Test 1

Question 1

the nursing process-6 steps

Answer 1

Assessment, Diagnosis, Planning, Implementation, Evaluation

Question 2

assessment step

Answer 2

collect and document data using evidence based techniques

Question 3

diagnosis step and identify outcome

Answer 3

compare data to normal/abnormal values, interpret data, validate the diagnosis
identify the expected outcomes

Question 4

planning step

Answer 4

establish priorities, set timelines, set interventions, evidence based

Question 5

Benner’s stages (5)

Answer 5

Novice
Advanced Beginner
Competent
Proficient
Expert

Question 6

Clinical Judgement Model (Tanner)

Answer 6

Notice, Interpret, Respond, Reflect

Question 7

1st level priorities (definition)

Answer 7

emergent, life threatening, and immediate

Question 8

1st level priorities (examples)

Answer 8

airway, breathing, circulation

Question 9

2nd level priorities (definition)

Answer 9

requiring your prompt intervention to forestall further deterioration

Question 10

2nd level priorities (examples)

Answer 10

mental status changes, acute pain, infection risk, abnormal laboratory values, and elimination problems.

Question 11

3rd level priorities (definition)

Answer 11

important to the patient’s health but can be attended to after more urgent health problems are addressed

Question 12

3rd level priorities (examples)

Answer 12

lack of knowledge, mobility problems, and family coping

Question 13

purpose of palpation

Answer 13

assess the following factors: texture; temperature; moisture; organ location and size; and any swelling, vibration or pulsation, rigidity or spasticity, crepitation, presence of lumps or masses, and presence of tenderness or pain

Question 14

fingertip palpation

Answer 14

fine tactile discrimination, as of skin texture,swelling, pulsation, and determining presence of lumps

Question 15

grasping action of the fingers and thumb palpation

Answer 15

detect the position, shape, and consistency of an organ or mass

Question 16

dorsa (backs) of hands and fingers palpation

Answer 16

determining temperature because the skin is thinner than on the palms

Question 17

Base of fingers palpation or ulnar surface of hand

Answer 17

Best for vibration