Exam 3

Question 1

What is subjective data in nursing assessment?

Answer 1

What the patient says (e.g., “I have chest pain”)

Subjective data reflects the patient’s personal experiences and symptoms.

Question 2

What is objective data in nursing assessment?

Answer 2

What you observe/measure (e.g., HR 120 bpm)

Objective data includes measurable and observable facts.

Question 3

What are the sources of data in nursing assessment?

Answer 3

• Patient
• Family
• Health records
• Other caregivers

Question 4

What are the methods of data collection in nursing assessment?

Answer 4

• Interview
• Observation
• Physical exam

Question 5

What is the difference between subjective and objective data?

Answer 5

• Subjective = Symptoms: Pain, dizziness, fatigue
• Objective = Signs: Lab values, BP, wounds, vital signs

Question 6

What is a comprehensive assessment?

Answer 6

Full health history + physical exam (e.g., admission)

Question 7

What is a problem-oriented assessment?

Answer 7

Focused on specific issue

Question 8

What is a focused assessment?

Answer 8

For ongoing problems or changes

Question 9

What are open-ended questions?

Answer 9

Questions that encourage detail (e.g., “Tell me more…”)

Open-ended questions promote more detailed responses from patients.

Question 10

What are closed-ended questions?

Answer 10

Questions that elicit yes/no answers

Question 11

What are the phases of the nurse-patient helping relationship?

Answer 11

• Preinteraction
• Orientation
• Working
• Termination

Question 12

What is the purpose of the orientation phase?

Answer 12

Build trust, set goals

Question 13

What are therapeutic outcomes in nursing?

Answer 13

• Trust
• Collaboration
• Emotional support

Question 14

What does SBAR stand for?

Answer 14

• Situation
• Background
• Assessment
• Recommendation

Question 15

What are important communication techniques with older adults?

Answer 15

• Speak clearly
• Face them
• Reduce background noise
• Use gestures, touch (if appropriate)
• Allow extra time to respond

Question 16

What are effective strategies for communication with hearing-impaired patients?

Answer 16

• Sign language
• Whiteboards
• Speak slowly

Question 17

What should you do when communicating with unresponsive patients?

Answer 17

Always speak respectfully — they may hear you

Question 18

What are the purposes of patient education?

Answer 18

• Health promotion
• Illness prevention
• Restoration of health
• Coping with impaired function

Question 19

What are the basic learning principles in patient education?

Answer 19

• Motivation
• Readiness
• Ability to learn

Question 20

What is the difference between readiness and ability in learning?

Answer 20

• Readiness = Willingness (Are they open to learning?)
• Ability = Capacity (Can they understand and act?)

Question 21

What is the teach-back method?

Answer 21

Ask patients to explain how they will take their medication at home

Question 22

What are the purposes of health records?

Answer 22

• Communication
• Legal record
• Billing
• Research
• Education

Question 23

What are the legal guidelines for health records?

Answer 23

• Must be accurate
• Timely
• Legible
• Objective

Question 24

What does HIPAA stand for?

Answer 24

Health Insurance Portability and Accountability Act

Question 25

What are the five quality guidelines for health records?

Answer 25

* Factual * Accurate * Complete * Current * Organized

Question 26

What are the nursing diagnoses for mobility issues?

Answer 26

* Impaired bed mobility * Risk for pressure injury * Risk for falls * Social isolation

Question 27

What are the benefits of exercise?

Answer 27

* Improves cardiovascular/respiratory function * Enhances mood * Increases energy * Improves sleep * Prevents complications of immobility (e.g., DVT, pressure ulcers)

Question 28

What are the nursing interventions for impaired mobility?

Answer 28

* Encourage ROM * Use mobility aids * Gradually increase activity * Prevent falls and pressure ulcers

Question 29

What factors influence hygiene?

Answer 29

* Culture * Socioeconomic status * Physical condition * Developmental stage

Question 30

Who are at risks for oral mucous membrane issues?

Answer 30

* Chemotherapy * NPO * Oxygen use * Poor hygiene * Mouth-breathers

Question 31

What are the stages of pressure ulcers?

Answer 31

* Stage I: Red, non-blanching * Stage II: Partial-thickness loss * Stage III: Full-thickness, visible fat * Stage IV: Exposed bone/tendon * Unstageable: Necrotic tissue covering wound

Question 32

What are the healing promoters for wounds?

Answer 32

* Good nutrition * Hydration * Perfusion * Cleanliness

Question 33

What are the impediments to wound healing?

Answer 33

* Infection * Poor nutrition * Steroids * Smoking * Diabetes

Question 34

What is the difference between acute and chronic wound care?

Answer 34

* Acute: Timely healing, clean edges * Chronic: Takes longer, may need advanced dressings