Exam 1 NURS-108 questions and
answers graded A+ passed
Nursing Process is a five-step critical thinking process involving: - correct answer ✔✔ADPIE
Assessing
Diagnosing
Planning
Implementing
Evaluating
mild hypothermia - correct answer ✔✔93.2-96.8 F
moderate hypothermia - correct answer ✔✔86-93.2 F
Severe hypothermia - correct answer ✔✔Less than 86 F
basal cell carcinoma - correct answer ✔✔Most common and least severe type of skin cancer;
often characterized by light or pearly nodules.
.5-1 cm crusty lesions that is flat and raised with widely dilated blood vessels within the lesion
squamous cell carcinoma - correct answer ✔✔Type of skin cancer more serious than basal cell
carcinoma; often characterized by scaly red papules or nodules. Occur on mucusal surfaces, etc.
.5-1.5 cm scaly and sometimes ulcerated or crusted; grows rapidly
Melanoma - correct answer ✔✔The most serious form of skin cancer. .5-1cm flat lesions with
irregular borders and indistinct margins.
,Complete eye test with - correct answer ✔✔Snellen chart and examination
Complete hearing test with: - correct answer ✔✔Hearing acuity test, such as whisper test or
tuning fork test (Weber's and Rinne)
Mouth and pharyngeal assessment with: - correct answer ✔✔- Test throat function, lips,
speech, color of mouth, teeth detention, gag reflex, buccal, inner lips, under tongue, etc.
Complete neck assessment with: - correct answer ✔✔Test lymph nodes, thyroid, trachea, etc.
Types of therapeutic communication - correct answer ✔✔verbal and nonverbal
Sites and normal ranges of vital signs in infants, adults, and the elderly - correct answer
✔✔Acceptable temperature range:
96.8° F to 100.4° F or 36° C to 38° C
Temperature sites:
Oral, rectal, axillary, tympanic membrane, temporal artery, esophageal, pulmonary artery
Pulse Sites: temporal, carotid, apical, brachial, radial, ulnar, femoral, popliteal, posterior tibial,
and dorsalis pedis
Assessment of Diffusion and Perfusion: Measurement of arterial oxygen saturation (SaO2), the
percent of hemoglobin that is bound with oxygen in the arteries
Usually 95% to 100%
Normal oral temperature - correct answer ✔✔98.6 F
Normal axillary temperature - correct answer ✔✔97.7 F
,Normal rectal temperature - correct answer ✔✔99.5 F
Types of Nursing Diagnoses - correct answer ✔✔Actual (Problem focused)
Risk
Health Promotion
Syndrome
Nursing Diagnosis - correct answer ✔✔describes a health problem that can be treated by
nursing measures; a step in the nursing process
Ex. the medical diagnosis is stroke and the nursing diagnosis is the pt has limited mobility due to
stroke.
Collaborative problem - correct answer ✔✔Physiological complication that requires the nurse to
use nursing- and health care provider-prescribed interventions to maximize patient outcomes.
Nurses do's of three types of planning - correct answer ✔✔• Initially, they develop a
comprehensive plan of care for clients based on comprehensive assessments they complete. (i.e
on admission to a health care facility or to a home health organization)
• Nurses do ongoing planning throughout the provision of care. While obtaining new
information and evaluating responses to care, they modify and individualize the initial plan of
care.
• Discharge planning is a process of anticipating and planning for clients' needs after discharge.
To be effective discharge planning must begin as soon as clients are admitted.
PES Format - correct answer ✔✔3-part labeling
P (problem) - NANDA-I label
E (etiology) - Related factor
S (symptoms or defining characteristics)
, Etiology - correct answer ✔✔(aka related factor) of a nursing diagnosis is always with in the
domain of nursing practice and a condition that responds to nursing interventions.
Labels one or more probable causes of the health problem.
The purpose of concept mapping a nursing diagnosis - correct answer ✔✔Concept mapping a
nursing diagnosis is a way to graphically represent the connections among concepts (nursing
diagnosis) and ideas that are related to a central subject (patient's problems).
Guidelines to reduce errors when formulating the diagnostic statement - correct answer ✔✔1.
Identify the patient's response, not the medical diagnosis.
2. Identify a NANDA-I diagnostic statement rather than the symptom.
3. Identify a treatable cause or risk factor rather than a clinical sign or chronic problem that is
not treatable through nursing intervention.
4. Identify the problem caused by the treatment or diagnostic study rather than the treatment
or study itself.
5. Identify the patient's response to the equipment rather than the equipment itself.
6. Identify the patient's problems rather than your problems with nursing care.
7. Identify the patient problem rather than nursing intervention.
8. Identify the patient's problem rather than the goal of care.
9. Make professional rather than prejudicial judgments.
10. Avoid legally inadvisable statements.
11. . Identify the problem and its cause to avoid a circular statement.
12. . Identify only one patient problem in the diagnostic statement.
