Comprehensive 2025 Guide to Nursing 205: Essential
Concepts, Clinical Skills, Evidence-Based Practice, and
Exam Preparation for Nursing Students
A nurse is performing an initial comprehensive assessment of a patient admitted to a longterm
care facility from home. The nurse begins the assessment by asking the patient, "How would
you describe your health status and well-being?" The nurse also asks the patient, "What do you
do to keep yourself healthy?" Which model for organizing data is this nurse following?
A. Maslow's human needs
B. Gordon's functional health patterns
C. Human response patterns
D. Body system model - -CORRECT ANS- -b.
Gordon's functional health patterns begin with the patient's perception of health and wellbeing
and progress to data about nutritional-metabolic patterns, elimination patterns, activity,
sleep/rest, self-perception, role relationship, sexuality, coping, and values/beliefs. Maslow's
model is based on the human needs hierarchy. Human responses include exchanging,
communicating, relating, valuing, choosing, moving, perceiving, knowing, and feeling. The body
system model is based on the functioning of the major body systems.
he nurse is surprised to detect an elevated temperature (102°F) in a patient scheduled for
surgery. The patient has been afebrile and shows no other signs of being febrile. What is the
priority nursing action?
A. Inform the charge nurse.
B. Inform the surgeon.
C. Validate the finding.
D. Document the finding. - -CORRECT ANS- -c.
,The nurse should first validate the finding if it is unusual, deviates from normal, and is
unsupported by other data. Should the initial recording prove to be in error, it would have been
premature to notify the charge nurse or the surgeon. The nurse should be sure that all data
recorded are accurate; thus, all data should be validated before documentation if there are any
doubts about accuracy.
A student nurse tells the instructor that a patient is fine and has "no complaints." What would
be the instructor's best response?
A. "You made an inference that she is fine because she has no complaints. How did you validate
this?"
B. "She probably just doesn't trust you enough to share what she is feeling. I'd work on
developing a trusting relationship."
C. "Sometimes everyone gets lucky. Why don't you try to help another patient?"
D. "Maybe you should reassess the patient. She has to have a problem—why else would she be
here?" - -CORRECT ANS- -a.
The instructor is most likely to challenge the inference that the patient is "fine" simply because
she is telling you that she has no problems. It is appropriate for the instructor to ask how the
student nurse validated this inference. Jumping to the conclusion that the patient does not trust
the student nurse is premature and is an invalidated inference. Answer c is wrong because it
accepts the invalidated inference. Answer d is wrong because it is possible that the condition is
resolving.
A registered nurse is writing a diagnosis for a patient who is in traction because of multiple
fractures from a motor vehicle accident. Which nursing actions are related to this step in the
nursing process? Select all that apply.
A. The nurse uses the nursing interview to collect patient data.
B. The nurse analyzes data collected in the nursing assessment.
, C. The nurse develops a care plan for the patient.
D. The nurse points out the patient's strengths.
E. The nurse assesses the patient's mental status.
F. The nurse identifies community resources to help his family cope. - -CORRECT ANS- -b, d, f.
The purposes of diagnosing are to identify how an individual, group, or community responds to
actual or potential health and life processes; identify factors that contribute to or cause health
problems (etiologies); and identify resources or strengths the individual, group, or community
can draw on to prevent or resolve problems. In the diagnosing step of the nursing process, the
nurse interprets and analyzes data gathered from the nursing assessment, identifies patient
strengths, and identifies resources the patient can use to resolve problems. The nurse assesses
and collects patient data in the assessment step and develops a care plan in the planning step of
the nursing process
The nurse collects objective and subjective data when conducting patient assessments. Which
patient situations are examples of subjective data? Select all that apply.
A. A patient tells the nurse that she is feeling nauseous.
B. A patient's ankles are swollen.
C. A patient tells the nurse that she is nervous about her test results.
D. A patient complains that the skin on her arms is tingling.
E. A patient rates his pain as a 7 on a scale of 1 to 10.
F. A patient vomits after eating supper. - -CORRECT ANS- -a, c, d, e.
Subjective data are information perceived only by the affected person; these data cannot be
perceived or verified by another person. Examples of subjective data are feeling nervous,
nauseated, tingling, and experiencing pain. Objective data are observable and measurable data
that can be seen, heard, or felt by someone other than the person experiencing them. Examples
of objective data are an elevated temperature reading (e.g., 101°F), edema, and vomiting.
When a nurse enters the patient's room to begin a nursing history, the patient's wife is there.
