All Actual Answers 2026 Updated.
Oder of assessment- IPPA - Answer Inspect, Palpate, Percuss, Auscultate
Order of assessment- IAPP - Answer Inspect, Auscultate, Percuss, Palpate
Sources of data- Primary - Answer Patient
Sources of data- Secondary - Answer Family, friends, other support people, other healthcare
professionals, medical records, labs & tests, & relevant literature.
Subjective data - Answer Information that's apparent to only the patient affected & can be
described or verified by only that patient. (Symptoms)
Objective data - Answer Information that's detectable by an observer or can be measured or
tested against an accepted standard. (Signs)
Erikson's stages of development (Birth-adolescents) - Answer Infancy: Birth-18 months, Trust
versus mistrust.
Early Childhood: 18 months-3 years, Autonomy versus shame and doubt.
Late Childhood: 3-5 years, Initiative versus guilt.
School Age: 6-12 years, Industry versus inferiority.
Adolescents: 12-20 years, Identity versus role confusion.
Assessment of bruits - Answer Turn the patient's head slightly away from the side being
examined. Rationale: This facilitates the placement of the stethoscope.
Auscultate the carotid artery on one side and then the other using the bell side of the
stethoscope.
Listen for the presence of a bruit (an abnormal sound heard with a stethoscope indicating
turbulent blood flow and carotid artery disease). If you hear a bruit, gently palpate the artery to
,determine the presence of a thrill (a vibration felt indicating turbulent blood flow and carotid
artery disease).
Assessment: Romberg Test - Answer Ask the patient to stand with feet together and arms
resting at the sides, first with eyes open, then closed. Stand close during this test. Rationale:
This prevents the patient from falling.
Negative Romberg: may sway slightly but is able to maintain upright posture and foot stance.
Positive Romberg: cannot maintain foot stance; moves the feet apart to maintain stance
-If patient cannot maintain balance with the eyes shut, patient may have sensory ataxia (lack of
coordination of the voluntary muscles).
-If balance cannot be maintained whether the eyes are open or shut, patient may have
cerebellar ataxia.
Assessment of thyroid - Answer Palpate the trachea for lateral deviation.
-Place your fingertip or thumb on the trachea in the suprasternal notch and then move your
finger laterally to the left and the right in spaces bordered by the clavicle, the anterior aspect of
the sternocleidomastoid muscle, and the trachea.
Abnormal: Deviation to one side, indicating possible neck tumor; thyroid enlargement; enlarged
lymph nodes
Assessment of JVD - Answer Inspect the jugular veins for distention while the patient is placed
in a semi-Fowler's position (15-45-degree angle), with the head supported on a small pillow.
Abnormal: Veins visibly distended (indicating advanced cardiopulmonary disease)
Assessment of pedal pulses - Answer Simultaneously and systematically palpate the peripheral
pulses on both sides of the patient's body individually (except the carotid pulse), to determine
the symmetry of pulse volume. If you have difficulty palpating some of the peripheral pulses,
use a Doppler ultrasound (DUS) probe.
Abnormal: Asymmetric volumes (indicate impaired circulation)
-Absence of pulsation (indicates arterial spasm or occlusion)
Decreased, weak, thready pulsations (indicate impaired cardiac output)
-Increased pulse volume (may indicate hypertension, high cardiac output, or circulatory
overload)
, Caring behaviors towards the dying client - Answer Arranging a visit from a spiritual leader or
loved one(s), honoring patient's wishes, being present, & providing comfort.
Concepts related to caring - Answer -Culture & diversity: Western cultural influences →
autonomous coping highly valued → sense of weakness associated with seeking social support
→ tendency to avoid asking for help when needed → ineffective self-care.
-Ethics: Conflict between providing the best possible care for the patient could clash with the
family's wishes or the constraining factors of the institution → leads nurse to experience moral
distress → ↑ feelings of stress → ↑ risk for burnout.
-Grief & loss: Western cultural influences assume personal autonomy and involvement in end-
of-life decisions and care → disregard for non-Western patient/family preferences regarding
end-of-life preferences → impaired patient/family/provider communication → increased grief
and unhappiness by patient and family during stressful life event.
-Professionalism: Inadequate self-care → decreased level of physical and psychosocial wellness
→ decreased quality of work performance and weakened affiliation with profession of nursing
→ decreased level of demonstrated professionalism toward patients, peers, and other members
of the healthcare team.
-Safety: Lack of knowledge regarding patient culture → incomplete nursing assessment and
miscommunication → poor patient outcomes and dissatisfaction with HCPs and facility.
-Stress & coping: Impaired coping → absence of self-care → stress, anxiety, or mild depression
→ errors in patient care
Stages of change - Answer -Precontemplation: Unaware of problem/Unable to accept
-Contemplation: May or may not commit
-Preparation: Begins to make plans for behavior change
-Action: Starts making changes
-Maintenance: Continued perseveration of changed behavior
Caring interventions - Answer -Presencing: Being present with a patient & being open, &
available at all levels w/out judging or labeling.