NUR 514 - EXAM 1 STUDY
QUESTIONS
What9are9the959steps9of9the9nursing9process9&9an9example9of9each?9-
9ans✔Assessment9-9Collecting9subjective9&9objective9data9from9the9patient
Diagnosis9-Data9is9collected9&9analyzed9in9order9to9make9a9nursing9judgment9
Planning9-9Nurse9decides9the9best9plan9while9considering9data9
Implementation9-Carrying9out9the9plan
Evaluation9-Determining9whether9plan9was9successful9&9what9can9be9improved
Write9an9example9of9an9initial9comprehensive9assessment9-ongoing/
partial9assessment9-9focused9assessment9&9emergent9assessment9-
9ans✔Initial9comprehensive:9seeing9a9new9patient9for9the9first9time9at9that9practice
Ongoing/partial:9a9check9up/follow9up
Emergent:9Pt9coming9into9ER9w/9gunshot9wound
Focused:9Pt9broke9arm9or9is9having9stomach9pains
How9can9the9nurse9prepare9for9the9assessment?9-9ans✔Review9pt9record9
Review9pt9previous9&9current9health9status9w/9other9healthcare9professionals
Take9time9to9educate9themselves9about9pt9diagnosis9&9tests9performed
What9is9a9nursing9diagnosis?9Give9an9example.9-
9ans✔Data9analyzed9and9by9definition9of9NANDA9"a9clinical9judgment9concerning9a9hu
man9response9to9health9conditions/
life9processes,9or9vulnerability9for9that9response9by9an9individual,9family,9group9or9com
munity."9It9serves9as9a9basis9for9nursing9interventions9w/
9achievable9outcomes9by9nursing9staff
Example:9Pt9came9back9from9surgery9→9"Risk9for9infection9r/
t9new9incision9&9increased9WBC9from9possible9inflammation"
What9is9the9health9belief9model?9When9would9we9use9it?9-
9ans✔The9health9belief9model9is9based9on939concepts:9
the9existence9of9sufficient9motivation9
the9belief9that9one9is9susceptible9or9vulnerable9to9a9serious9problem
the9belief9that9change9following9a9health9recommendation9would9be9beneficial9to9the9in
dividual9at9a9level9of9acceptable9cost.9
,This9model9would9be9used9to9analyze9health9promotion9and9disease9prevention.
What9are9some9examples9of9subjective9data?9-9ans✔Anything9patient9states
Does9not9involve9measured,9numeric9data
Examples:9sensations/
symptoms,9feelings,9perceptions,9desires,9preferences,9beliefs,9ideas,9values,9personal9
information
What9are9the939phases9of9the9interview?9Define9them.9-9ans✔Pre9Introductory:9
Review9medical9record
Introductory:9
Nurse9introduces9themselves
Explain9purpose9of9the9interview,9what9type9of9questions9will9be9asked,9and9why9they9w
ill9be9taking9notes
Nurses9makes9sure9pt9is9comfortable9and9ensures9their9privacy9
Working9phase:9
Nurse9listens9to9patients9comments9on9biographical9data,9reasons9for9seeking9care,9his
tory9of9present9health9concern,9past9health9history,9family9history,9review9of9body9syste
ms9for9current9health9problems,9lifestyle9&9health9practices
Nurse9&9patient9together9determine9pt9problem9&9goal
Summary9&9Closing:
Nurse9summarizes9information9obtained9during9working9phase9&9validates9pt9problems9
and9goals
They9discuss9possible9plans9to9resolve9the9problem
Nurse9asks9if9there9are9any9other9questions9or9concerns
Give9examples9of9nonverbal9communication9&9what9to9avoid9when9interviewing9a9patie
nt9-
9ans✔Nonverbal9communication9pertains9to9anything9&9everything9that9is9not9communi
cated9directly9using9your9voice9to9speak
Examples:9silence,9stands9(hands9folded9over9chest),9body9language9(standing9vs.9sitti
ng,9too9much9eye9contact9vs.9not9enough)
Nurse9interviewer9should9avoid9silence9&9having9an9aggressive9stance/
body9language,9maintain9an9appropriate9amount9of9eye9contact
Give9examples9of9verbal9communication9tactics9-9ans✔Open9ended9questions
Close9ended9questions
Laundry9listing9
Giving9options:9"is9pain9sharp,9radiating,9pulsing,9etc."
