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NUR 310 Health Assessment Exam 1 Information questions with correct answers
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NUR 310 Health Assessment Exam 1Information questions with correct
answers
What are the different parts of The Nursing Process? - correct answer -Assessment,
Diagnosis/Analysis, Planning, Implementation, and Evaluation
What happens in the "Assessment" portion of The Nursing Process? (This is the first
step) - correct answer -Nurse collects data, and health assessment data is
characterized as either subjective or objective
What is subjective data? - correct answer -Data that includes interpretations and
information provided by an individual about himself or herself
- typically gathered from health history; pt. presents this information to you (ex: "I
feel nauseous")
What is objective data? - correct answer -Data that is measurable and observable
- typically obtained through physical examination or lab/diagnostic tests
- can be observed by someone else
**ALWAYS verify information from the patient!!
What is a health database? - correct answer -The patient's laboratory and diagnostic
studies, and objective and subjective data collected by the nurse
What happens during the "Diagnosis/Analysis" portion of The Nursing Process? (this
is the second step) - correct answer -the nurse analyzes the data collected during
the assessment using clinical judgement; nursing diagnosis is formed here; nurse
collaborates with patient to develop the plan of care and will identify both actual
and potential problems
What happens during the "Planning" step of The Nursing Process? (third step) -
correct answer -The nurse establishes priorities based on the patient outcomes and
NUR 310 Health Assessment Exam 1
,starts to identify interventions that will allow those outcomes to be met within a
timeframe
- identifies priorities: 1st, 2nd, 3rd level
First level priority problems - correct answer -emergent, life-threatening, and
immediate, such as establishing an airway or supporting breathing
Second-level priority problems - correct answer -those that are next in urgency
requiring your prompt intervention to prevent further deterioration. (mental status
change, acute pain, acute urinary elimination problem, untreated medical problems,
abnormal lab test results
Third-level priority problems - correct answer -those that are important to the
patient's health but can be addressed after more urgent health problems are
addressed. (Knowledge deficit, altered family processes, and low self esteem)
What happens during the "Implementation" stage of The Nursing Process? (fourth
step) - correct answer -the nurse will DO something
- implement evidence-based interventions in a safe and timely manner using
collaboration and delegation
What happens during the "Evaluation" stage of The Nursing Process? (fourth and
final step) - correct answer -The nurse will refer to established outcomes to:
1) evaluation individual's condition and progress toward outcomes
2) identify reasons for failure to achieve expected outcomes
3) take corrective action to modify plan of care
4) Document evaluation in plan of care
medical diagnosis - correct answer -has an actual pathophysiology; (ex: broken arm,
depression); the basis on which a nursing diagnosis can be made
nursing diagnosis - correct answer -NOT medical; decisions nurses make in response
to a medical diagnosis
NUR 310 Health Assessment Exam 1
,Nonmaleficence - correct answer -Duty to do no harm
Beneficence - correct answer -The "doing of good" ; return to health is the goal for
the patient!
Autonomy - correct answer -Individuals have the right to determine their own
actions and freedom to make their own decisions
Justice - correct answer -treat everyone fairly, regardless of their ability to pay for
treatment, social status, etc
Confidentiality - correct answer -respecting the rights of the pt. to maintain privacy
What are the ethical principles of nursing care? - correct answer -Nonmaleficence,
Beneficence, Autonomy, Justice, Confidentiality
What does the CDC recommend as the first line of defense to decrease nosocomial
infections and prevent transmission of microorganisms? - correct answer -hand
washing
Alcohol based hand rub - correct answer -kill more organisms more quickly, less
damaging to skin
- use mechanical soap-and-water washing when hands are visibly soiled
Standard precautions - correct answer -consider all waste and contact as potentially
infectious; they also ensure that all health care providers treat all patients equally
What is the intent of standard precautions? - correct answer -prevent disease
transmission during contact with non-intact skin, mucous membranes, body
substances, and blood-borne contacts
What can a latex allergy result from? - correct answer -repeated exposure to
proteins found in natural rubber latex through skin contact or inhalation
NUR 310 Health Assessment Exam 1
, - reaction can occur within minutes or hours
Why should gloves be worn, according to the CDC? - correct answer -1) to reduce
the risk of acquiring infections from patients
2) to prevent the transmission of flora from health care workers to patients
3) to reduce transient contamination of the hands of personnel by flora that can be
transmitted from one patient to another
**Gloves should NOT be worn from room out into the hallway
What are the different aspects of The Process of Communication? - correct answer -
Sending (nurse conscious of messages sent), Receiving (receiver uses his or her
own interpretations to process sent messages), Internal Factors (nurse maintains
respect, empathy, listening factors, self-awareness), External factors (nurse should
make sure the physical setting is comfortable)
What should be done to prepare for the physical assessment? - correct answer -1)
organize the examination
2) prepare the environment
3) prepare the patient
What are the four assessment techniques in order? - correct answer -Inspection,
Palpation, Percussion, Auscultation
What is the assessment order for the abdomen? - correct answer -Inspection,
Auscultation, Percussion, Palpation
What should be done during the "inspection" portion of the physical assessment? -
correct answer -look carefully and thoroughly at the patient; this offers an overall
impression of the patient and severity of the situation
- most revealing and provides a LOT of info
- note symmetry b/w right and left side, skin characteristics, shape of chest, facial
features, patient mood
NUR 310 Health Assessment Exam 1
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