Nursing Assessment Exam 1 (1-9) 100% Correct
Answers | Verified | Latest 2024 Version
What are the 6 steps of the nursing process? if asking for 5 remove (outcome identification) -
ADOPIE
Assessment
Diagnosis
Outcome Identification
Planning
Implementation
Evaluation
What are the types of...
Nursing Assessment Exam 1 (1-9) 100% Correct
Answers | Verified | Latest 2024 Version
What are the 6 steps of the nursing process? if asking for 5 remove (outcome identification) - ✔✔
ADOPIE
Assessment
Diagnosis
Outcome Identification
Planning
Implementation
Evaluation
What are the types of Health Assessment? - ✔✔
1) Comprehensive assessment
2)Problem-based/Focused assessment
3) Emergency assessment
What are the 3 primary components of Health Assessment? - ✔✔
History (subjective data)
Physical examination (objective data)
Documentation of data
Why do we document all of our data? - ✔✔
Improves plan of care
It is a legal document of patient's health
Draws a baseline for future evaluations
It must be accurate, concise, and without bias
,T/F If it is not documented you did not do it. - ✔✔True
What is context of care? - ✔✔it refers to circumstance or situation related to health care delivery.
1) may be related to setting or environment
2) may be related to physical, psychological, or SES circumstances involving the pt.
What is a comprehensive assessment? - ✔✔A detailed H&P exam performed at the onset of care in a
primary care setting or on admission to a hospital or long-term facility.
What is a Problem-based/focused assessment? - ✔✔the problem-based or focused assessment involves
a history and examination that are limited to a specific problem or complaint. This type of assessment is
most commonly used in a walk-in clinic or emergency department, but it may also be applied in other
outpatient setting.
What is emergency assessment? - ✔✔life-threatening situation
What is a screening assessment? - ✔✔a short examination focused on disease detection. usually
conducted in health fairs.
What is Health promotion? - ✔✔Behavior motivated by desire to increase well-being and actualize
health potential.
What is Health protection? - ✔✔Behavior motivated by desire to avoid illness, detect illnesses early, and
maintain functioning when ill.
What are the 3 levels of health promotion? - ✔✔Primary= preventing disease from developing through
promoting a healthy lifestyle.
Secondary= Screening efforts to promote early detection of disease.
Tertiary= minimizing disability from acute or cronic illness or injury and allowing for most productive life
within lilmitations.
,What are examples for the 3 levels of health promotion? - ✔✔Primary= Immunizations
Secondary= Mammogram
Tertiary = The disease is already present: Hypertension management.
A mother of three is being seen for a screening assessment. While planning the initial part of the visit
with this patient, the nurse needs to ensure that:
a)The patient receives a refill for her thyroid medication.
b)The patient is instructed on preventive measures for hypertension.
C)Other family members are present during the interview.
D)Information about the patient's lifestyle habits is gathered. - ✔✔Correct Answer: D
Rationale: There are multiple types of health assessments. If a patient receives a refill, this is an episodic
or follow-up assessment. If a patient is instructed in preventive measures, this is more along the lines of
a comprehensive assessment. A screening assessment would require the nurse to have data about
lifestyle habits.
The medical-surgical nurse is reviewing the practice related to a patient who acquired pneumonia while
recovering from a hip replacement. The unit documents this event as failure to rescue and would like the
nurse to develop a personal professional action plan. This plan will most likely include:
A)Reflection on action
B)Tertiary prevention of health care-associated infections
C)Reasoning patterns - ✔✔Correct Answer: A
Rationale: Reflection on action represents the contribution of an experience to a nurse's collective
experiences. Reflection in action specifically relates to evaluating outcomes of interventions. The nurse
needs to look at his practice to identify whether something can change.
A nurse is assessing a female teenager. The nurse asks the young woman to bend over and touch her
toes. The nurse assesses the curvature of the spine as a means of detecting scoliosis. Assessing the
curvature of the spine is an example of:
A)Health education
, B)Primary prevention
C)Secondary prevention
D)Tertiary prevention - ✔✔Correct Answer: C
Rationale: Primary prevention is preventing the disease before it begins. Secondary prevention means
that the nurse is trying to detect disease as early as possible to improve outcomes.
What are the two primary components of health assessment? - ✔✔Health history
Physical examination
Is a health history subjective or objective data? - ✔✔Subjective
Single-most important factor for successful interviewing is the ______ skill of the nurse. -
✔✔communication
What are some factors that affect a nurses therapeutic communication? - ✔✔Physical setting, nurse
behaviors, type of questions asked, how questions are asked. Behavior of pt. How the pt. feels during the
interview, nature of information being discussed or problem being confronted
Begin interviews with what type of questions? - ✔✔open-ended. encourage a free-flowing open
response.
If want more precise data from your patients what type of question should you ask? - ✔✔Close-ended
What do directive questions do? - ✔✔lead patient to focus on one set of thoughts. Most often used in
reviewing systems and evaluation functional status.
Use _____ to help concentrate on pt. responses and subtleties. - ✔✔listening
_______ uses verbal and nonverbal phrases to encrourage patinets to continue to talk further. -
✔✔Facilitation
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