HONDROS NUR 155 EXAM 1
QUESTIONS WITH COMPLETE
SOLUTIONS
Nursing Process: Assessment - Answer-Observe and report to Charge Nurse or HCP.
Determine risk for injury or infection.
Nursing Process: Diagnosis - Answer-Assist with accurate diagnosis. Gather data to
confirm or eliminate problems. Specific causes of safety risk to an individual.
Nursing Process: Planning/Outcomes Identifications - Answer-Assist with setting
priorities and goals, suggestions interventions. To prevent threats to safety.
Nursing Process: Implementation (putting a decision or plan into effect) - Answer-Carry
out planned interventions. Interventions, education, environment/development
considerations.
Nursing Process: Evaluation - Answer-Assist with re-evaluation and make suggestions.
Compare response/results to the original goals, plan of care.
Data Collection-Scope of Practice - Answer-LPN's collect data, RN's complete
Assessments.
Main Assessments - Answer-3 types:
*Focus Assessment
*Systemic Assessment
*Head to Toe Assessment
(FOCUS) Assessment - Answer-Focusses on one body part.
example: Heart, Lung, Stomach, etc...
(SYSTEMIC) Assessment - Answer-Focusses on one body system.
example: Respiratory, Digestive, Cardiac, etc...
(Head-to-Toe) Assessment - Answer-Total body examination.
Parts of Clinical Thinking - Answer-*Assess/learn/gain knowledge
*Understand and ask questions
*Store information/memorize
*Recall information/bring it back
, *Know what to do when information isn't in memory (know where to look it up)
*Draw your own conclusion
Humble Attitude - Answer-We don't know everything.
2 main types of data - Answer-Objective vs Subjective
Objective Data - Answer-(Signs) Observable and measurable data that can be seen and
heard, or felt, smelled by someone other than you, or by physical examination and lab
data.
example: elevated temperature, vomiting, skin moisture...
Subjective Data - Answer-(Symptoms) Information perceived only by the affected
person, personal taste, symptoms, verbal statements provided by the patients point of
view or perception. What the patient tells you.
Clinical - Answer-_____________ observation Is related to/or conducted in a healthcare
setting involving direct observation of the patient.
Judgement - Answer-Your interpretation that influences your actions to take.
Clinical Judgement - Answer-Interpretation or conclusion about a patient's needs,
concerns, or health problems. Whether or not you should take action. Sometimes you
have to improvise new actions or plans.
Why do we need Clinical Judgement? - Answer-We need it to provide safe quality care.
How do we develop Clinical Judgement? - Answer-We use the Nursing Process, and
Tanner's Model to develop the skills to establish Clinical Judgement.
Emergency! - Answer-Emergencies cease to exist when you prepare for them!
SPICES: - Answer-A tool that can be used to obtain information necessary to prevent
health alterations in older adult patients.
SPICES: S - Answer-SLEEP Disorders
SPICES: P - Answer-PROBLEMS with Eating or Feeding
SPICES: I - Answer-Incontinence bowel and/or bladder
SPICES: C - Answer-Confusion
SPICES: E - Answer-EVIDENCE of Falls
SPICES: S(2) - Answer-SKIN Breakdown
QUESTIONS WITH COMPLETE
SOLUTIONS
Nursing Process: Assessment - Answer-Observe and report to Charge Nurse or HCP.
Determine risk for injury or infection.
Nursing Process: Diagnosis - Answer-Assist with accurate diagnosis. Gather data to
confirm or eliminate problems. Specific causes of safety risk to an individual.
Nursing Process: Planning/Outcomes Identifications - Answer-Assist with setting
priorities and goals, suggestions interventions. To prevent threats to safety.
Nursing Process: Implementation (putting a decision or plan into effect) - Answer-Carry
out planned interventions. Interventions, education, environment/development
considerations.
Nursing Process: Evaluation - Answer-Assist with re-evaluation and make suggestions.
Compare response/results to the original goals, plan of care.
Data Collection-Scope of Practice - Answer-LPN's collect data, RN's complete
Assessments.
Main Assessments - Answer-3 types:
*Focus Assessment
*Systemic Assessment
*Head to Toe Assessment
(FOCUS) Assessment - Answer-Focusses on one body part.
example: Heart, Lung, Stomach, etc...
(SYSTEMIC) Assessment - Answer-Focusses on one body system.
example: Respiratory, Digestive, Cardiac, etc...
(Head-to-Toe) Assessment - Answer-Total body examination.
Parts of Clinical Thinking - Answer-*Assess/learn/gain knowledge
*Understand and ask questions
*Store information/memorize
*Recall information/bring it back
, *Know what to do when information isn't in memory (know where to look it up)
*Draw your own conclusion
Humble Attitude - Answer-We don't know everything.
2 main types of data - Answer-Objective vs Subjective
Objective Data - Answer-(Signs) Observable and measurable data that can be seen and
heard, or felt, smelled by someone other than you, or by physical examination and lab
data.
example: elevated temperature, vomiting, skin moisture...
Subjective Data - Answer-(Symptoms) Information perceived only by the affected
person, personal taste, symptoms, verbal statements provided by the patients point of
view or perception. What the patient tells you.
Clinical - Answer-_____________ observation Is related to/or conducted in a healthcare
setting involving direct observation of the patient.
Judgement - Answer-Your interpretation that influences your actions to take.
Clinical Judgement - Answer-Interpretation or conclusion about a patient's needs,
concerns, or health problems. Whether or not you should take action. Sometimes you
have to improvise new actions or plans.
Why do we need Clinical Judgement? - Answer-We need it to provide safe quality care.
How do we develop Clinical Judgement? - Answer-We use the Nursing Process, and
Tanner's Model to develop the skills to establish Clinical Judgement.
Emergency! - Answer-Emergencies cease to exist when you prepare for them!
SPICES: - Answer-A tool that can be used to obtain information necessary to prevent
health alterations in older adult patients.
SPICES: S - Answer-SLEEP Disorders
SPICES: P - Answer-PROBLEMS with Eating or Feeding
SPICES: I - Answer-Incontinence bowel and/or bladder
SPICES: C - Answer-Confusion
SPICES: E - Answer-EVIDENCE of Falls
SPICES: S(2) - Answer-SKIN Breakdown
