Nur 216 Exam 1 Questions With Correct Answers Latest Update 2026

NUR 216 EXAM 1 QUESTIONS WITH CORRECT ANSWERS LATEST UPDATE 2026 comprehensive assessment - Answers An assessment that includes a complete health history and physical assessment; Usually brand new patients focused assessment - Answers assessment conducted to assess a specific problem; focuses on pertinent history and body regions HIPAA - Answers Health Insurance Portability and Accountability Act The nursing process - Answers Assessment Diagnosis Planning Implementation Evaluation Assessment (ADPIE) - Answers Data collection (objective/subjective) Prioritize Data: Primary (life threatening), Secondary (requires prompt attention), Tertiary (not urgent) Planning (ADPIE) - Answers Develop SMART goals, plan nursing interventions Implementation (ADPIE) - Answers Perform planned nursing interventions Evaluation (ADPIE) - Answers Were the goals met? If not, re-assess assessment skills - Answers Inspection Palpation Percussion Auscultation (Bowels: Inspection, Auscultation, Percussion. Auscultation) Do not want to alter the bowel sounds Inspection - Answers Observe for Symmetry, size, color, shape Direct: Visualize with our eyes Indirect: Use and instrument Fingertips/pads: Palpation - Answers Fine sensation (texture, swelling, pulsation. lumps) Dorsa of hands: Palpation - Answers Best for determining temperature Base of fingers or ulnar surface: - Answers vibrations Palpation - Answers Light: surface characteristics Deep: Organs, masses, tenderness (use intermittent pressure) Ballpottement: Size/Shape of free floating objects - Always palpate tender areas last Percussion - Answers tapping on a surface to determine the difference in the density of the underlying structure Ausculation - Answers listening to sounds within the body Bell - Answers low pitched sounds (mummers) Diaphragm - Answers high pitched sounds (bowel and lung sounds) What should we do before leaving the patients room? - Answers Patients safety Bed to lowest position Side Rails Call button and personal belongings in reach Contextual awareness - Answers Understanding the status of the client and the events that led to their interaction Analyzing assumptions - Answers Evaluating the client's clinical situation Exploring alternatives - Answers The use of holistic approaches for treating the whole person (physical health, lifestyle choices, culture, living environment, life experiences) Reflecting and deciding - Answers Reflect on the client's goals and decide on the intervention with client input Steps for communicating with members of the health care team - Answers 1.Identify the member by name and title 2.Provide info regarding the current situation 3.Provide info regarding the background situation 4.Give the most recent set of vital signs 5.Provide suggestions that may be helpful to the situation 6.Repeat the orders back that are given to you by the provider Nonmaleficence - Answers Do no harm Beneficence - Answers Promote good Autonomy - Answers the right to make own choice Justice - Answers Fairness Confidentiality - Answers HIPPA Identify steps to ensure client privacy and safety. Privacy - Answers -Physical privacy is needed to make the client feel secure. -Personal privacy: Maintaining confidentiality and ensuring the client has been identified properly. -Infection control -Hand Hygiene -PPE 5 factors influencing the use of therapeutic communication. - Answers -Maintain professionalism -Maintain a neutral attitude -Do not impose own values on others -Practice empathy -Cultural competence Therapeutic Communication - Answers an approach to communicate that is both verbal and nonverbal. Focus on the person and not the problem. Electronic Records (EHR) - Answers Communication tools for documenting progress, treatments, interventions, and client responses to care. Paper Records - Answers Maintain integrity. Properly date and time each entry followed by a full signature and title. 9 Types of Nursing Documentation Errors - Answers -Sloppy or illegible handwriting -Failure to date, time and sign a medical entry -Lack of documentation -Incomplete or missing documentation -Adding entries later on -Documenting Subjective data -Not questioning incomprehensive orders -Using wrong abbreviations -Entering info into the wrong chart steps to performing general survey - Answers 1.General appearance 2.Behavior 3.Body structure 4.Mobility 5.Measurement 6.Vital signs 7.Pain approach of the initial survey and assessment - Answers The initial survey and assessment will help determine a client's health status. The observation begins right when you step into the room. While performing the initial survey be sure to establish trust and build a rapport with the client through therapeutic communication. Glasgow Coma Scale - Answers Eyes 4 Voice 5 Motor 6 Cyanosis - Answers bluish discoloration of the skin Erythema - Answers redness of the skin Pallor - Answers Extreme or unnatural paleness Dysarthria - Answers speech sounds are unclear Aphasia - Answers struggles to find words or express ideas Kyphosis - Answers older adults are hunched over Tripod position - Answers When hunched over with arms on knees because of difficulty breathing Crepitus - Answers Cracking sound made when bone surfaces rub against each other Spasticity - Answers Alteration in muscle tone manifested as increased tonicity. Ex: Increased resistance when attempting to extend a joint Rigidity - Answers Alteration in muscle movement seen as a continuous, rapid, twitching of a muscle at rest Myoclonus - Answers Alteration in muscle movement that is seen as a sudden jerking of muscle. Ex: hiccups, seizure activity, and a single myoclonic jerk of the arm or leg when falling asleep Tic - Answers Alteration in muscle movement characterized by involuntary, repetitive movement. Neurologic or psychogenic cause.