Hondros Nursing 200, Exam 1
Noticing - Answer-Indicate when a situation is normal, abnormal or has changed. Get an initial grasp on
the situation
Application to thinking noticing - Answer-Collect: Subjective & objective data
VS, Complaints, self-described symptoms. What nurse notices, such as rashes, swelling, bruising, etc
Identifying signs and symptoms - Answer-Noticing
Gathering Complete and Accurate Data - Answer-Noticing
Assessing Systematically and Comprehensively - Answer-Noticing
Predicting (and Managing) Potential Complications - Answer-Noticing
Identifying Assumptions - Answer-Noticing
,5 concepts of critical thinking - Answer-Standards Attitudes Competencies Experience Specific
Knowledge Base
Nursing Process - Answer-The nursing process is a variation of scientific reasoning that involves five
steps: assessment, nursing diagnosis, planning, implementation, and evaluation.Assess (collection
verification of data and analysis of data) Diagnose, Plan, Implement, Evaluate
cue - Answer-obtain information that you obtain through sense. (Lies still with arms along side: tense.
States has not turned in some time. Reports pain a 7 and on scale of 0-10)
Sources of Data - Answer-Patient, family and significant other, health care team, medical records, other
records and scientific literature
An initial patient-centered interview involves - Answer-(1) setting the stage, (2) gathering information
about the patient's problems and setting an agenda, (3) collecting the assessment or a nursing health
history, and (4) terminating the interview.
A nurse assesses a patient who comes to the pulmonary clinic. "I see that it's been over 6 months since
you've been here, but your appointment was for every 2 months. Tell me about that. Also I see from
your last visit that the doctor recommended routine exercise. Can you tell me how successful you've
been in following his plan?" The nurse's assessment covers which of Gordon's functional health
patterns? - Answer-Health perception-health management pattern
The nurse observes a patient walking down the hall with a shuffling gait. When the patient returns to
bed, the nurse checks the strength in both of the patient's legs. The nurse applies the information
gained to suspect that the patient has a mobility problem. This conclusion is an example of: - Answer-
Clinical inference.
A 72-year-old male patient comes to the health clinic for an annual follow-up. The nurse enters the
patient's room and notices him to be diaphoretic, holding his chest and breathing with difficulty. The
nurse immediately checks the patient's heart rate and blood pressure and asks him, "Tell me where your
pain is." Which of the following assessment approaches does this scenario describe? - Answer-A
problem-oriented approach
,The nurse asks a patient, "Describe for me a typical night's sleep. What do you do to fall asleep? Do you
have difficulty falling or staying asleep? This series of questions would likely occur during which phase of
a patient-centered interview? - Answer-Working phase
A nurse is assigned to a 42-year-old mother of 4 who weighs 136.2 kg (300 lbs), has diabetes, and works
part time in the kitchen of a restaurant. The patient is facing surgery for gallbladder disease. Which of
the following approaches demonstrates the nurse's cultural competence in assessing the patient's
health care problems? - Answer-"You have four children; do you have any concerns about going home
and caring for them?"
A nurse is checking a patient's intravenous line and, while doing so, notices how the patient bathes
himself and then sits on the side of the bed independently to put on a new gown. This observation is an
example of assessing: - Answer-Patient's level of function.
A patient who visits the surgery clinic 4 weeks after a traumatic amputation of his right leg tells the
nurse practitioner that he is worried about his ability to continue to support his family. He tells the nurse
he feels that he has let his family down after having an auto accident that led to the loss of his left leg.
The nurse listens and then asks the patient, "How do you see yourself now?" On the basis of Gordon's
functional health patterns, which pattern does the nurse assess - Answer-Self-perception-self-concept
pattern
During a visit to the clinic, a patient tells the nurse that he has been having headaches on and off for a
week. The headaches sometimes make him feel nauseated. Which of the following responses by the
nurse is an example of probing? - Answer-Tell me what makes your headaches begin.
Steps of NOTICING - Answer-Identifying Assumptions
Predicting (and Managing) Potential Complications
Assessing Systematically and Comprehensively
Gathering Complete and Accurate Data
Identifying signs and symptoms
, SPICES tool - Answer-a framework for assessing older adults that focuses on six common "marker
conditions": sleep problems, problems with eating and feeding, incontinence, confusion, evidence of
falls, and skin breakdown. These conditions provide a snapshot of a patient's overall health and the
quality of care.
Noticing-Identifying signs and symptoms - Answer-Ability to identify signs and symptoms indicating a
situation is different, changed or not of normal state.
Noticing-Gathering complete and accurate data - Answer-When assessing a situation it is important to
gather complete and accurate data. The data is used as the basis for identifying problems, issues and
concerns, solving problems and making decisions.
Noticing-Assessing systematically and comprehensively - Answer-Nurses use a systematic method such
as body systems, a head to toe approach or focused assessment so no areas are forgotten.
Noticing-Predicting and managing potential complications - Answer-Nurses must look at the big picture
to predict potential complications that may exist for individual patients
Noticing-identifying assumptions - Answer-Taking something for granted or hastily arriving at a
conclusion without supporting evidence.
Interpreting-clustering related information - Answer-Grouping together information with a common
theme to form the basis for problem identification.
Interpreting-recognizing inconsistencies - Answer-In reviewing data, nurses are cognizant of any
inconsistencies that may indicate additional problems that may not be readily apparent.
Interpreting-checking accuracy and reliability - Answer-If something doesn't seem quite right, the nurse
must take action to determine if the information is accurate.
