«(CO #1) – Utilize prior knowledge of theories and principles of nursing and related disciplines to explain
expected client behaviors, while differentiating between normal findings, variations, and abnormalities. (PO

1)

« (CO #2) – Recognize the influence that developmental stages have on physical, psychosocial, cultural,
and Spiritual functioning. (PO #1)

« (CO #4) – identify teaching/learning needs from the health history of an individual. (PO #2)

As the school nurse working in a college health clinic, you see many opportunities to promote health. Maria
is a 40-year-old Hispanic who is in her second year of nursing school. She complains of a 14-pound weight
gain since starting school and is afraid of what this will do to both her appearance and health if the trend
continues. After conducting her history, you learn that she is an excellent cook and she and her family love
to eat foods that reflect their Hispanic heritage. She is married with two school-age children. She attends
class a total of 15 hours per week, plus she must be present for 12 hours of labs and clinical. She
maintains the household essentially by herself and does all the shopping, cooking, cleaning, and
chauffeuring of the children. She states that she is lucky to get 5 hours of sleep per night, but that is okay
with her. She drinks coffee all morning to “keep her going.” She lives 1 hour from campus and commutes
each day, and often drinks diet cola to “stay awake.” When asked what she does to relax and de-stress,
Maria states she “doesn’t even have time to think about that.”

Maria’s vitals today are as follows; T 98.6, R 20, HR 88, BP 148/90

Using the lesson and text as your guide, answer the following questions.

1. What additional assessment data (subjective and/or objective) would you like to gather from Maria?
2. What actual health concerns and risk factors have you identified?
3. What are some opportunities to promote health and wellness for Maria?
4. Write one nursing diagnosis for Maria (actual, wellness or risk), based on one of the health concerns or opportunities you have identified.
   Weber, J.R. & Kelley, J.H. (2018). Health assessment in nursing (6th ed.). Philadelphia, PA: Wolters
   Kluwer.

• Chapter 2: Collecting Subjective Data: The Interview and Health History
• Chapter 4: Validating and Documenting Data (pp. 44-45 only)
• Chapter 5: Thinking Critically to Analyze Data and Make Informed Nursing Judgments

Sample Solution