Nursing 101 exam 2

Question 1

What is the Nursing Process? (the 5 parts)

Answer 1

1. assess
2. (nursing) diagnoses
3. planning and outcome identification
4. implement
5. evaluate

Question 2

List the 5 characteristics of the Nursing Process

Answer 2

1. Systematic

(part of an ordered sequence of activities)

2. Dynamic

(great interacting and overlap among the 5 steps)

3. Interpersonal

(human being at the heart of nursing)

4. Outcome oriented

(nurses and patients work together)

5. Universally Applicable

(a framework for all nursing activities)

Question 3

Give 3 potential errors in decision making

Answer 3

*Bias

* Failure to consider the total situation

* Impatience

Question 4

List the 7 characteristics of nursing Assessment

Answer 4

• purposeful
• prioritized
• complete
• systematic
• accurate
• relevant
• recorded in a standard manner

Question 5

List the four different types of nursing assessment

Answer 5

Question 6

which of the four nursing assessment types deals with

• getting info for a specific problem already identified or to identify new or overlooked problems
• happens during initial assessment or as routine ongoing data collection
• performed by a nurse to collect data about a specific problem

Answer 6

Focused Assessment

Question 7

Which of the 4 types of nursing assessment types is

• performed to identify life threatening problems
• performed when a physiologic or psychological crisis occurs
• performed by a nurse to gather data about a life threatening problem

Answer 7

Emergency Assessment

Question 8

Which of the 4 types of nursing assessments is

• performed shortly after admittance to the hospital or service
• performed to establish a complete database for problem identification and care planning
• performed by the nurse to collect data on all aspects of patients health

Answer 8

Initial Comprehensive Assessment

Question 9

Which of the 4 nursing assessment types is

• performed to compare a patient’s current status to baseline data obtained earlier
• to reassess health stautus and make necessary revisions in plan of care
• performed by the nurse to collect data about current health status of patient

Answer 9

Time-Lapsed Assessment

Question 10

What is the focus of Medical Assessments and what is the focus of Nursing Assessments?

Answer 10

Medical Assessments: target data to help identify disease

Nursing Assessment: focus on patients response to health problems; clinical judgment

Question 11

What is the difference between subjective data and objective data?

Answer 11

Subjective data: what the patient says they are feeling; you can’t see subjective (I feel tired, I have a headache)

Objective data: what you can observe, scientific data, visual

(vital signs, sweat, vomit, shivering, etc.)

Question 12

List five different sources (ways to obtain) a patients data

Answer 12

• patient
• family/significant others
• patient record
• medical history
• lab reports/ other diagnostic studies
• reports of therapy from other healthcare pros

Question 13

What is the purpose of nursing observation?

(what are you learning about the patient?)

Answer 13

to get the patients..

• current responses (physical and emotional)
• current ability to manage care
• determines the immediate environment and it’s safety
• determines the larger environment (hospital or community)

Question 14

What are these 4 phases referring to?

1. preparatory phase
2. Introduction
3. Working phase
4. Termination

Answer 14

The 4 phases of the nursing interview

Question 15

What is the purpose of doing a nursing physical assessment?

(3 reasons)

Answer 15

• Appraisal of health status
• Identify health problems
• establish a database for nursing intervention

Question 16

When does data need to be validated?

Answer 16

When there’s a discrepancy between what the person is saying and what the nurse is observing.

When the data lacks objectivity

Question 17

What is concept mapping?

Answer 17

a strategy where learners identify, link, and display key concepts.

cognitive tools for learning that promote critical thinking and self-directed learning

also called cognitive maps and mind maps

Question 18

List some ways to verify and validate data

Answer 18

• physical exam using proper equipment and procedure
• use clarifying statements
• share inferences with other team members

Question 19

Referring to Maslow’s Hierarchy of needs, what does Maslow say is the first two things you need before you can have anything else?

Answer 19

• Physiological (basic needs)

(air, food,water, sleep, homeostasis, excretion)

• safety

(security of body, morality, health)

Question 20

What is the specific type of practice that is a purposeful activity that leads to action, improvement of practice, and better patient outcomes?

(it’s about looking at an event, understanding it, and learning from it)

Answer 20

Reflective practice

Question 21

Describe the term Nursing Diagnoses

Answer 21

Actual or potential health problems that can be prevented or resolved by independent nursing intervention.

The nurse formulates, validates, and lists nursing diagnoses for each patient.

Question 22

What does Alfaro recommend using to organize assessment data to detect both nursing and medical problems?

Answer 22

he recommends using both a nursing model and a body systems approach

Question 23

The term nursing diagnoses first appeared in literature in the 1950’s. Hammond wrote that nurses need to be what?

Hammond wrote that nurses need to have a good background of what?

Answer 23

nurses need to be competant in information seeking strategies and should have a good background of theoretical knowledge to search for cues and evaluate evidence.

Question 24

What do you call a condition that necessitates intervention to prevent or resolve disease or illness or to promote coping and wellness

Answer 24

A health problem

Question 25

Nursing diagnoses are written to describe patient problems or issues that nurses can treat independently, such as ________, pain and comfort, and ______ integrity and perfusion problems

Answer 25

activity

tissue integrity

Question 26

Nursing diagnoses focus on unhealthy response to health and illness, whereas Medical Diagnoses ________ ________

Answer 26

identify diseases

Question 27

Medical diagnoses describe problems for which the physician directs the primary treatment, whereas nursing diagnoses describe problems treated by nurses within the scope of ____________ _______ ________

Answer 27

independent nursing practice

Question 28

A Nursing Diagnosis may change from day to day as the patient’s responses change, whereas as a Medical diagnosis……….

Answer 28

remains the same for as long as the disease is present

Question 29

Myocardial Infarction (heart attack) is a Medical Diagnosis. Examples of Nursing Diagnoses for a person with Myocardial Infarction may include Fear, Altered Health Maintenance, Deficient Knowledge, Pain, and altered Tissue Perfusion.

true or false?

Answer 29

true

Question 30

What are Collaborative Problems?

(according to Carpenito)

Answer 30

Certain physiologic complications that Nurses monitor to detect onset or changes in status.

Question 31

Are Collaborative Problems a type of diagnoses?

Answer 31

yes

Question 32

How are Collaborative Problems managed?

Answer 32

by using physician-prescribed and nursing-prescribed interventions

Question 33

When a Nurse writes patient outcomes that require delegated medical orders for goal achievement, is this situation considered a Nursing Diagnosis or a Collaborative Problem?

Answer 33

Collaborative Problem

Question 34

A helpful way to remember the difference between nursing diagnoses and collaborative problems is to connect the “ C’s “.

what does that mean?

Answer 34

Collaborative equals Complications

Question 35

If you were going to write a diagnostic statement for a collaborative problem, what would you be focused on writing about?

Answer 35

potential complications of the problem

(PC)