Discuss conditions that place patients at risk for impaired skin integrity - correct answer
✔✔Immobilization, Reduced sensation, nutrition & hydration, altered cognition, external
devices, vascular insufficiency, and alterations, secretions & excretions.
answers graded A+ passed
Nursing Process is a five-step critical thinking process involving: - correct answer ✔✔ADPIE
Assessing
Diagnosing
Planning
Implementing
Evaluating
mild hypothermia - correct answer ✔✔93.2-96.8 F
moderate hypothermia - correct answer ✔✔86-93.2 F
Severe hypothermia - correct answer ✔✔Less than 86 F
basal cell carcinoma - correct answer ✔✔Most common and least severe type of skin cancer;
often characterized by light or pearly nodules.
.5-1 cm crusty lesions that is flat and raised with widely dilated blood vessels within the lesion
squamous cell carcinoma - correct answer ✔✔Type of skin cancer more serious than basal cell
carcinoma; often characterized by scaly red papules or nodules. Occur on mucusal surfaces, etc.
.5-1.5 cm scaly and sometimes ulcerated or crusted; grows rapidly
Melanoma - correct answer ✔✔The most serious form of skin cancer. .5-1cm flat lesions with
irregular borders and indistinct margins.
,Complete eye test with - correct answer ✔✔Snellen chart and examination
Complete hearing test with: - correct answer ✔✔Hearing acuity test, such as whisper test or
tuning fork test (Weber's and Rinne)
Mouth and pharyngeal assessment with: - correct answer ✔✔- Test throat function, lips,
speech, color of mouth, teeth detention, gag reflex, buccal, inner lips, under tongue, etc.
Complete neck assessment with: - correct answer ✔✔Test lymph nodes, thyroid, trachea, etc.
Types of therapeutic communication - correct answer ✔✔verbal and nonverbal
Sites and normal ranges of vital signs in infants, adults, and the elderly - correct answer
✔✔Acceptable temperature range:
96.8° F to 100.4° F or 36° C to 38° C
Temperature sites:
Oral, rectal, axillary, tympanic membrane, temporal artery, esophageal, pulmonary artery
Pulse Sites: temporal, carotid, apical, brachial, radial, ulnar, femoral, popliteal, posterior tibial,
and dorsalis pedis
Assessment of Diffusion and Perfusion: Measurement of arterial oxygen saturation (SaO2), the
percent of hemoglobin that is bound with oxygen in the arteries
Usually 95% to 100%
Normal oral temperature - correct answer ✔✔98.6 F
Normal axillary temperature - correct answer ✔✔97.7 F
,Normal rectal temperature - correct answer ✔✔99.5 F
Types of Nursing Diagnoses - correct answer ✔✔Actual (Problem focused)
Risk
Health Promotion
Syndrome
Nursing Diagnosis - correct answer ✔✔describes a health problem that can be treated by
nursing measures; a step in the nursing process
Ex. the medical diagnosis is stroke and the nursing diagnosis is the pt has limited mobility due to
stroke.
Collaborative problem - correct answer ✔✔Physiological complication that requires the nurse to
use nursing- and health care provider-prescribed interventions to maximize patient outcomes.
Nurses do's of three types of planning - correct answer ✔✔• Initially, they develop a
comprehensive plan of care for clients based on comprehensive assessments they complete. (i.e
on admission to a health care facility or to a home health organization)
• Nurses do ongoing planning throughout the provision of care. While obtaining new
information and evaluating responses to care, they modify and individualize the initial plan of
care.
• Discharge planning is a process of anticipating and planning for clients' needs after discharge.
To be effective discharge planning must begin as soon as clients are admitted.
PES Format - correct answer ✔✔3-part labeling
P (problem) - NANDA-I label
E (etiology) - Related factor
S (symptoms or defining characteristics)
, Etiology - correct answer ✔✔(aka related factor) of a nursing diagnosis is always with in the
domain of nursing practice and a condition that responds to nursing interventions.
Labels one or more probable causes of the health problem.
The purpose of concept mapping a nursing diagnosis - correct answer ✔✔Concept mapping a
nursing diagnosis is a way to graphically represent the connections among concepts (nursing
diagnosis) and ideas that are related to a central subject (patient's problems).
Guidelines to reduce errors when formulating the diagnostic statement - correct answer ✔✔1.
Identify the patient's response, not the medical diagnosis.
2. Identify a NANDA-I diagnostic statement rather than the symptom.
3. Identify a treatable cause or risk factor rather than a clinical sign or chronic problem that is
not treatable through nursing intervention.
4. Identify the problem caused by the treatment or diagnostic study rather than the treatment
or study itself.
5. Identify the patient's response to the equipment rather than the equipment itself.
6. Identify the patient's problems rather than your problems with nursing care.
7. Identify the patient problem rather than nursing intervention.
8. Identify the patient's problem rather than the goal of care.
9. Make professional rather than prejudicial judgments.
10. Avoid legally inadvisable statements.
11. . Identify the problem and its cause to avoid a circular statement.
12. . Identify only one patient problem in the diagnostic statement.
Discuss conditions that place patients at risk for impaired skin integrity - correct answer
✔✔Immobilization, Reduced sensation, nutrition & hydration, altered cognition, external
devices, vascular insufficiency, and alterations, secretions & excretions.
