NURS 214 Exam 1 Questions All Correct
Detailed Answers 2025 Update
Types of Data - Answers -✔✔ Subjective
- what the client says about themselves
Objective
- what you observe
- inspecting, percussing, palpating, auscultating
Purpose of Assessment - Answers -✔✔ to make a judgement or diagnosis
starting point of diagnostic reasoning
Diagnostic Reasoning - Answers -✔✔ · process of analyzing health data and drawing
conclusions to identify diagnoses
· Always validate your data = example: nurse aide who made up BPs
4 Major Components of Diagnostic Reasoning - Answers -✔✔ Attending to initially
available cues
-What is a cue? A piece of information: a sign or symptom (s/s), lab data, imaging data,
etc.
Formulating diagnostic hypotheses
-What is a hypothesis? Tentative explanation for a cue/set of cues, Can be used as
basis for further investigation
Gathering data relative to the hypotheses
Evaluating each hypothesis with the new data collected
Nursing Process - Answers -✔✔ Assessment
Diagnosis
Outcome Identificaton
Planning
Implementation
Evaluation
Iterative process = can move back and forth while caring for the needs of complex
patients
Assessment - Answers -✔✔ Collect data:
-Review of the clinical record, health history, physical examination, functional
assessment
-Risk assessment
-Review of the literature
Use evidence-based assessment techniques
,Document relevant data
Diagnosis - Answers -✔✔ Compare clinical findings with normal and abnormal
Interpret data
-Identify clusters of clues, make hypotheses, test hypotheses, derive diagnoses
Validate diagnoses
Document diagnoses
Outcome Identification - Answers -✔✔ o Identify expected outcomes
o Individualize to the person
o Identify expected culturally appropriate outcomes
o Establish realistic and measurable outcomes
o Develop a timeline
Planning - Answers -✔✔ o Establish priorities
o Develop outcomes
o Set timelines for outcomes
o Identify interventions
o Integrate evidence-based trends and research
o Document plan of care
Implementation - Answers -✔✔ o Implement in a safe and timely manner
o Used evidence-based interventions
o Collaborate with colleagues
o Use community resources
o Coordinate care delivery
o Provide health teaching and health promotion
o Document implementation and any modification
Evaluation - Answers -✔✔ o Progress toward outcomes
o Conduct systematic, ongoing, criterion-based evaluation
o Include patient and significant others
o Use ongoing assessment to revise diagnoses, outcomes, plan
o Disseminate results to patient and family
4 levels of experience - Answers -✔✔ -Novice· : no experience with a specified patient
population and uses rules to guide performance.
-Competency: takes 2 to 3 years in similar clinical situations, in which you see actions in
the context of patient goals or plans of care.
-Proficient: understands a pt situation as a whole rather than as a list of tasks. Sees
long-term goals for the pt. Understands how today's interventions will help the patient in
the future.
,-Expert: vault over the steps and arrive at a clinical judgment in one leap. Has an
intuitive grasp of a clinical situation and zeroes in on the accurate solution.
Critical Thinking - Answers -✔✔ Required for sound diagnostic reasoning and clinical
judgement
- no ONE protocol that will fit in every situation
Requires you to put cues together
- critical thinking is multidimensional
- case studies, simulation help to develop these skills
- cluster cues together. . . can start to develop a picture
- ex: SOB, Weight gain, Pitting edema BLE, Palpitations = HF
Approach problems in a nonjudgmental way
- Avoid making assumptions
Critical Thinking Skills (Alfaro-Lefevre, 1999) - Answers -✔✔ 1. Identifying assumptions
2. Identify an organized and comprehensive approach to assessment
3. Validation
4. Distinguish normal from abnormal signs/symptoms
5. Making inferences/drawing valid conclusions
6. Clustering related cues
7. Distinguish relevant from irrelevant
8. Recognize inconsistencies
9. Identifying patterns
10. Identifying missing information
11. Promoting health by identifying risk factors
12. Prioritizing
identifying assumptions - Answers -✔✔ -what info are you taking for granted?
- What are you overlooking?
-Clinician bias = primary cause of misdiagnosis
Distinguish relevant from irrelevant - Answers -✔✔ -Patient with HF c/o HA (irrelevant)
and abdominal pain and difficulty buttoning pants (both relevant due to presence of
ascites with the HF).
