NSG 122 exam 1 UPDATED ACTUAL Questions and CORRECT
Answers
Standards of Nursing Practice Standards allow nurses to carry out professional duties and protect the nurse,
patient and institution
Nurse Practice Acts laws established in each state in the US to regulate the practice of nursing
Code of Ethics for Nurses provide the foundation for nursing practice and guide interactions with patients
Data Collection: Assessment collection, validation and communication of patient data
Nursing aims To promote health
To prevent illness
To restore health
Facilitate coping with disability and death
Nursing Diagnosis analysis of patient data to identify patient strengths and health problems that
independent nursing intervention can prevent or solve
planning and identification of outcome goals specify patient outcomes to prevent, reduce or resolve problems identified in the
nursing diagnosis
Nursing interventions
implementation carrying out care plan
teaching assess the patients knowledge first then assess their knowledge on different
treatment options
evaluation measuring the extent to which the patient achieved the outcome goal, identify
factors that positively or negatively impacted the goal
Assessment should be complete, relevant, systematic, purposeful, factual, and recording in a standard
matter
Initial assessment preformed shortly after patient admission, establish a data base of patient care
plan and problem identification
client centered assessment consider culture, health orientation, developmental stage
focused assessment The nurse gathers data about a specific problem that has already been identified.,
routinely part of ongoing data collection
time-lapsed assessment Scheduled to compare a patient's current status to the baseline data obtained
earlier.
emergency assessment ABCDE, rapid life threatening problem
, Validating data keep data free of error, bias or misinterpretation
How do we reduce data errors validating data, clinical reasoning skills, observation, prepare for what data you
need to collect, clustering data
Inspection deliberate, purposeful observations in a systematic way
palpitation use sense of touch to assess skin turgor, temp, texture and moisture
percussion act of striking one object against another for the purpose of producing a sound
auscultation act of listening with a stethoscope
recognizing significant data determine the deviation from the standard, normal health, normal patient
population and normal patient health
recognizing patterns nursing diagnosis should come from patterns of data recognized rather than a
single cue
reaching conclusions no problem- no nursing needed
possible problem- further data collection
actual problem- begin planning and implementing
patient motivation identify strengths and weakness as well as the patients motivation
problem statement clinical judgement concerning an undesirable human response in a health
condition
actual or potential problem identification identifies what is unhealthy about the patient and indicates need for change
etiology factors maintaining the unhealthy state
defining characteristics subjective and objective data that signal the problem
Problem example self-care deficient
etiology example fear of falling in the tub and obesity
defining characteristics example strong body odor and unclean hair
Maslow's Hierarchy of Needs physiological needs, safety, love and belonging, self-esteem, self actualization
short-term goals a goal that you can reach in a short period of time
long term goals require more than a week to be achieved, may be used as discharge goals
Nurse-intiated intervention autonomous action by the nurse backed by scientific evidence and benefits the
patient in a predictable way
Answers
Standards of Nursing Practice Standards allow nurses to carry out professional duties and protect the nurse,
patient and institution
Nurse Practice Acts laws established in each state in the US to regulate the practice of nursing
Code of Ethics for Nurses provide the foundation for nursing practice and guide interactions with patients
Data Collection: Assessment collection, validation and communication of patient data
Nursing aims To promote health
To prevent illness
To restore health
Facilitate coping with disability and death
Nursing Diagnosis analysis of patient data to identify patient strengths and health problems that
independent nursing intervention can prevent or solve
planning and identification of outcome goals specify patient outcomes to prevent, reduce or resolve problems identified in the
nursing diagnosis
Nursing interventions
implementation carrying out care plan
teaching assess the patients knowledge first then assess their knowledge on different
treatment options
evaluation measuring the extent to which the patient achieved the outcome goal, identify
factors that positively or negatively impacted the goal
Assessment should be complete, relevant, systematic, purposeful, factual, and recording in a standard
matter
Initial assessment preformed shortly after patient admission, establish a data base of patient care
plan and problem identification
client centered assessment consider culture, health orientation, developmental stage
focused assessment The nurse gathers data about a specific problem that has already been identified.,
routinely part of ongoing data collection
time-lapsed assessment Scheduled to compare a patient's current status to the baseline data obtained
earlier.
emergency assessment ABCDE, rapid life threatening problem
, Validating data keep data free of error, bias or misinterpretation
How do we reduce data errors validating data, clinical reasoning skills, observation, prepare for what data you
need to collect, clustering data
Inspection deliberate, purposeful observations in a systematic way
palpitation use sense of touch to assess skin turgor, temp, texture and moisture
percussion act of striking one object against another for the purpose of producing a sound
auscultation act of listening with a stethoscope
recognizing significant data determine the deviation from the standard, normal health, normal patient
population and normal patient health
recognizing patterns nursing diagnosis should come from patterns of data recognized rather than a
single cue
reaching conclusions no problem- no nursing needed
possible problem- further data collection
actual problem- begin planning and implementing
patient motivation identify strengths and weakness as well as the patients motivation
problem statement clinical judgement concerning an undesirable human response in a health
condition
actual or potential problem identification identifies what is unhealthy about the patient and indicates need for change
etiology factors maintaining the unhealthy state
defining characteristics subjective and objective data that signal the problem
Problem example self-care deficient
etiology example fear of falling in the tub and obesity
defining characteristics example strong body odor and unclean hair
Maslow's Hierarchy of Needs physiological needs, safety, love and belonging, self-esteem, self actualization
short-term goals a goal that you can reach in a short period of time
long term goals require more than a week to be achieved, may be used as discharge goals
Nurse-intiated intervention autonomous action by the nurse backed by scientific evidence and benefits the
patient in a predictable way
