CSN Nursing 101 Exam 2--The Nursing Process Questions With 100% Correct Answers 2024

CSN Nursing 101 Exam 2--The Nursing Process Questions With 100% Correct Answers 2024 What is a nurse's framework for critical thinking? - answerThe nursing process If a patient had a goal of walking 150 steps by end of day, and only ended up walking 10, what would the nurse's next step be? - answerEvaluate the goal. Goal not met, so must re-assess: Was it a good goal? Restart the nursing process. Which are true of the nursing process? SATA. A. It is a framework for critical thinking. B. It helps to guide the nursing practice. C. It creates problems to solve. D. It is systematic. E. It is dynamic. F. It begins with a NANDA diagnosis. - answerA, B, D, E (C--it does not create problems; it is a problem-solving method. F--it begins with assessment, not diagnosis.) A patient's call light goes off. Upon entering, the nurse sees blood oozing out from a wrapped wound. What should the nurse do first? A. Call the physician on duty. B. Call another nurse for backup. C. Figure out what the situation is by removing the bandage. D. Get another bandage to soak up the bleeding. E. Amend the care plan. - answerC The first thing the nurse should do is ASSESS the situation. Patient Z is admitted to the hospital at 9:00 am for vomiting and diarrhea. What kind of assessment would the nurse perform? - answerInitial assessment Later than day, the nurse checks on Patient Z. What would you expect the nurse to check in his focused (priority) assessment of Patient Z? SATA. A. Vital signs B. Bowel sounds C. Pupil dilation D. Ability to walk - answerA, B The nurse would check vital signs (always) and the specific issue Patient Z came in for Patient P is admitted to the hospital at 11:00 pm with a gun shot wound. What kind of assessment would the nurse perform? - answerEmergency assessment, because although it is Patient P's initial visit, the situation is life-threatening. No time for a lengthy initial assessment. What are examples of time-lapsed assessments? SATA. A. Nurse checks on a patient one hour after pain meds are given to assess if pain has lessened. B. Nurse checks the healing progress of a wound after 30 days. C. Nurse follows up after revisions in the care plan. D. Nurse checks on a patient one hour after giving acetaminophen to determine if fever has decreased. - answerA, B, C, D Which assessment provides the baseline for all other assessments? - answerInitial assessment Which assessment includes a health history and head-to-toe assessment? - answerInitial assessment Which are primary sources for collecting data? SATA. A. Facebook profile B. Best friend C. Patient him-/herself D. Parent of an 18-year-old E. Parent of an 8-year-old - answerC, E What are examples of secondary data sources? SATA. A. Family members B. Health history C. Respiratory therapist report D. Lab reports E. Diagnostic tests F. Parent, if the patient is 20 years old - answerA, B, C, D, E, F Signs and Symptoms: what is the difference? - answerSigns--objective data. What can be measured. BP 130/80, temp 100.5. Symptoms--subjective data. What the patient tells you. "I feel sick." When taking a health history, what kind of information is gathered first: subjective or objective? - answersubjective Which is NOT a part of gathering a health history? A. Medications B. Socioeconomic status C. Health habits