Nursing 251 final exam questions well
answered already passed
introductory phase - correct answer ✔✔introduce self, explain purpose of the interview, assure
privacy, time frame, build rapport
working phase - correct answer ✔✔nurse collects data by collaborating with patient to identify
problems and set goals.
uses skills of listening/thinking/observing
summary/closing phase - correct answer ✔✔- summarize/restate findings
- validates problems/goals
- discusses plan to solve problem
Facilitation - correct answer ✔✔cueing to patient to continue by saying "mm-hmm", or silent
gestures like head nod. it assures that you are listening and want them to keep going
interpretation - correct answer ✔✔inference about feelings or concerns.
ex) "you seem anxious. are you nervous about that upcoming test?"
confrontation - correct answer ✔✔identifying and stating observations that seem to be at odds
with statements/behavior.
ex) "you say you don't care, but yet you are crying."
not always the best approach
,empathetic response - correct answer ✔✔saying things like "I know that must have been really
hard for you"
-nonverbal: offering tissue if pt is crying, gently touching patient's hand.
-therapeutic use of self: "I can relate to what you are going through. I got surgery last year."
clarification - correct answer ✔✔ex) "you said you and your mom had a falling out. what exactly
do you mean by falling out?"
reflection - correct answer ✔✔reiterating what the patient said
patient: "the pain got worse and began to spread"
you: "it spread?"
nursing process - correct answer ✔✔ADPIE
Assessment
Diagnosis
Planning
Implementation
Evaluation
initial comprehensive assessment - correct answer ✔✔-collect subjective/objective data
- done at doctors office
- occurs when patient first presents to health care setting
ongoing/partial assessment - correct answer ✔✔-reassessment of initial problem or baseline
looking for improvement or deterioration
-beginning of shift assessment in hospitals, weekly home visits
-occurs after comprehensive database is established
, focused/problem assessment - correct answer ✔✔- occurs in relation to a specific topic
* patient admitted w SOB
* begin with cardiorespiratory system assessment then follow with a comprehensive
assessment
emergency assessment - correct answer ✔✔- immediate diagnosis needed to begin treatment
* ABC airway breathing cardiovascular
- occurs rapidly when life saving acting needs to be taken
Vital signs - correct answer ✔✔temp, pulse, respirations, BP, PAIN
temperature ranges - correct answer ✔✔37 deg C or 98.6 deg F
pulse ranges - correct answer ✔✔60 - 100 adult
80 - 120 child
120 -160 infant
(rate: BPM, 2+ normal)
Respiration ranges - correct answer ✔✔12-20 bpm
<12 = bradypnea (head injury, stroke)
> 20 = tachypnea (fever, anxiety, exercise)
Blood pressure - correct answer ✔✔pressure exerted on artery walls
ventricles contract = systole
ventricles relax = diastole
answered already passed
introductory phase - correct answer ✔✔introduce self, explain purpose of the interview, assure
privacy, time frame, build rapport
working phase - correct answer ✔✔nurse collects data by collaborating with patient to identify
problems and set goals.
uses skills of listening/thinking/observing
summary/closing phase - correct answer ✔✔- summarize/restate findings
- validates problems/goals
- discusses plan to solve problem
Facilitation - correct answer ✔✔cueing to patient to continue by saying "mm-hmm", or silent
gestures like head nod. it assures that you are listening and want them to keep going
interpretation - correct answer ✔✔inference about feelings or concerns.
ex) "you seem anxious. are you nervous about that upcoming test?"
confrontation - correct answer ✔✔identifying and stating observations that seem to be at odds
with statements/behavior.
ex) "you say you don't care, but yet you are crying."
not always the best approach
,empathetic response - correct answer ✔✔saying things like "I know that must have been really
hard for you"
-nonverbal: offering tissue if pt is crying, gently touching patient's hand.
-therapeutic use of self: "I can relate to what you are going through. I got surgery last year."
clarification - correct answer ✔✔ex) "you said you and your mom had a falling out. what exactly
do you mean by falling out?"
reflection - correct answer ✔✔reiterating what the patient said
patient: "the pain got worse and began to spread"
you: "it spread?"
nursing process - correct answer ✔✔ADPIE
Assessment
Diagnosis
Planning
Implementation
Evaluation
initial comprehensive assessment - correct answer ✔✔-collect subjective/objective data
- done at doctors office
- occurs when patient first presents to health care setting
ongoing/partial assessment - correct answer ✔✔-reassessment of initial problem or baseline
looking for improvement or deterioration
-beginning of shift assessment in hospitals, weekly home visits
-occurs after comprehensive database is established
, focused/problem assessment - correct answer ✔✔- occurs in relation to a specific topic
* patient admitted w SOB
* begin with cardiorespiratory system assessment then follow with a comprehensive
assessment
emergency assessment - correct answer ✔✔- immediate diagnosis needed to begin treatment
* ABC airway breathing cardiovascular
- occurs rapidly when life saving acting needs to be taken
Vital signs - correct answer ✔✔temp, pulse, respirations, BP, PAIN
temperature ranges - correct answer ✔✔37 deg C or 98.6 deg F
pulse ranges - correct answer ✔✔60 - 100 adult
80 - 120 child
120 -160 infant
(rate: BPM, 2+ normal)
Respiration ranges - correct answer ✔✔12-20 bpm
<12 = bradypnea (head injury, stroke)
> 20 = tachypnea (fever, anxiety, exercise)
Blood pressure - correct answer ✔✔pressure exerted on artery walls
ventricles contract = systole
ventricles relax = diastole
