Ivy Tech Fundamentals Of Nursing Test 1 Practice

Nursing diagnoses are based on the nurse’s assessment data—what the patient reports, what is observed, and how the patient responds to health issues. This collection of assessment findings, patient responses, and behaviors provides the real-time picture of the patient’s status and helps the nurse identify actual or potential problems that nursing care can address. That’s why assessment findings, patient responses, and behaviors are the best data source for formulating a nursing diagnosis. Medical test results, physician notes, and billing information aren’t the primary basis for a nursing diagnosis. Medical tests and physician notes guide medical diagnoses and treatment plans, while billing data serves administrative purposes. They may inform care in a broader sense, but the nursing diagnosis specifically rests on the nurse’s own assessment data about the patient.