NURS 202 – Midterm Exam Questions
with Complete Solutions
The Nursing Process - Answer-Systematic, person-centered, goal-oriented method of
caring that provides a framework for nursing practice. It is nursing practice in action
ADPIE - Answer--Assessment
-Diagnosis
-Planning/Outcome Identification
-Implementation
-Evaluation
Nursing Diagnosis - Answer-When nursing interventions are used to prevent or resolve
actual or potential health problems
Diagnostic Statement - Answer--Problem
-Etiology
-Defining Characteristics
(Ex: Anxiety (Problem) related to situational crises and stress (related factors) as
evidenced by restlessness, insomnia, anguish and anorexia (defining characteristics).
Sources of Data - Answer--Patient history
-Data from family
-Signs and symptoms
-Test results and findings
Assessing - Answer-Collection, validation, and communication of patient data
(identifying the patient needs)
Diagnosing - Answer-Analysis of patient data to identify patient strengths and health
problems that independent nursing interventions can prevent or resolve.
Outcome Identification & Planning - Answer-(1) Patient outcomes to prevent, reduce, or
resolve the problems identified in the nursing diagnosis
(2) related nursing interventions
Implementing - Answer-Carrying out the plan of care
Evaluating - Answer-Measuring the extent to which the patient has achieved the
outcomes specified in the plan of care; identifying factors that positively or negatively
influenced outcome achievement; revising the plan of care if necessary
SMART Outcomes - Answer--Specific
,-Measurable
-Attainable
-Realistic
-Time-framed
Outcome statement components - Answer--Subject
-Verb
-Condition
-Performance criteria/Qualifier
-Target time
SOAP - Answer--Subjective
-Objective
-Assessment
-Plan
SOAPIER - Answer--Subjective
-Objective
-Assessment
-Plan
-Implementation
-Evaluation
-Revision
PIO - Answer--Problem
-Intervention
-Outcome
DAR - Answer--Data
-Action
-Response
PIE - Answer--Problem
-Intervention
-Evaluation
CBE - Answer--Charting by exception
-This a shorthand method
Downside: does not prove useful when a negligence claim is made against a nurse
because of the lack of detail
Focus Charting - Answer--To bring the focus of care back to the patient and the
patient's concerns
-Holistic emphasis on the patient and the patients priorities
, Content - Answer--Enter information in a concise, complete, accurate, current, and
factual manner
-Record patient findings NOT your interpretation of these findings
-Record precautions and preventative measures used
-Avoid stereotypes or derogatory terms
Timing - Answer--Document in a timely manner
-This can be crucial if legal claims arise
-Use military time to avoid AM PM confusion
-Never document interventions before carrying them out
Format - Answer--Date and time each entry
-Use proper terminology
-Record nursing interventions in chronological order
Accountability - Answer--Sign your first initial and last name and title to each entry
-Use a pen, do not erase (single line through to omit an incorrect entry), and make note
saying "error in charting" or "mistaken entry"
-Recognize that the patient chart is permanent, and assure that it is complete before
submitting it to medical records
Confidentiality - Answer-Follow HIPAA guidelines
Validation - Answer-The act of confirming or verifying to keep data as free from error,
bias, and misinterpretation. Suspicions are not objective. Must validate suspicions with
pt
(ex. suspicion of hearing loss)
Observation - Answer-Conscious and deliberate use of the five senses to gather data
Observation of cues - Answer-Conscious and deliberate use of the five senses to gain
significant information that is helpful in making decisions. Make inference after
identifying cues.
Inference - Answer-Judgment reached about a cue. Validate after nurse inference.
Inductive Reasoning - Answer-Bottom-up logic. begin with some data, and then
determine what general conclusion(s) can logically be derived from those data.
Deductive Reasoning - Answer-Top-down logic. Begin with some statements, called
'premises', that are assumed to be true, you then determine what else would have to be
true if the premises are true.
