation in decisions; better outcomes; less duplication	Organized thinking; better use of time; confidence and job satisfaction; basis for communication and documentation; professional growth	Defines the unique role of nursing; standard of practice; basis for research, audit and legal protection; improves quality and continuity of care

• Provides a common language for the team (nursing diagnoses).
• Prevents omissions and errors; makes care measurable.
• Promotes critical thinking and evidence-based practice.

Q-4. Explain the assessment step. Describe the types of data and the sources and methods of collection.

Assessment is the systematic, continuous collection, organization, validation and recording of data about the client’s health status.

Classification	Meaning	Example
Subjective (symptoms, covert)	What only the client can describe	“I have a headache.” Pain, nausea, fear
Objective (signs, overt)	Observable and measurable by the nurse	BP 150/90 mmHg, temperature 38.5°C, pallor
Primary data	From the client	Client’s own words
Secondary data	From family, chart, health team, literature	Relative reports a fall, lab results
Constant / variable	Does not change (age, blood group) / changes (pulse, mood)

Types of assessment

Type	Description	Example
Initial (comprehensive)	On admission; full database	Admission assessment using Gordon’s patterns
Problem-focused	Specific problem	Pain assessment
Emergency	Life-threatening; quick (ABC)	Airway, breathing, circulation check
Time-lapsed (ongoing)	Compare with baseline after a period	Reassessment each shift

Sources

• Client (primary), family and significant others, health team, medical records, laboratory and diagnostic reports, literature.

Methods

• Observation (using all five senses throughout the contact).
• Interview (health history; therapeutic communication; open and closed questions).
• Physical examination (inspection, palpation, percussion, auscultation, measurements).
• Review of records and tests.

Q-5. Describe the steps of data collection, validation, organization and documentation.

1. Collect data in an organized way using a framework (Gordon’s Functional Health Patterns, body systems, head-to-toe, Maslow’s needs).
2. Validate data: check accuracy and completeness (repeat measurements, compare subjective with objective, involve another nurse, clarify with the client).
3. Organize and cluster data to see patterns and gaps.
4. Document data accurately, completely, objectively and promptly; use the client’s words in quotation marks; avoid vague terms such as “good” or “normal” without a measurement.

Common errors: making assumptions, incomplete data, recording judgements rather than observations, mixing up data of different clients, delay in recording.

Q-6. What is a nursing diagnosis? How does it differ from a medical diagnosis? State its purposes.

According to NANDA International, a nursing diagnosis is a clinical judgement about a human response to health conditions or life processes, or a vulnerability to that response, by an individual, family, group or community. It provides the basis for selecting interventions to reach outcomes for which the nurse is accountable.

Point	Nursing diagnosis	Medical diagnosis
Focus	Client’s responses to illness or life process	Disease or pathology
Made by	Nurse	Physician
Treated by	Nursing interventions (independent)	Medical treatment: drugs, surgery
Changes	Changes as responses change, often quickly	Remains the same while the disease lasts
Orientation	Whole person; individual, family, community	Disease process
Example	Ineffective airway clearance	Pneumonia

Purposes

• Gives a standard language for nursing.
• Directs planning of care and selection of interventions.
• Identifies the nurse’s area of responsibility.
• Provides a basis for outcome evaluation, research and education.

Collaborative problems

Some problems, such as potential complications of a disease (e.g. haemorrhage after surgery), are managed jointly with the physician; they are written as “Risk for complication: …”, and nurses monitor and manage them with medical orders.

Q-7. Classify nursing diagnoses and describe their types.

Type	Description	Example
Problem-focused (actual)	A human response that is present, supported by defining characteristics	Acute pain related to surgical incision, as evidenced by grimacing and rating 7/10
Risk	Vulnerability to a problem; supported by risk factors, not by signs	Risk for infection related to invasive catheter
Health promotion	Motivation and desire to increase well-being (formerly “wellness”)	Readiness for enhanced nutrition
Syndrome	A cluster of problems that occur together	Frail elderly syndrome
Possible (older term)	Suspected problem needing more data; not used in current NANDA-I lists	Possible low self-esteem

NANDA-I organizes diagnoses in domains and classes, and revises the list regularly; always use the current edition.

Q-8. Describe the format of a nursing diagnosis. Give examples and the rules for writing it.

PES format of a nursing diagnosis.