Rephrasing9the9question
Well-placed9phrases
Inferring
Providing9information
, What9are9some9examples9of9cultural9-
9emotional9&9age9related9considerations9when9conducting9an9assessment?9-
9ans✔Example:9Assessment9on9Indian9girl
No9male9presence9in9the9room,9even9if9it9is9her9father
Have9mom9there9for9emotional9support
For9age,9do9not9ask9any9questions9related9to9personal9matters9in9front9of9her9mom
Age9related9example:9hearing9abilities9of9pt.9
Cultural9example:9space9b/w9you9and9pt.
What9mnemonic9is9used9to9explore9pt9symptoms?
9What9does9each9letter9in9the9mnemonic9stand9for?9-9ans✔COLDSPA
Character:9describe9the9signs/symptoms9(feeling,9appearance,9smell,9sound9taste)
Onset:9when9did9it9begin?
Location:9where9is9it?9Where9does9it9radiate?9Other9locations?
Duration:9how9long9does9it9last?9Is9it9continuous9or9intermittent?
Severity:9how9bad9is9the9pain9(0-10)?
Pattern:9what9relieves9it?9What9worsens9it?
Associated9factors:9other9symptoms9that9may9be9related9to9the9main9symptom?
What9kind9of9information9is9explored9when9you9review9the9lifestyle9&9health9practice9of9
the9patient?9-9ans✔Description9of9a9typical9day9(AM9to9PM)
Nutrition9&9weight9management
249hr9dietary9intake9(foods9&9fluids)
Who9purchases9&9prepares9meals?
Activities9on9a9typical9day
Exercise9patterns9&9habits
Sleep9&9rest9patterns
Use9of9medications9and9other9substances9(caffeine,9nicotine,9alcohol,9recreational9drug
s)
Self9concept
Self9care9responsibilities
Social9activities9for9fun9&9relaxation
Relationships9w/9family,9significant9others,9pets9
Values,9religious9affiliation,9spirituality
Past,9current,9&9future9plans9for9education
Type9of9work,9level9of9job9satisfaction,9work9stressors
Finances
Stressors9in9life,9coping9strategies
Residency,9type9of9environment,9neighborhood
Environmental9risks
What9are9some9examples9of9objective9data?9-9ans✔Presence9of9a9wound
Vital9signs
Ht/wt9
General9appearance
Level9of9consciousness
QUESTIONS
What9are9the959steps9of9the9nursing9process9&9an9example9of9each?9-
9ans✔Assessment9-9Collecting9subjective9&9objective9data9from9the9patient
Diagnosis9-Data9is9collected9&9analyzed9in9order9to9make9a9nursing9judgment9
Planning9-9Nurse9decides9the9best9plan9while9considering9data9
Implementation9-Carrying9out9the9plan
Evaluation9-Determining9whether9plan9was9successful9&9what9can9be9improved
Write9an9example9of9an9initial9comprehensive9assessment9-ongoing/
partial9assessment9-9focused9assessment9&9emergent9assessment9-
9ans✔Initial9comprehensive:9seeing9a9new9patient9for9the9first9time9at9that9practice
Ongoing/partial:9a9check9up/follow9up
Emergent:9Pt9coming9into9ER9w/9gunshot9wound
Focused:9Pt9broke9arm9or9is9having9stomach9pains
How9can9the9nurse9prepare9for9the9assessment?9-9ans✔Review9pt9record9
Review9pt9previous9&9current9health9status9w/9other9healthcare9professionals
Take9time9to9educate9themselves9about9pt9diagnosis9&9tests9performed
What9is9a9nursing9diagnosis?9Give9an9example.9-
9ans✔Data9analyzed9and9by9definition9of9NANDA9"a9clinical9judgment9concerning9a9hu
man9response9to9health9conditions/
life9processes,9or9vulnerability9for9that9response9by9an9individual,9family,9group9or9com
munity."9It9serves9as9a9basis9for9nursing9interventions9w/
9achievable9outcomes9by9nursing9staff
Example:9Pt9came9back9from9surgery9→9"Risk9for9infection9r/
t9new9incision9&9increased9WBC9from9possible9inflammation"
What9is9the9health9belief9model?9When9would9we9use9it?9-
9ans✔The9health9belief9model9is9based9on939concepts:9
the9existence9of9sufficient9motivation9
the9belief9that9one9is9susceptible9or9vulnerable9to9a9serious9problem
the9belief9that9change9following9a9health9recommendation9would9be9beneficial9to9the9in
dividual9at9a9level9of9acceptable9cost.9
,This9model9would9be9used9to9analyze9health9promotion9and9disease9prevention.
