Moderate

A nurse records weight gain, dependent oedema, elevated blood pressure and crackles at both lung bases. Which action represents analysis of the assessment data?

Correct answer: A. Group the findings as a possible fluid retention pattern

  • A. Group the findings as a possible fluid retention pattern
  • B. Record each finding without linking related information
  • C. Begin discharge teaching about a low-salt diet
  • D. Ask the patient whether the hospital food is acceptable

Explanation

Analysis involves clustering related cues and identifying patterns that may support a nursing diagnosis. Teaching and interventions should follow interpretation of the collected data, not replace it.

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About Nursing Process and Health Assessment

Assessment gathers subjective and objective data through health history, physical examination and observation. The nursing process then uses nursing diagnoses, planning, implementation and evaluation to provide individualised care, while distinguishing a nursing diagnosis from a medical diagnosis and identifying priorities such as airway, breathing, circulation and safety.

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