Nur 514 Exam Questions With Correct Answers Latest UPDATED 2024/2025 (100% SOLVED)

What are the 5 steps of the nursing process & an example of each? - answers Assessment - Collecting subjective & objective data from the patient Diagnosis -Data is collected & analyzed in order to make a nursing judgment Planning - Nurse decides the best plan while considering data Implementation -Carrying out the plan Evaluation -Determining whether plan was successful & what can be improved Write an example of an initial comprehensive assessment -ongoing/partial assessment - focused assessment & emergent assessment - answers Initial comprehensive: seeing a new patient for the first time at that practice Ongoing/partial: a check up/follow up Emergent: Pt coming into ER w/ gunshot wound Focused: Pt broke arm or is having stomach pains How can the nurse prepare for the assessment? - answers Review pt record Review pt previous & current health status w/ other healthcare professionals Take time to educate themselves about pt diagnosis & tests performed What is a nursing diagnosis? Give an example. - answers Data analyzed and by definition of NANDA "a clinical judgment concerning a human response to health conditions/life processes, or vulnerability for that response by an individual, family, group or community." It serves as a basis for nursing interventions w/ achievable outcomes by nursing staff Example: Pt came back from surgery → "Risk for infection r/t new incision & increased WBC from possible inflammation" What is the health belief model? When would we use it? - answers The health belief model is based on 3 concepts: the existence of sufficient motivation the belief that one is susceptible or vulnerable to a serious problem the belief that change following a health recommendation would be beneficial to the individual at a level of acceptable cost. Nur 514 Exam 1 Study Questions With Correct Answers Latest UPDATED 2024/2025 (100% SOLVED) This model would be used to analyze health promotion and disease prevention. What are some examples of subjective data? - answers Anything patient states Does not involve measured, numeric data Examples: sensations/symptoms, feelings, perceptions, desires, preferences, beliefs, ideas, values, personal information What are the 3 phases of the interview? Define them. - answers Pre Introductory: Review medical record Introductory: Nurse introduces themselves Explain purpose of the interview, what type of questions will be asked, and why they will be taking notes Nurses makes sure pt is comfortable and ensures their privacy Working phase: Nurse listens to patients comments on biographical data, reasons for seeking care, history of present health concern, past health history, family history, review of body systems for current health problems, lifestyle & health practices Nurse & patient together determine pt problem & goal Summary & Closing: Nurse summarizes information obtained during working phase & validates pt problems and goals They discuss possible plans to resolve the problem Nurse asks if there are any other questions or concerns Give examples of nonverbal communication & what to avoid when interviewing a patient - answers Nonverbal communication pertains to anything & everything that is not communicated directly using your voice to speak Examples: silence, stands (hands folded over chest), body language (standing vs. sitting, too much eye contact vs. not enough) Nurse interviewer should avoid silence & having an aggressive stance/body language, maintain an appropriate amount of eye contact Give examples of verbal communication tactics - answers Open ended questions Close ended questions Laundry listing Giving options: "is pain sharp, radiating, pulsing, etc." Rephrasing the question Well-placed phrases Inferring Providing information What are some examples of cultural - emotional & age related considerations when conducting an assessment? - answers Example: Assessment on Indian girl No male presence in the room, even if it is her father Have mom there for emotional support For age, do not ask any questions related to personal matters in front of her mom Age related example: hearing abilities of pt. Cultural example: space b/w you and pt. What mnemonic is used to explore pt symptoms? What does each letter in the mnemonic stand for? - answers COLDSPA Character: describe the signs/symptoms (feeling, appearance, smell, sound taste) Onset: when did it begin? Location: where is it? Where does it radiate? Other locations? Duration: how long does it last? Is it continuous or intermittent? Severity: how bad is the pain (0-10)? Pattern: what relieves it? What worsens it? Associated factors: other symptoms that may be related to the main symptom? What kind of information is explored when you review the lifestyle & health practice of the patient? - answers Description of a typical day (AM to PM) Nutrition & weight management 24 hr dietary intake (foods & fluids) Who purchases & prepares meals? Activities on a typical day Exercise patterns & habits Sleep & rest patterns Use of medications and other substances (caffeine, nicotine, alcohol, recreational drugs) Self concept Self care responsibilities Social activities for fun & relaxation Relationships w/ family, significant others, pets Values, religious affiliation, spirituality Past, current, & future plans for education Type of work, level of job satisfaction, work stressors Finances Stressors in life, coping strategies Residency, type of environment, neighborhood Environmental risks What are some examples of objective data? - answers Presence of a wound Vital signs Ht/wt General appearance Level of consciousness Anything the nurse can see with their own eyes What are the 4 physical exam techniques that you must do in order? - answers