The nurse is completing the health history on a patient admitted for cardiac rehabilitation. The health history is conducted in which step of the nursing process?

Question

a. Assessment
b. Diagnosis
c. Implementation
d. Evaluation

Answer 1

ANS: A
During the assessment step, patient care data are gathered through observation, interviews, and physical assessment. In the diagnosis step, patient data are analyzed, validated, and clustered to identify patient problems. Each problem is then stated in standardized language as a specific nursing diagnosis to provide greater clarity and universal understanding by all care providers. The implementation step includes initiating specific nursing interventions and treatments designed to help the patient achieve established goals or outcomes. In the evaluation step, the nurse determines whether the patient's goals are met, examines the effectiveness of interventions, and decides whether the plan of care should be discontinued, continued, or revised.