Type	Format	Example
Problem-focused	Problem (label) + related to + etiology + as evidenced by + defining characteristics	Impaired physical mobility related to pain and weakness as evidenced by reluctance to move and reduced range of motion
Risk	Risk label + as evidenced by risk factors (two parts)	Risk for falls as evidenced by age over 65, dizziness and unfamiliar environment
Health promotion	Readiness label (one part)	Readiness for enhanced knowledge

Rules for writing

• Use the standard NANDA-I label as the problem; never write a medical diagnosis as the nursing problem. Prefer a cause that nursing care can change (write “Acute pain related to surgical incision”, not “related to appendicitis”).
• The etiology must be something nursing interventions can change.
• Do not write the nursing diagnosis as a nursing need (“needs suction”) or as a goal.
• Avoid legally risky or judgemental statements (“non-compliant due to laziness”).
• Do not write it as a sign or symptom alone, and do not reverse the cause and the effect.
• State the problem and its cause in clear, specific terms; use a single problem per diagnosis.
• Base it on data and keep it client-centred.

Q-9. Describe the diagnostic process: how does the nurse reach a nursing diagnosis? How are priorities set?

Steps

1. Analyze data: compare with norms, identify patterns and gaps.
2. Identify health problems, risks and strengths.
3. Formulate diagnostic statements (PES).
4. Validate with the client, colleagues and reference sources.
5. Document the list of diagnoses, then set priorities.

Setting priorities

Method	Explanation
Maslow’s hierarchy	Physiological needs (airway, breathing, circulation) → safety → love and belonging → esteem → self-actualization
ABC	Airway, Breathing, Circulation first
High, intermediate, low	High: life-threatening (ineffective airway clearance). Intermediate: non-life-threatening but needing attention (acute pain). Low: not directly related to illness (readiness for enhanced knowledge)
Client preference and resources	Client’s values, available time, staff, equipment, urgent versus important issues

Example (made up): a post-operative patient with pain, anxiety, and a potential for infection: priority order is usually airway and breathing (if compromised), then acute pain, risk for infection, then anxiety and knowledge needs.

Q-10. Explain the planning step. What are goals and expected outcomes? How are they written?

Planning is the process of setting priorities, writing goals and expected outcomes, selecting interventions and writing the nursing care plan.

Term	Meaning	Example
Goal (long term)	Broad aim over weeks to months	Client will regain independent mobility
Goal (short term)	Aim in hours to days	Client will walk 10 metres with assistance by day 3
Expected outcome	Specific measurable client behaviour or sign showing the goal is met	Rest pain score 3 or less within 1 hour of analgesia

Writing outcomes: SMART and ABCD

SMART	ABCD
Specific, Measurable, Achievable, Realistic, Time-bound	Audience (client), Behaviour, Condition, Degree (and time)

Example: “The client (A) will walk (B) with a walker (C) for 20 metres without dizziness (D) by 3 June.”

• Client-centred (what the client will do, not what the nurse will do).
• One behaviour in each outcome; realistic and agreed with the client and family.
• Compatible with other therapies; use action verbs (state, walk, demonstrate); avoid “will improve”.

Q-11. Describe nursing interventions: types, selection and how to write nursing orders.

Type	Meaning	Example
Independent	Nurse initiates on her own judgement	Turning every 2 hours, teaching, positioning
Dependent	Carried out on physician’s order	Giving a prescribed antibiotic
Interdependent (collaborative)	With other team members	Dietary plan with the dietitian and physiotherapy

Interventions can also be direct (with the client) or indirect (away from the client, such as ordering supplies or consulting). Classifications such as the Nursing Interventions Classification (NIC) and Nursing Outcomes Classification (NOC) provide standard language.

Selecting interventions

• Linked to the etiology and outcome.
• Safe, realistic and based on evidence.
• Acceptable to the client (culture, values).
• Within the nurse’s competence and the available resources.

Writing nursing orders

A good order includes: date, action verb, what, how, when, how often, and signature. Example: “12 June: Turn and reposition client every 2 hours; check skin over bony areas at each turn. (Signature)”. Give a rationale (reason) for each intervention.

Q-12. Describe the format of a nursing care plan. Define and classify care plans. Give a sample plan.

A nursing care plan is a written guide that organizes information about the client’s care: diagnoses, outcomes, interventions and evaluation.