-Patient with heart attack (MI) w/ c/o right foot pain (irrelevant) , SOB (relevant),
shoulder pain (relevant), and nausea (relevant)
Recognize inconsistencies - Answers -✔✔ what patients say from one visit to the next
Prioritizing - Answers -✔✔ First-level priority problems
- Emergent, life-threatening, immediate
- CPR, airway (ALWAYS FIRST), someone is passed out, severe hypoglycemia,
bleeding
, Second-level priority problems
-Require prompt intervention to prevent further deterioration
-Mental status change, acute pain, acute urinary elimination problems, untreated
medical problems, abnormal lab values, risk to safety/security, broken ankle, risk of
infection, pain
Third-level priority problems
-Important to client's health, but not of urgent nature
-Need long term interventions
-May require collaborative efforts between client and health care professionals
-Lack of knowledge, mobility problems, family coping, etc.
Priority Practice: Heroin Overdose - Answers -✔✔ -First-level priority = airway,
breathing, circulation
-Second-level priority = abnormal labs??, infection risk?? (for needle use) and risky
behavior
-Third-level priority = lack of knowledge, drug rehab (could also be a second level)
Priority Practice: Broken Leg - Answers -✔✔ -First level priority = circulation
-Second level priority = pain; infection risk (open skin)
-Third level priority = use of crutches, use of braces for activity
5 steps to EBP - Answers -✔✔ o Ask the question
o Acquire sources of evidence
o Appraise and synthesize evidence
o Apply relevant evidence in practice
o Assess the outcomes
Clinical decision making based on EBP depends on 4 factors: - Answers -✔✔ o Best
evidence from a critical review of literature
o Clinician's experience and expertise
o Patient preference
o Physical examination and assessment
Types of Databases - Answers -✔✔ Complete (total health)
Focused (Problem-Centered)
Follow-up
Emergency
Complete Database (Total Health) - Answers -✔✔ o Complete health history and full
physical exam
o Current and past health state
o Forms baseline
o Yields first diagnosis
o Often collected in primary care setting (PCP office, e.g., others); may also be
collected in acute care (hospital) setting
Detailed Answers 2025 Update
Types of Data - Answers -✔✔ Subjective
- what the client says about themselves
Objective
- what you observe
- inspecting, percussing, palpating, auscultating
Purpose of Assessment - Answers -✔✔ to make a judgement or diagnosis
starting point of diagnostic reasoning
Diagnostic Reasoning - Answers -✔✔ · process of analyzing health data and drawing
conclusions to identify diagnoses
· Always validate your data = example: nurse aide who made up BPs
4 Major Components of Diagnostic Reasoning - Answers -✔✔ Attending to initially
available cues
-What is a cue? A piece of information: a sign or symptom (s/s), lab data, imaging data,
etc.
Formulating diagnostic hypotheses
-What is a hypothesis? Tentative explanation for a cue/set of cues, Can be used as
basis for further investigation
Gathering data relative to the hypotheses
Evaluating each hypothesis with the new data collected
Nursing Process - Answers -✔✔ Assessment
Diagnosis
Outcome Identificaton
Planning
Implementation
Evaluation
Iterative process = can move back and forth while caring for the needs of complex
patients
Assessment - Answers -✔✔ Collect data:
-Review of the clinical record, health history, physical examination, functional
assessment
-Risk assessment
-Review of the literature
Use evidence-based assessment techniques
,Document relevant data
Diagnosis - Answers -✔✔ Compare clinical findings with normal and abnormal
Interpret data
-Identify clusters of clues, make hypotheses, test hypotheses, derive diagnoses
Validate diagnoses
Document diagnoses
Outcome Identification - Answers -✔✔ o Identify expected outcomes
o Individualize to the person
o Identify expected culturally appropriate outcomes
o Establish realistic and measurable outcomes
o Develop a timeline
Planning - Answers -✔✔ o Establish priorities
o Develop outcomes
o Set timelines for outcomes
o Identify interventions
o Integrate evidence-based trends and research
o Document plan of care
Implementation - Answers -✔✔ o Implement in a safe and timely manner
o Used evidence-based interventions
o Collaborate with colleagues
o Use community resources
o Coordinate care delivery
o Provide health teaching and health promotion
o Document implementation and any modification
Evaluation - Answers -✔✔ o Progress toward outcomes
o Conduct systematic, ongoing, criterion-based evaluation
o Include patient and significant others
o Use ongoing assessment to revise diagnoses, outcomes, plan
o Disseminate results to patient and family
4 levels of experience - Answers -✔✔ -Novice· : no experience with a specified patient
population and uses rules to guide performance.
