,NUR 155 Exam 2 – Foundations of Nursing – Actual
Q&A (GCN) (Updated PDF)
1. The nurse is preparing to assess a newly admitted client. Which action is the
first step in Caputi's clinical judgment model?
A) Making meaning of the information
B) Determining actions to take
C) Getting the information
D) Evaluating outcomes
Correct Answer: C) Getting the information
Rationale: Caputi's model begins with "Getting the Information," which involves
scanning the environment, identifying signs and symptoms, assessing
systematically, and ensuring accurate data. This foundational step precedes
interpretation and action.
2. A nursing student is learning about critical thinking indicators. Curiosity is
best demonstrated when the student:
A) Follows a checklist without deviation
B) Asks questions and seeks additional information
C) Accepts information without verification
D) Relies solely on the textbook
Correct Answer: B) Asks questions and seeks additional information
,Rationale: Curiosity is a critical thinking indicator characterized by an eagerness
to explore, ask questions, and pursue deeper understanding. It promotes
comprehensive assessment and clinical inquiry.
3. The nurse is reviewing a patient's care plan. Which statement is an example
of a subjective symptom?
A) The patient's skin is warm and dry.
B) The patient's blood pressure is 130/80 mmHg.
C) The patient reports feeling nauseated.
D) The patient has a productive cough with green sputum.
Correct Answer: C) The patient reports feeling nauseated.
Rationale: Subjective data are the patient's verbal descriptions of their
experience, such as pain, nausea, or anxiety. Objective data are observable and
measurable findings like vital signs or physical exam results.
4. A nurse is performing a comprehensive assessment. Which action ensures
accurate information?
A) Relying on the previous shift's report solely
B) Verifying findings with the patient and rechecking abnormal values
C) Documenting only normal findings
D) Skipping parts of the exam to save time
Correct Answer: B) Verifying findings with the patient and rechecking abnormal
values
, Rationale: Ensuring accurate information involves confirming data, rechecking
abnormal findings, and validating with the patient to avoid errors. This is a key
component of "Getting the Information."
5. A patient with diabetes is hospitalized for an infection. The nurse identifies
that the patient has a risk for unstable blood glucose. This is an example of
which type of nursing diagnosis?
A) Actual diagnosis
B) Risk diagnosis
C) Wellness diagnosis
D) Medical diagnosis
Correct Answer: B) Risk diagnosis
Rationale: A risk diagnosis describes a potential problem that may develop if
preventive measures are not taken, such as "Risk for Unstable Blood Glucose
Level." Actual diagnoses describe current problems, wellness diagnoses focus on
health promotion.
6. The nurse is planning care for a patient. Which goal is correctly written as a
short-term goal?
A) The patient will walk to the end of the hall by discharge.
B) The patient will remain free of infection throughout the hospital stay.
C) The patient will ambulate 50 feet with a walker by the end of the shift.
D) The patient will lose 20 pounds within 3 months.
Q&A (GCN) (Updated PDF)
1. The nurse is preparing to assess a newly admitted client. Which action is the
first step in Caputi's clinical judgment model?
A) Making meaning of the information
B) Determining actions to take
C) Getting the information
D) Evaluating outcomes
Correct Answer: C) Getting the information
Rationale: Caputi's model begins with "Getting the Information," which involves
scanning the environment, identifying signs and symptoms, assessing
systematically, and ensuring accurate data. This foundational step precedes
interpretation and action.
2. A nursing student is learning about critical thinking indicators. Curiosity is
best demonstrated when the student:
A) Follows a checklist without deviation
B) Asks questions and seeks additional information
C) Accepts information without verification
D) Relies solely on the textbook
Correct Answer: B) Asks questions and seeks additional information
,Rationale: Curiosity is a critical thinking indicator characterized by an eagerness
to explore, ask questions, and pursue deeper understanding. It promotes
comprehensive assessment and clinical inquiry.
3. The nurse is reviewing a patient's care plan. Which statement is an example
of a subjective symptom?
A) The patient's skin is warm and dry.
B) The patient's blood pressure is 130/80 mmHg.
C) The patient reports feeling nauseated.
D) The patient has a productive cough with green sputum.
Correct Answer: C) The patient reports feeling nauseated.
Rationale: Subjective data are the patient's verbal descriptions of their
experience, such as pain, nausea, or anxiety. Objective data are observable and
measurable findings like vital signs or physical exam results.
4. A nurse is performing a comprehensive assessment. Which action ensures
accurate information?
A) Relying on the previous shift's report solely
B) Verifying findings with the patient and rechecking abnormal values
C) Documenting only normal findings
D) Skipping parts of the exam to save time
Correct Answer: B) Verifying findings with the patient and rechecking abnormal
values
, Rationale: Ensuring accurate information involves confirming data, rechecking
abnormal findings, and validating with the patient to avoid errors. This is a key
component of "Getting the Information."
5. A patient with diabetes is hospitalized for an infection. The nurse identifies
that the patient has a risk for unstable blood glucose. This is an example of
which type of nursing diagnosis?
A) Actual diagnosis
B) Risk diagnosis
C) Wellness diagnosis
D) Medical diagnosis
Correct Answer: B) Risk diagnosis
Rationale: A risk diagnosis describes a potential problem that may develop if
preventive measures are not taken, such as "Risk for Unstable Blood Glucose
Level." Actual diagnoses describe current problems, wellness diagnoses focus on
health promotion.
6. The nurse is planning care for a patient. Which goal is correctly written as a
short-term goal?
A) The patient will walk to the end of the hall by discharge.
B) The patient will remain free of infection throughout the hospital stay.
C) The patient will ambulate 50 feet with a walker by the end of the shift.
D) The patient will lose 20 pounds within 3 months.