Type	Description
Informal	Mental plan or verbal
Formal	Written; may be standardized or individualized
Standardized	Pre-printed for common problems; must be individualized
Individualized	Adapted to the client’s specific needs
Critical (clinical) pathways / computerized	Multi-disciplinary, time-based, electronic plans

Common format (5 columns)

Assessment (data)	Nursing diagnosis	Goal / expected outcome	Nursing interventions with rationale	Evaluation
Subjective: “I cannot cough anything out; I feel tight.” Objective: RR 28, SpO₂ 90%, thick yellow sputum, crackles in right base	Ineffective airway clearance related to thick secretions as evidenced by ineffective cough, crackles and SpO₂ 90%	Client will have a clear airway: SpO₂ 95% or above and clear breath sounds within 24 hours; client will demonstrate effective coughing within 8 hours	Position semi-Fowler’s (expands lungs); teach deep breathing and coughing; give fluids as allowed (liquefy secretions); give humidified oxygen and nebulization as ordered; chest physiotherapy; suction if needed; monitor respiratory status every 2 hours	After 24 hours: SpO₂ 96%, breath sounds clear, effective cough — goal met

A care plan must be dated, signed, updated regularly and should include discharge planning and client teaching.

Q-13. Explain the implementation step. What activities are involved?

Implementation is putting the care plan into action to reach the outcomes. It begins after the plan is written and continues with reassessment.

• Reassess the client (status may have changed).
• Review and revise the plan; prioritize.
• Organize resources: equipment, time, staff, environment, client readiness.
• Perform interventions safely (cognitive, interpersonal and technical skills); involve the client and family; teach.
• Delegate appropriately and supervise (five rights: right task, circumstance, person, direction/communication, supervision).
• Supervise, coordinate and communicate with the team.
• Document the care and the client’s response.

Nurses use three types of skills: cognitive (critical thinking), interpersonal (communication and caring), and technical (procedures).

Q-14. Explain the evaluation step. How is it done? Write an evaluation statement.

Evaluation is the planned, ongoing, purposeful judgement of the client’s progress toward outcomes and of the effectiveness of the nursing care plan.

Steps

1. Collect data about the client’s response.
2. Compare with the expected outcomes.
3. Decide: goal met, partially met or not met.
4. Identify factors that helped or hindered (was the assessment correct? were the goals realistic? was the plan carried out? did the client co-operate?).
5. Continue, modify or terminate the plan, and document.

Evaluation statement
Outcome: “Client will walk 20 metres with a walker without dizziness by day 5.” Evaluation: “On day 5, client walked 20 metres with walker, no dizziness, pulse 82 — goal met. Plan: continue gradual increase and discharge teaching.”

Type of evaluation	Meaning
Formative (ongoing)	During care; adjust the plan
Summative	At discharge or end of care
Structure, process, outcome	Quality assurance levels: resources, nursing actions, results

Q-15. Describe the methods of recording the nursing process (SOAP, SOAPIE, PIE, DAR, focus charting).

Format	Meaning	Example
SOAP	Subjective, Objective, Assessment, Plan	S: “It hurts when I breathe.” O: RR 26, SpO₂ 92%. A: Ineffective breathing pattern. P: Semi-Fowler, oxygen as ordered, reassess in 30 min
SOAPIE	SOAP + Intervention + Evaluation	I: Oxygen at 2 L/min started. E: SpO₂ 96%, less pain
PIE	Problem, Intervention, Evaluation	P: Acute pain; I: analgesic given, repositioned; E: pain 3/10
DAR (Focus)	Data, Action, Response	D: pain 8/10; A: analgesic given; R: pain 3/10 after 1 hour
Narrative	Chronological story	Used for many routine notes

Rules of recording

• Accurate, objective, complete, concise and legible; use accepted abbreviations.
• Date and time every entry; sign with name and designation.
• Record promptly, never in advance; do not erase (draw a single line and write “error”).
• Maintain confidentiality; follow hospital policy.
• “If it is not recorded, it was not done.”

Q-16. Explain the relationship between the nursing process, problem solving and critical thinking.