After introducing herself to the patient and his wife, what should the nurse do?
Concepts, Clinical Skills, Evidence-Based Practice, and
Exam Preparation for Nursing Students
A nurse is performing an initial comprehensive assessment of a patient admitted to a longterm
care facility from home. The nurse begins the assessment by asking the patient, "How would
you describe your health status and well-being?" The nurse also asks the patient, "What do you
do to keep yourself healthy?" Which model for organizing data is this nurse following?
A. Maslow's human needs
B. Gordon's functional health patterns
C. Human response patterns
D. Body system model - -CORRECT ANS- -b.
Gordon's functional health patterns begin with the patient's perception of health and wellbeing
and progress to data about nutritional-metabolic patterns, elimination patterns, activity,
sleep/rest, self-perception, role relationship, sexuality, coping, and values/beliefs. Maslow's
model is based on the human needs hierarchy. Human responses include exchanging,
communicating, relating, valuing, choosing, moving, perceiving, knowing, and feeling. The body
system model is based on the functioning of the major body systems.
he nurse is surprised to detect an elevated temperature (102°F) in a patient scheduled for
surgery. The patient has been afebrile and shows no other signs of being febrile. What is the
priority nursing action?
A. Inform the charge nurse.
B. Inform the surgeon.
C. Validate the finding.
D. Document the finding. - -CORRECT ANS- -c.
,The nurse should first validate the finding if it is unusual, deviates from normal, and is
unsupported by other data. Should the initial recording prove to be in error, it would have been
premature to notify the charge nurse or the surgeon. The nurse should be sure that all data
recorded are accurate; thus, all data should be validated before documentation if there are any
doubts about accuracy.
A student nurse tells the instructor that a patient is fine and has "no complaints." What would
be the instructor's best response?
A. "You made an inference that she is fine because she has no complaints. How did you validate
this?"
B. "She probably just doesn't trust you enough to share what she is feeling. I'd work on
developing a trusting relationship."
C. "Sometimes everyone gets lucky. Why don't you try to help another patient?"
D. "Maybe you should reassess the patient. She has to have a problem—why else would she be
here?" - -CORRECT ANS- -a.
The instructor is most likely to challenge the inference that the patient is "fine" simply because
she is telling you that she has no problems. It is appropriate for the instructor to ask how the
student nurse validated this inference. Jumping to the conclusion that the patient does not trust
the student nurse is premature and is an invalidated inference. Answer c is wrong because it
accepts the invalidated inference. Answer d is wrong because it is possible that the condition is
resolving.
A registered nurse is writing a diagnosis for a patient who is in traction because of multiple
fractures from a motor vehicle accident. Which nursing actions are related to this step in the
nursing process? Select all that apply.
A. The nurse uses the nursing interview to collect patient data.
B. The nurse analyzes data collected in the nursing assessment.
, C. The nurse develops a care plan for the patient.
D. The nurse points out the patient's strengths.
E. The nurse assesses the patient's mental status.
F. The nurse identifies community resources to help his family cope. - -CORRECT ANS- -b, d, f.
The purposes of diagnosing are to identify how an individual, group, or community responds to
actual or potential health and life processes; identify factors that contribute to or cause health
problems (etiologies); and identify resources or strengths the individual, group, or community
can draw on to prevent or resolve problems. In the diagnosing step of the nursing process, the
nurse interprets and analyzes data gathered from the nursing assessment, identifies patient
strengths, and identifies resources the patient can use to resolve problems. The nurse assesses
and collects patient data in the assessment step and develops a care plan in the planning step of
the nursing process
The nurse collects objective and subjective data when conducting patient assessments. Which
patient situations are examples of subjective data? Select all that apply.
A. A patient tells the nurse that she is feeling nauseous.
B. A patient's ankles are swollen.
C. A patient tells the nurse that she is nervous about her test results.
D. A patient complains that the skin on her arms is tingling.
E. A patient rates his pain as a 7 on a scale of 1 to 10.
F. A patient vomits after eating supper. - -CORRECT ANS- -a, c, d, e.
Subjective data are information perceived only by the affected person; these data cannot be
perceived or verified by another person. Examples of subjective data are feeling nervous,
nauseated, tingling, and experiencing pain. Objective data are observable and measurable data
that can be seen, heard, or felt by someone other than the person experiencing them. Examples
of objective data are an elevated temperature reading (e.g., 101°F), edema, and vomiting.
When a nurse enters the patient's room to begin a nursing history, the patient's wife is there.
After introducing herself to the patient and his wife, what should the nurse do?
