Nurs 120 Exam 2 Study Guide Questions and Answers Top Graded
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Module
Nurs 120
Institution
Nurs 120
what are the 5 steps of the nursing process?
-assess
-diagnose
-plan
-implement
-evaluate
what is the formula for writing a the actual problem in a nursing care plan?
nursing diagnosis/patient problem related to the cause of the problem
(ex. acute pain related to injury)
(ex. dehydration r...
Nurs 120 Exam 2 Study Guide Questions and
Answers Top Graded 2024-2025
what are the 5 steps of the nursing process?
-assess
-diagnose
-plan
-implement
-evaluate
what is the formula for writing a the actual problem in a nursing care plan?
nursing diagnosis/patient problem related to the cause of the problem
(ex. acute pain related to injury)
(ex. dehydration related to diarrhea and vomiting)
what is the formula for writing the potential problem in a nursing care plan?
risk for nursing diagnosis/problem, risk factors; list of risk factors
(ex. risk for infection, risk factors: open wounds and malnutrition)
what is the formula to writing an outcome/goal (short/long term) in a nursing care
plan?
patient will + behavior + time frame
(ex. patient will report tolerable pain level <4/10 w/in 1 hr of administering
hydromorphone)
what is the formula to writing an implementation (intervention) in a nursing care
plan?
nurse will + behavior + time frame + rationale + citation
(ex. nurse will administer hydromorphone 1mg IV every 3 hrs as needed to treat
pain (davi's drug guide, 2022, p.640)
what is the formula to writing an evaluation in a nursing care plan?
outcome + met/partially met/not met + evidence +
will continue/modify/discontinue POC (plan of care)
NURS 120 exam 2
,NURS 120 exam 2
(ex. outcome met, the patient reported pain 2/10 1hr after administration of
hydromorphone, cont. with POC)
(all components must be met, if only some met then the outcome is partially
met)
(evaluate the goal not each intervention)
what are the negative effects of immobility on the cardiovascular system?
-increase cardiac workload
-increase risk for orthostatic hypotension
-increase risk for venous thrombosis
what are the negative effects of immobility on the respiratory system?
-decrease rate of respirations
-pooling of secretions
-impaired gas exchange
what are the negative effects of immobility on the GI system?
-decrease appetite
-alt. protein metabolizm/digestion/nutrients
-decrease peristalsis
what are the negative effects of immobility on the urinary system?
-increase urine retention
-increase kidney stones
-decrease bladder muscle tone
what are the negative effects of immobility on the musculoskeletal system?
-decrease muscle size/tone/strength
-decrease joint mobility/flexion
what are the negative effects of immobility on the integumentary system?
-increase risk for skin breakdown
what are the negative effects of immobility on the metabolic system?
-increase electrolyte imbalance/exchange of nutrients/gas
what are the negative effects of immobility on the pysiological system?
NURS 120 exam 2
, NURS 120 exam 2
-decrease social interaction
-decrease sensory stim.
-increase depression
What is the supine position?
lying of back
what is prone position?
lying on stomach
What is Semi-Fowler's position?
head elevated 30-45 degrees
What is Fowler's position?
Sitting with head 45-60 degrees elevated
what is high-fowlers position?
head elevated 60-90 degrees
NURS 120 exam 2
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