Problem solving / scientific method	Nursing process
Collect data; identify the problem	Assessment
Define the problem	Nursing diagnosis
Plan solutions; set objectives	Planning
Test the solution	Implementation
Evaluate the result	Evaluation

Critical thinking is purposeful, reflective, evidence-based thinking about what to believe and do. Elements: knowledge, experience, attitudes (curiosity, humility, perseverance, creativity, fair-mindedness) and intellectual standards (clarity, accuracy, relevance, logic). Nurses use critical thinking at every step to question assumptions, avoid errors and make safe decisions.

Related concepts include clinical judgement, concept mapping (diagrams linking problems, causes and interventions) and evidence-based practice.

Q-17. Solve these exercises (made up).

Exercise 1. Classify as subjective or objective: (a) “I feel dizzy.” (b) BP 90/60 mmHg. (c) Client is anxious (says “I am afraid”). (d) Urine output 200 mL in 8 hours. (e) Nausea.

Answer: (a) subjective; (b) objective; (c) subjective (statement), with objective signs if observed; (d) objective; (e) subjective.

Exercise 2. Write a PES nursing diagnosis: a bed-bound elderly client with redness on the sacrum, who cannot turn without help.

Answer: Risk for impaired skin integrity related to immobility and pressure over the sacrum (risk diagnosis), or, if skin is already broken, Impaired skin integrity related to prolonged pressure as evidenced by a 2 cm area of redness over the sacrum.

Exercise 3. Identify the error: “Nursing diagnosis: Needs oxygen related to pneumonia.”

Answer: It is a nursing need and uses a medical diagnosis as cause. Correct: Impaired gas exchange related to alveolar-capillary membrane changes as evidenced by SpO₂ 88% and dyspnoea.

Exercise 4. Rewrite this goal in SMART form: “Patient will improve nutrition.”

Answer: “Client will eat at least 75% of each meal and gain 0.5 kg within 7 days.”

Exercise 5. Order these by priority: anxiety about discharge, ineffective airway clearance, acute pain, knowledge deficit.

Answer: Ineffective airway clearance → acute pain → anxiety → knowledge deficit (airway first; knowledge needs later).

Q-18. Write the importance of the nursing process for a Post RN BSN nurse.

• It is the common framework for all later pattern-based assessment in this course (Gordon’s patterns, Parts 3–10).
• It makes care plans, case studies and clinical records organized and safe.
• It develops critical thinking and professional accountability.
• It is the basis of nursing research and quality improvement.

Conclusion: The nursing process is a continuous cycle of assessing, diagnosing, planning, implementing and evaluating, and good nursing care depends on using each step accurately and documenting it honestly.

Suggested references (see the syllabus page for its own reading list): Gordon, M. Manual of Nursing Diagnosis (Functional Health Patterns; latest edition). Jones & Bartlett / Elsevier.
Herdman, T. H., Kamitsuru, S., & Lopes, C. T. (Eds.). NANDA International Nursing Diagnoses: Definitions and Classification (current edition). Thieme.
Potter, P. A., & Perry, A. G. Fundamentals of Nursing (latest edition). Elsevier.
Smeltzer, S. C., & Bare, B. G. Brunner & Suddarth’s Textbook of Medical-Surgical Nursing (latest edition). Lippincott.
Kozier, B., Erb, G., et al. Fundamentals of Nursing (latest edition). Pearson.

Source syllabus: Post RN BSN Nursing ACN-I Course (course syllabus) (original post dated April 12, 2019).

Series (Advanced Concepts in Nursing I, Course No. 701): Part 1: Unit I – Nursing Process and Diagnoses. Part 2: Unit II – Theoretical Frameworks. Part 3: Unit III – Functional Health Patterns. Part 4: Unit IV – Health Perception and Health Management. Part 5: Unit V – Nutritional-Metabolic Pattern. Part 6: Unit VI – Elimination Pattern. Part 7: Units VII–VIII – Activity-Exercise and Coping-Stress. Part 8: Units IX–X – Sleep-Rest and Sexuality-Reproduction. Part 9: Units XI–XII – Role Relationships and Pain. Part 10: Units XIII–XIV – Self-Perception and Values-Beliefs. Part 11: Clinical Objectives. Part 12: Learning Advanced Nursing Concepts – facts, skills, uses, benefits and hurdles.

Independent educational resource: POST RN BSN Nursing Resources is not affiliated with, endorsed by or an official publication of LUMHS or PNMC. Model answers are study aids; verify against your course notes and textbooks.

POST RN BSN Nursing Resources