Handwashing - Soap - Answer--3-5ml of soap
-Scrub 15 seconds w/ warm water
with Complete Solutions
The Nursing Process - Answer-Systematic, person-centered, goal-oriented method of
caring that provides a framework for nursing practice. It is nursing practice in action
ADPIE - Answer--Assessment
-Diagnosis
-Planning/Outcome Identification
-Implementation
-Evaluation
Nursing Diagnosis - Answer-When nursing interventions are used to prevent or resolve
actual or potential health problems
Diagnostic Statement - Answer--Problem
-Etiology
-Defining Characteristics
(Ex: Anxiety (Problem) related to situational crises and stress (related factors) as
evidenced by restlessness, insomnia, anguish and anorexia (defining characteristics).
Sources of Data - Answer--Patient history
-Data from family
-Signs and symptoms
-Test results and findings
Assessing - Answer-Collection, validation, and communication of patient data
(identifying the patient needs)
Diagnosing - Answer-Analysis of patient data to identify patient strengths and health
problems that independent nursing interventions can prevent or resolve.
Outcome Identification & Planning - Answer-(1) Patient outcomes to prevent, reduce, or
resolve the problems identified in the nursing diagnosis
(2) related nursing interventions
Implementing - Answer-Carrying out the plan of care
Evaluating - Answer-Measuring the extent to which the patient has achieved the
outcomes specified in the plan of care; identifying factors that positively or negatively
influenced outcome achievement; revising the plan of care if necessary
SMART Outcomes - Answer--Specific
,-Measurable
-Attainable
-Realistic
-Time-framed
Outcome statement components - Answer--Subject
-Verb
-Condition
-Performance criteria/Qualifier
-Target time
SOAP - Answer--Subjective
-Objective
-Assessment
-Plan
SOAPIER - Answer--Subjective
-Objective
-Assessment
-Plan
-Implementation
-Evaluation
-Revision
PIO - Answer--Problem
-Intervention
-Outcome
DAR - Answer--Data
-Action
-Response
PIE - Answer--Problem
-Intervention
-Evaluation
CBE - Answer--Charting by exception
-This a shorthand method
Downside: does not prove useful when a negligence claim is made against a nurse
because of the lack of detail
Focus Charting - Answer--To bring the focus of care back to the patient and the
patient's concerns
-Holistic emphasis on the patient and the patients priorities
, Content - Answer--Enter information in a concise, complete, accurate, current, and
factual manner
-Record patient findings NOT your interpretation of these findings
-Record precautions and preventative measures used
-Avoid stereotypes or derogatory terms
Timing - Answer--Document in a timely manner
-This can be crucial if legal claims arise
-Use military time to avoid AM PM confusion
-Never document interventions before carrying them out
Format - Answer--Date and time each entry
-Use proper terminology
-Record nursing interventions in chronological order
Accountability - Answer--Sign your first initial and last name and title to each entry
-Use a pen, do not erase (single line through to omit an incorrect entry), and make note
saying "error in charting" or "mistaken entry"
-Recognize that the patient chart is permanent, and assure that it is complete before
submitting it to medical records
Confidentiality - Answer-Follow HIPAA guidelines
Validation - Answer-The act of confirming or verifying to keep data as free from error,
bias, and misinterpretation. Suspicions are not objective. Must validate suspicions with
pt
(ex. suspicion of hearing loss)
Observation - Answer-Conscious and deliberate use of the five senses to gather data
Observation of cues - Answer-Conscious and deliberate use of the five senses to gain
significant information that is helpful in making decisions. Make inference after
identifying cues.
Inference - Answer-Judgment reached about a cue. Validate after nurse inference.
Inductive Reasoning - Answer-Bottom-up logic. begin with some data, and then
determine what general conclusion(s) can logically be derived from those data.
Deductive Reasoning - Answer-Top-down logic. Begin with some statements, called
'premises', that are assumed to be true, you then determine what else would have to be
true if the premises are true.
Handwashing - Soap - Answer--3-5ml of soap
-Scrub 15 seconds w/ warm water
