NRSG 2220 Exam 3 Questions With Complete Solutions
1-part nursing diagnosis Correct Answers health promotion
includes: one part statement
examples:
readiness for enhanced breastfeeding
rape trauma syndrome
readiness for enhanced coping
just a statement - no evidence
1st part of the nursing diagnosis Correct Answers (Problem
Statement)
Identifies the unhealthy response
Indicates what should change
Suggests patient goals/outcomes (expectations for change)
2-part nursing diagnosis Correct Answers risk for nursing
diagnosis - always a 2 part because we do not have the evidence
yet
includes: diagnostic label +validation for risk (why is this a risk)
examples:
risk for infection r/t compromised post-defenses
,risk for falls r/t patient's confucion
do not put medical diagnosis
24-hour urine specimens Correct Answers collect all urine
voided in a 24 hour period
2nd part of nursing diagnosis Correct Answers - etiology
- identifies factors causing or contributing to the undesirable
response and preventing desired change
- suggests nursing interventions
3-part nursing diagnosis Correct Answers actual nursing
diagnosis
includes: diagnostic label + contributing factor (related to) signs
& symptoms + objective/subjective data (as evidence by)
PES format: problem, etiology, signs/symptoms
examples:
acute pain related to tissue ischemia as evidenced by statement
of "i feel severe pain on my chest"
impaired physical mobility related to decreased muscle control
AEB inability to control lower extremities
abdominal assessment Correct Answers inspection,
auscultation, percussion, palpation
, ALWAYS AUSCULTATE BEFORE PALPATING BECAUSE
THEY STIMULATE BOWEL SOUNDS
auscultation:
warm stethoscope, light pressure, diaphragm RLQ-RUQ-LUQ-
LLQ, bowel sounds occur every 5-34 seconds, normoactive
(normal), hypoactive, hyperactive, absent, infrequent
listen for 2 min each quadrant
alveolar system Correct Answers alveoli is the site of gas
exchange
oxygenates venous blood
removes carbon dioxide from blood
anthelmintic retention enema Correct Answers destroy
intestinal parasites
aspiration Correct Answers give small, frequent feedings
elevate HOB at least 30-45 degrees during feeding, 1 hour after
avoid oversedation of patient
check residual
assessment Correct Answers gather information about the
patient's condition
focuses on the patient's response to health problem
1-part nursing diagnosis Correct Answers health promotion
includes: one part statement
examples:
readiness for enhanced breastfeeding
rape trauma syndrome
readiness for enhanced coping
just a statement - no evidence
1st part of the nursing diagnosis Correct Answers (Problem
Statement)
Identifies the unhealthy response
Indicates what should change
Suggests patient goals/outcomes (expectations for change)
2-part nursing diagnosis Correct Answers risk for nursing
diagnosis - always a 2 part because we do not have the evidence
yet
includes: diagnostic label +validation for risk (why is this a risk)
examples:
risk for infection r/t compromised post-defenses
,risk for falls r/t patient's confucion
do not put medical diagnosis
24-hour urine specimens Correct Answers collect all urine
voided in a 24 hour period
2nd part of nursing diagnosis Correct Answers - etiology
- identifies factors causing or contributing to the undesirable
response and preventing desired change
- suggests nursing interventions
3-part nursing diagnosis Correct Answers actual nursing
diagnosis
includes: diagnostic label + contributing factor (related to) signs
& symptoms + objective/subjective data (as evidence by)
PES format: problem, etiology, signs/symptoms
examples:
acute pain related to tissue ischemia as evidenced by statement
of "i feel severe pain on my chest"
impaired physical mobility related to decreased muscle control
AEB inability to control lower extremities
abdominal assessment Correct Answers inspection,
auscultation, percussion, palpation
, ALWAYS AUSCULTATE BEFORE PALPATING BECAUSE
THEY STIMULATE BOWEL SOUNDS
auscultation:
warm stethoscope, light pressure, diaphragm RLQ-RUQ-LUQ-
LLQ, bowel sounds occur every 5-34 seconds, normoactive
(normal), hypoactive, hyperactive, absent, infrequent
listen for 2 min each quadrant
alveolar system Correct Answers alveoli is the site of gas
exchange
oxygenates venous blood
removes carbon dioxide from blood
anthelmintic retention enema Correct Answers destroy
intestinal parasites
aspiration Correct Answers give small, frequent feedings
elevate HOB at least 30-45 degrees during feeding, 1 hour after
avoid oversedation of patient
check residual
assessment Correct Answers gather information about the
patient's condition
focuses on the patient's response to health problem