Noticing - Answer-Indicate when a situation is normal, abnormal or has changed. Get an initial grasp on
the situation
Application to thinking noticing - Answer-Collect: Subjective & objective data
VS, Complaints, self-described symptoms. What nurse notices, such as rashes, swelling, bruising, etc
Identifying signs and symptoms - Answer-Noticing
Gathering Complete and Accurate Data - Answer-Noticing
Assessing Systematically and Comprehensively - Answer-Noticing
Predicting (and Managing) Potential Complications - Answer-Noticing
Identifying Assumptions - Answer-Noticing
,5 concepts of critical thinking - Answer-Standards Attitudes Competencies Experience Specific
Knowledge Base
Nursing Process - Answer-The nursing process is a variation of scientific reasoning that involves five
steps: assessment, nursing diagnosis, planning, implementation, and evaluation.Assess (collection
verification of data and analysis of data) Diagnose, Plan, Implement, Evaluate
cue - Answer-obtain information that you obtain through sense. (Lies still with arms along side: tense.
States has not turned in some time. Reports pain a 7 and on scale of 0-10)
Sources of Data - Answer-Patient, family and significant other, health care team, medical records, other
records and scientific literature
An initial patient-centered interview involves - Answer-(1) setting the stage, (2) gathering information
about the patient's problems and setting an agenda, (3) collecting the assessment or a nursing health
history, and (4) terminating the interview.
A nurse assesses a patient who comes to the pulmonary clinic. "I see that it's been over 6 months since
you've been here, but your appointment was for every 2 months. Tell me about that. Also I see from
your last visit that the doctor recommended routine exercise. Can you tell me how successful you've
been in following his plan?" The nurse's assessment covers which of Gordon's functional health
patterns? - Answer-Health perception-health management pattern
The nurse observes a patient walking down the hall with a shuffling gait. When the patient returns to
bed, the nurse checks the strength in both of the patient's legs. The nurse applies the information
gained to suspect that the patient has a mobility problem. This conclusion is an example of: - Answer-
Clinical inference.
A 72-year-old male patient comes to the health clinic for an annual follow-up. The nurse enters the
patient's room and notices him to be diaphoretic, holding his chest and breathing with difficulty. The
nurse immediately checks the patient's heart rate and blood pressure and asks him, "Tell me where your
pain is." Which of the following assessment approaches does this scenario describe? - Answer-A
problem-oriented approach
,The nurse asks a patient, "Describe for me a typical night's sleep. What do you do to fall asleep? Do you
have difficulty falling or staying asleep? This series of questions would likely occur during which phase of
a patient-centered interview? - Answer-Working phase
A nurse is assigned to a 42-year-old mother of 4 who weighs 136.2 kg (300 lbs), has diabetes, and works
part time in the kitchen of a restaurant. The patient is facing surgery for gallbladder disease. Which of
the following approaches demonstrates the nurse's cultural competence in assessing the patient's
health care problems? - Answer-"You have four children; do you have any concerns about going home
and caring for them?"
A nurse is checking a patient's intravenous line and, while doing so, notices how the patient bathes
himself and then sits on the side of the bed independently to put on a new gown. This observation is an
example of assessing: - Answer-Patient's level of function.
A patient who visits the surgery clinic 4 weeks after a traumatic amputation of his right leg tells the
nurse practitioner that he is worried about his ability to continue to support his family. He tells the nurse
he feels that he has let his family down after having an auto accident that led to the loss of his left leg.
The nurse listens and then asks the patient, "How do you see yourself now?" On the basis of Gordon's
functional health patterns, which pattern does the nurse assess - Answer-Self-perception-self-concept
pattern
During a visit to the clinic, a patient tells the nurse that he has been having headaches on and off for a
week. The headaches sometimes make him feel nauseated. Which of the following responses by the
nurse is an example of probing? - Answer-Tell me what makes your headaches begin.
Steps of NOTICING - Answer-Identifying Assumptions
Predicting (and Managing) Potential Complications
Assessing Systematically and Comprehensively
Gathering Complete and Accurate Data
Identifying signs and symptoms
, SPICES tool - Answer-a framework for assessing older adults that focuses on six common "marker
conditions": sleep problems, problems with eating and feeding, incontinence, confusion, evidence of
falls, and skin breakdown. These conditions provide a snapshot of a patient's overall health and the
quality of care.
Noticing-Identifying signs and symptoms - Answer-Ability to identify signs and symptoms indicating a
situation is different, changed or not of normal state.
Noticing-Gathering complete and accurate data - Answer-When assessing a situation it is important to
gather complete and accurate data. The data is used as the basis for identifying problems, issues and
concerns, solving problems and making decisions.
Noticing-Assessing systematically and comprehensively - Answer-Nurses use a systematic method such
as body systems, a head to toe approach or focused assessment so no areas are forgotten.
Noticing-Predicting and managing potential complications - Answer-Nurses must look at the big picture
to predict potential complications that may exist for individual patients
Noticing-identifying assumptions - Answer-Taking something for granted or hastily arriving at a
conclusion without supporting evidence.
Interpreting-clustering related information - Answer-Grouping together information with a common
theme to form the basis for problem identification.
Interpreting-recognizing inconsistencies - Answer-In reviewing data, nurses are cognizant of any
inconsistencies that may indicate additional problems that may not be readily apparent.
Interpreting-checking accuracy and reliability - Answer-If something doesn't seem quite right, the nurse
must take action to determine if the information is accurate.