-Competency: takes 2 to 3 years in similar clinical situations, in which you see actions in
the context of patient goals or plans of care.
-Proficient: understands a pt situation as a whole rather than as a list of tasks. Sees
long-term goals for the pt. Understands how today's interventions will help the patient in
the future.
,-Expert: vault over the steps and arrive at a clinical judgment in one leap. Has an
intuitive grasp of a clinical situation and zeroes in on the accurate solution.
Critical Thinking - Answers -✔✔ Required for sound diagnostic reasoning and clinical
judgement
- no ONE protocol that will fit in every situation
Requires you to put cues together
- critical thinking is multidimensional
- case studies, simulation help to develop these skills
- cluster cues together. . . can start to develop a picture
- ex: SOB, Weight gain, Pitting edema BLE, Palpitations = HF
Approach problems in a nonjudgmental way
- Avoid making assumptions
Critical Thinking Skills (Alfaro-Lefevre, 1999) - Answers -✔✔ 1. Identifying assumptions
2. Identify an organized and comprehensive approach to assessment
3. Validation
4. Distinguish normal from abnormal signs/symptoms
5. Making inferences/drawing valid conclusions
6. Clustering related cues
7. Distinguish relevant from irrelevant
8. Recognize inconsistencies
9. Identifying patterns
10. Identifying missing information
11. Promoting health by identifying risk factors
12. Prioritizing
identifying assumptions - Answers -✔✔ -what info are you taking for granted?
- What are you overlooking?
-Clinician bias = primary cause of misdiagnosis
Distinguish relevant from irrelevant - Answers -✔✔ -Patient with HF c/o HA (irrelevant)
and abdominal pain and difficulty buttoning pants (both relevant due to presence of
ascites with the HF).
-Patient with heart attack (MI) w/ c/o right foot pain (irrelevant) , SOB (relevant),
shoulder pain (relevant), and nausea (relevant)
Recognize inconsistencies - Answers -✔✔ what patients say from one visit to the next
Prioritizing - Answers -✔✔ First-level priority problems
- Emergent, life-threatening, immediate
- CPR, airway (ALWAYS FIRST), someone is passed out, severe hypoglycemia,
bleeding
, Second-level priority problems
-Require prompt intervention to prevent further deterioration
-Mental status change, acute pain, acute urinary elimination problems, untreated
medical problems, abnormal lab values, risk to safety/security, broken ankle, risk of
infection, pain
Third-level priority problems
-Important to client's health, but not of urgent nature
-Need long term interventions
-May require collaborative efforts between client and health care professionals
-Lack of knowledge, mobility problems, family coping, etc.
Priority Practice: Heroin Overdose - Answers -✔✔ -First-level priority = airway,
breathing, circulation
-Second-level priority = abnormal labs??, infection risk?? (for needle use) and risky
behavior
-Third-level priority = lack of knowledge, drug rehab (could also be a second level)
Priority Practice: Broken Leg - Answers -✔✔ -First level priority = circulation
-Second level priority = pain; infection risk (open skin)
-Third level priority = use of crutches, use of braces for activity
5 steps to EBP - Answers -✔✔ o Ask the question
o Acquire sources of evidence
o Appraise and synthesize evidence
o Apply relevant evidence in practice
o Assess the outcomes
Clinical decision making based on EBP depends on 4 factors: - Answers -✔✔ o Best
evidence from a critical review of literature
o Clinician's experience and expertise
o Patient preference
o Physical examination and assessment
Types of Databases - Answers -✔✔ Complete (total health)
Focused (Problem-Centered)
Follow-up
Emergency
Complete Database (Total Health) - Answers -✔✔ o Complete health history and full
physical exam
o Current and past health state
o Forms baseline
o Yields first diagnosis
o Often collected in primary care setting (PCP office, e.g., others); may also be
collected in acute care (hospital) setting