What9are9some9examples9of9subjective9data?9-9ans✔Anything9patient9states
Does9not9involve9measured,9numeric9data
Examples:9sensations/
symptoms,9feelings,9perceptions,9desires,9preferences,9beliefs,9ideas,9values,9personal9
information
What9are9the939phases9of9the9interview?9Define9them.9-9ans✔Pre9Introductory:9
Review9medical9record
Introductory:9
Nurse9introduces9themselves
Explain9purpose9of9the9interview,9what9type9of9questions9will9be9asked,9and9why9they9w
ill9be9taking9notes
Nurses9makes9sure9pt9is9comfortable9and9ensures9their9privacy9
Working9phase:9
Nurse9listens9to9patients9comments9on9biographical9data,9reasons9for9seeking9care,9his
tory9of9present9health9concern,9past9health9history,9family9history,9review9of9body9syste
ms9for9current9health9problems,9lifestyle9&9health9practices
Nurse9&9patient9together9determine9pt9problem9&9goal
Summary9&9Closing:
Nurse9summarizes9information9obtained9during9working9phase9&9validates9pt9problems9
and9goals
They9discuss9possible9plans9to9resolve9the9problem
Nurse9asks9if9there9are9any9other9questions9or9concerns
Give9examples9of9nonverbal9communication9&9what9to9avoid9when9interviewing9a9patie
nt9-
9ans✔Nonverbal9communication9pertains9to9anything9&9everything9that9is9not9communi
cated9directly9using9your9voice9to9speak
Examples:9silence,9stands9(hands9folded9over9chest),9body9language9(standing9vs.9sitti
ng,9too9much9eye9contact9vs.9not9enough)
Nurse9interviewer9should9avoid9silence9&9having9an9aggressive9stance/
body9language,9maintain9an9appropriate9amount9of9eye9contact
Give9examples9of9verbal9communication9tactics9-9ans✔Open9ended9questions
Close9ended9questions
Laundry9listing9
Giving9options:9"is9pain9sharp,9radiating,9pulsing,9etc."
Rephrasing9the9question
Well-placed9phrases
Inferring
Providing9information
, What9are9some9examples9of9cultural9-
9emotional9&9age9related9considerations9when9conducting9an9assessment?9-
9ans✔Example:9Assessment9on9Indian9girl
No9male9presence9in9the9room,9even9if9it9is9her9father
Have9mom9there9for9emotional9support
For9age,9do9not9ask9any9questions9related9to9personal9matters9in9front9of9her9mom
Age9related9example:9hearing9abilities9of9pt.9
Cultural9example:9space9b/w9you9and9pt.
What9mnemonic9is9used9to9explore9pt9symptoms?
9What9does9each9letter9in9the9mnemonic9stand9for?9-9ans✔COLDSPA
Character:9describe9the9signs/symptoms9(feeling,9appearance,9smell,9sound9taste)
Onset:9when9did9it9begin?
Location:9where9is9it?9Where9does9it9radiate?9Other9locations?
Duration:9how9long9does9it9last?9Is9it9continuous9or9intermittent?
Severity:9how9bad9is9the9pain9(0-10)?
Pattern:9what9relieves9it?9What9worsens9it?
Associated9factors:9other9symptoms9that9may9be9related9to9the9main9symptom?
What9kind9of9information9is9explored9when9you9review9the9lifestyle9&9health9practice9of9
the9patient?9-9ans✔Description9of9a9typical9day9(AM9to9PM)
Nutrition9&9weight9management
249hr9dietary9intake9(foods9&9fluids)
Who9purchases9&9prepares9meals?
Activities9on9a9typical9day
Exercise9patterns9&9habits
Sleep9&9rest9patterns
Use9of9medications9and9other9substances9(caffeine,9nicotine,9alcohol,9recreational9drug
s)
Self9concept
Self9care9responsibilities
Social9activities9for9fun9&9relaxation
Relationships9w/9family,9significant9others,9pets9
Values,9religious9affiliation,9spirituality
Past,9current,9&9future9plans9for9education
Type9of9work,9level9of9job9satisfaction,9work9stressors
Finances
Stressors9in9life,9coping9strategies
Residency,9type9of9environment,9neighborhood
Environmental9risks
What9are9some9examples9of9objective9data?9-9ans✔Presence9of9a9wound
Vital9signs
Ht/wt9
General9appearance
Level9of9consciousness
