Answer to Question 1
D
After completing the client assessment, the nurse develops nursing diagnoses based on the data obtained. Nursing diagnoses distinguish the nurse's role from that of the physician, and help the nurse to focus on the role of nursing in client care.
Nursing diagnoses may facilitate communication among health professionals, but they do not necessarily render all client problems more quickly and easily resolved.
Medical problems are identified with medical diagnostic statements to treat a disease condition. Nursing diagnoses describe the client's actual or potential response to a health problem that the nurse is licensed and competent to treat. Nursing diagnoses distinguish the nurse's role from that of the physician.
Although the nursing diagnosis is part of basic nursing preparation in Canada, it has not yet been incorporated into provincial or territorial nursing practice standards or legislation. The exceptions are Ontario and Saskatchewan, where practice standards require the formulation and docu-mentation of nursing diagnoses.
Answer to Question 2
B
The first step in establishing the database is to collect subjective information by interviewing the client.
The physical examination follows the client interview so that data can be verified.
A review of medical records is not the first step the nurse should take in the process of data col-lection. The medical record is a valuable tool for checking the consistency and congruency of personal observations made during the client interview.
Discussion with other health team members may provide additional information and be used to relay information, but it is not the first step in the process of data collection.
Pupil assessment; B, moving penlight directly in front of pupil.
Assessment of coordination: heel slide.
NURSE CARING BEHAVIORS AS
Patient teaching: lung assessment
Nursing history for musculoskeletal assessment