Inspection Palpation Percussion Auscultation Always inspect before touching pt so you don't change appearance of the skin What are the different types of palpation and when you would use them? - answers Types of palpation Light: place hand lightly on surface, very little or no depression, feel using circular motion Use for pulses, tenderness, skin texture, temperature, moisture Moderate Depress skin 1-2 cm w/ hand Use circular motion Use for feeling easily palpable body organs and masses Can note size, consistency, mobility of structures Deep Place dominant hand on skin, nondominant hand on top to apply pressure Depress b/t 2.5-5 cm Used for feeling very deep organs or structures covered by thick muscle Bimanual palpation Use 2 hands, place one on each side of body Use one hand to apply pressure, other hand to feel structure Use for noting size, shape, consistency, mobility of structures Used in OB settings often (breast & uterus exams) Why do we use percussion? - answers Eliciting pain Determining location, size & shape Determining density Detecting abnormal masses Eliciting reflexes What are standard precautions during an exam? - answers Standard precautions during an exam include hand hygiene, PPE such as gloves, gowns, masks, goggles, and face shields (this depends on the type of exam p. 33), patient placement, patient care equipment and instruments/devices, care of the environment, linen, and safe injection practices What are methods of validating your data? - answers Asking client additional questions for clarification Ask another healthcare provider to concur data Confirming data with a repeat assessment Examine subjective and objective discrepancies What is the HITECH act? What are the abbreviations used for medical records that are kept electronically? - answers Encourages use of health information technology (EHR) What does SBAR stand for? When and why would you use it? - answers Situation Background Assessment Recommendation Used to communicate assessment data, improves quality & safety outcomes when used by health team members to communicate or hand off client information (ex. report to next shift), decreases errors What is step one of analyzing data? Give an example of an identified strength and abnormal finding of both an objective and subjective piece of data: - answers - Identifying strengths and abnormal findings. -The nurse should compare data with reference standards. -The nurse should know basic risk factors based on data obtained (i.e. gender, age, genetics) - Example of strength in subjective: Pt. reports she sleeps well, 8 hours per night with no interruptions. -Example of abnormal in subjective: Pt. reports skipping meals -Example of strength in objective: BP in normal range -Example of abnormal finding in objective: BP out of normal range What is step 2 of analyzing data? Give an example? - answers -Cluster data. Group both abnormal cues and strength cues. "Parking lot" Example: Client may have a nonproductive cough w/ labored respirations at a rate of 24 per minute, however you have gathered no data on the status of breath sounds. Assess client breath sounds to formulate appropriate nursing diagnosis/ collaborative problems. What is step 3 of analyzing data? Give an example? - answers Draw inferences Requires nurse to document inferences about each cue cluster Consider nursing diagnosis, collaborative problem, and referrals Ex. diabetic pt is having difficulty understanding a diabetic diet so the nurse refers the patient to a dietitian What is step 4 of analyzing data? Give an example? - answers Propose possible nursing diagnoses wellness/health promotion - the pt and support system has motivation to increase well being and enhance health behaviors Risk diagnosis - pt doesn't have a problem but is vulnerable to developing it Actual diagnosis is current problem What is step 6 of analyzing data? Give an example? - answers Check for defining characteristics Ex. making sure related factors are present in patient to confirm or deny diagnosis What is step 6 of analyzing data? Give an example? - answers Step 6: confirm or rule out diagnosis If cue cluster doesn't meet diagnosis, rule it out Diagnosis should be verified with client and other HC professionals caring for the client Consult w/ family members, significant others, other HC professionals What is step 7 of analyzing data? Give an example? - answers Documenting conclusions Document all your observations and data that supports diagnosis , collaboration problems, referrals and nursing diagnoses. What is the difference between actual - risk for - health promotion - collaborative and medical diagnosis? - answers Actual: is actually happening to the patient Risk for: could potentially happen if we don't intervene Health promotion: intervene/educate to improve pt health outcomes after discharge Collaborative: referral to external providers Medical diagnosis: done by physician or other provider What is the SBIRT tool? When would you use it? Why? - answers SBIRT (Screening, Brief Intervention, and Referral to Treatment) is a quick assessment tool used to examine and approach unhealthy drug and alcohol use. It would be used in a situation where a substance abuse disorder is not present, but the individual may have unhealthy behaviors. It aims to encourage the individual to make healthy decisions. What is the CAGE assessment? When would you use it and why? - answers The CAGE assessment is a screening tool used when providers suspect that tps are experiencing possible issues related to alcohol or alcoholism. This screening tool is uncomfortable but can be useful in recognizing potential reliance on alcohol and can be used preventatively to get the pt support to prevent further problems. C: Have you ever tried to cut back on your use? A: Have you ever been annoyed/angered when questioned about your sue? G: Have you ever felt guilty about your use? E: Have you ever had an eye opener to get started in the morning? What are some cultural considerations when asking about lifestyle and health practices? - answers Religion can affect the way people perceive troubles, it often can help relieve anxiety of it There is a link b/t socioeconomic factors, HIV risk, depression, substance abuse, violence and Latina health disparities Some cultures encourage care of parents and others encourage independence Seeking help may be seen as weakness What are some differences between a patient with dementia and normal age-related changes? What is the SLUMS assessment? - answers Pt with dementia may ask the same question repeatedly, repeat the same story over and over, forget how to perform daily tasks, get lost in familiar surroundings, forget to maintain hygiene, and rely on someone else to answer questions or make decisions for them SLUMS is a tool to assess mental status of older adults to determine if dementia might be present EMAIL ME: For help with report, Assignment, Essay and thesis writing It asks questions about orientations, identification of familiar objects, and simple cognitive tasks What is the SAD assessment? When and why is it used? - answers The SAD PERSONS scale is used to assess suicide risk in patients. Each category that relates to the patient would score them a point. The categories that are looked at are: (men automatically get 1 pt since they follow through/ suicide more often than women) age (>20,<45), depression, previous attempt of suicide, alcohol abuse, rational thinking loss, lacking social support, organized plan of suicide, no spouse, availability of lethal means & sickness What is the PHQ-9? Why and when is it used? - answers PHQ-9 is a screening tool used for depression after the use of PHQ-2. It allows further assess to the access to the client that indicates depression on the PHQ-2 tool. What are abnormal findings for level of consciousness (LOC)? - answers Lethargy: opens eyes, answer questions, falls back asleep Obtunded: opens eyes to loud voice, responds slowly with confusion, and seems unaware of environment Coma: remains unresponsive to all stimuli, eye stay closed Stupor: awakens to vigorous shake/painful stimuli, but returns to unresponsive sleep What are abnormal findings of voice and speech problems? - answers Lethargy: opens eyes, answers questions, falls back asleep Obtunded: opens eyes to loud voice, responds slowly with confusion, and seems unaware of environment. Coma: remains unresponsive to all stimuli, eyes stay closed. Stupor awakens to vigorous shake/painful stimuli, but returns to unresponsive sleep. What is the Glasgow coma scale? What is a normal score? Abnormal? - answers The glasgow coma scale measures one's response to stimuli. A client who scores 10 or lower needs emergency attention. A client with a score of 7 or lower is in a coma. What are some potential health promotion diagnoses? - answers Young adult: readiness for enhanced knowledge, readiness for self-health management, readiness for enhanced relationships, readiness for enhanced parenting Middle aged adult: Readiness of enhanced knowledge, readiness for enhanced self health management, readiness for enhanced family processes, readiness for enhanced coping, readiness for enhanced family coping, readiness for enhanced community coping Older adult: Readiness for enhanced knowledge, readiness for enhanced self-health management, readiness for enhanced relationships, readiness for enhanced religiosity What are potential risk diagnoses? - answers The client does not currently have the problem but is vulnerable to developing it Ex. poor nutrition, immobility causing impaired skin integrity, incontinence Young adult: Risk for disturbed personal identity, self violence, isolation, ineffective relationships, impaired parenting, impaired attachment, post-trauma syndrome, loneliness, situational low self-esteem, suicide Middle-aged adult: Risk for disturbed personal identity, loneliness, low self-esteem, caregiver role strain, post-trauma syndrome, spiritual distress, grieving, suicide What are potential actual diagnoses? - answers Determined depending on individuals levels of assessed development. Nursing diagnosis can be labeled as primarily "psychosocial" (the client is currently experiencing the stated problem or has a dysfunctional pattern Ex. impaired skin integrity: reddened area on hip Young adult: Anxiety, disturbed body image, parental role conflict, ineffective coping, dysfunctional family, fear, ineffective health maintenance, deficient knowledge, sedentary lifestyle, moral distress, imbalanced nutrition, impaired parenting, posttrauma syndrome, riskprone health behavior, ineffective role performance, chronic low self esteem, sexual dysfunction, sleep deprivation, social isolation, spiritual distress Middle-aged adult: Anxiety, disturbed body image, caregiver role strain, decisional conflict, parental role conflict, defensive coping, deficient knowledge, compromised family coping, fear, anticipatory grieving, moral distress, imbalanced nutrition, posttrauma syndrome, sexual dysfunction, sleep deprivation, social isolation, spiritual distress Older adult: Anxiety, disturbed body image, decisional conflict, ineffective community coping, deficient diversional activity, fear, impaired home maintenance, interrupted family processes, hopelessness, impaired physical mobility, moral distress, imbalance nutrition, powerlessness, relocation stress syndrome, disturbed sleep pattern, social isolation, spiritual distress, impaired religiosity What are the routes to measure temperature? What are the normal and abnormal values? - answers Oral: