NURS 3112 EXAM ONE STUDY GUIDE
QUESTIONS WITH VERIFIED
ANSWERS
Confidentiality - ANSWER-Requires that information is not shared beyond those who
have a need to know.
The Nursing Process (Definition) - ANSWER-A systematic patient-centered, goal-
oriented method of caring that provides a framework for nursing practice.
Components of the Nursing Process - ANSWER-ADPIE (Assessment, Diagnosis,
Plan, Implementation, Evaluation)
Three Types of Nursing Diagnoses - ANSWER-Actual (problem-focused,
Risk, and Health promotion
Actual Diagnosis - ANSWER-A clinical judgement concerning an undesirable human
response to a health condition/life process that exists in an individual, family, group,
or community.
Risk Diagnosis - ANSWER-A clinical judgement concerning the susceptibility of an
individual, family, group, or community for developing an undesirable human
response to health conditions/life processes.
Health Promotion Diagnosis - ANSWER-A clinical judgement concerning motivation
and desire to increase well-being and to actualize health potential. These responses
are expressed by a readiness to enhance specific health behaviors, and can be used
in any health state. In cases where individuals are unable to express their own
readiness to enhance health behaviors, the nurse may determine that a condition for
health promotions exists and then act on the client's behalf. Health promotion
responses may exist in an individual, family, group or communit
Components of an Actual Diagnosis - ANSWER-3 Parts:
1. Patient's problem
2. "Related to" - related factor, at risk populations, associated conditions
3: "As evidenced by (AEB)" - defining characteristics
Example: Excess Fluid volume related to excess sodium intake AEB edema
(2+lower extremities)
Components of an at Risk Diagnosis - ANSWER-2 Parts (because it hasn't
manifested)
1. Patient's problem
2. "Related to" - related factor, at-risk populations, associated conditions
Example: Risk for falls related to acute illness
,Maslow's Hierarchy of Needs - ANSWER-Helps the nurse prioritize the patient's
problems in order to decide the appropriate order of treatment.
Components of Maslow's Hierarchy of Needs - ANSWER-- Physiological (breathing,
food, water, sex, sleep, homeostasis, excretion)
- Safety (security of body, employment, resources, mortality, the family
- Need for love, affection, belongings
- Need for Esteem
- Need for Self-actualization
Who is the subject/target of goals? - ANSWER-Patients
7 Guidelines for Writing Patient-Centered Goals - ANSWER-Patient-centered
Specific
Measurable
Attainable
Relevant
Timely
What is the difference between short-term goals and long-term goals? - ANSWER-
Short term goals (STG) are expected within hours to a week, whereas long term
goals (LTG) are behaviors that are expected to be met in days, weeks, or months.
Direct Care - ANSWER-Treatment performed through interactions with patients
Examples: medication administration, insertion of an intravenous (IV) infusion,
counseling during a time of grief
Indirect Care - ANSWER-Treatment performed away from the patient but on behalf
of the patient or group (documentation)
Examples: managing patient's environment, documenting on your patient/ working to
be an advocate (interdisciplinary collaboration)
What is the focus during evaluation phase of the nursing process? - ANSWER-
Evaluation is continuous and ongoing - going back and looking at if what you're
doing is working.
During the evaluation step of the Nursing Process, identify if the outcome/goal was
met, taking corrective action.
Young Old Subgroup Ages - ANSWER-65 to 74 years
Middle Old Subgroup Ages - ANSWER-75 to 84 years
Old Old Subgroup Ages - ANSWER-85 to 99 years
Senescence - ANSWER-Normal age-related changes
,Sclerosis - ANSWER-Hardening
Stenosis - ANSWER-Narrowing
Atrophy - ANSWER-Loss of substance
Depression in the Elderly - ANSWER-- Early morning insomnia
- Daytime sleeping
- Poor appetite
- Lack of energy
- Unwillingness to participate in social or recreational activities
Primary Treatment
- Drug therapy/psychotherapy→ SSRI are the first drug choice
- Distraction & engagement→ volunteering, working, identifying a purpose
Dementia - ANSWER-- Slowly progressive cognitive decline (chronic confusion)
- Usually chronic
- Global impairment of intellectual function and is generally chronic and progressive.
- Types of Dementia:
- Alzheimer's Disease
- Multi-infarct dementia- vascular disorders and can cause infarcts and patient will
become more and more confused (20-25% of dementia)
Delirium - ANSWER-- Acute state of confusion
- Often Short Term and Reversible
- Occurs in up to 50% of older adults who are hospitalized so where they are not
familiar
Types of Delirium - ANSWER-- Hyperactive- restless, aggressive, etc.
- Hypoactive- quiet, empathetic, withdrawn
- Mixed
- Unclassified
Causes of Delirium - ANSWER-- Medications (anticholinergics/psychoactive)
- Electrolyte Imbalance
- Infections
- Fecal Impaction/Severe Diarrhea
- Surgery
- Metabolic disorders
- Neurologic disorders
- Circulatory disorders
- Renal function
- Nutritional deficiencies
- Hypoxia
- Major Loss
Activities of Daily Living (ADLs) - ANSWER-Day-in-day-out elements that a person
takes to care for themselves (bathing, dressing, etc.)
, Examples of ADLs - ANSWER-Bathing, dressing, toileting, transfers, grooming,
feeding
Instrumental Activities of Daily Living (IADLs) - ANSWER-The higher level activities
that someone must be able to maintain to live independently.
Examples of IADLs - ANSWER-Administering own medication, grocery shopping,
preparing meals, using the telephone, driving and transportation, handling own
finances, housekeeping, laundry
Identify issues that impact the nutrition and hydration of the older adult. - ANSWER--
Disrupted ability to store, use and absorb (Specifically Vitamin D and Calcium
become needed)
- Sedentary lifestyle & reduced metabolic rate
-Diminished taste and smell
- Tooth loss & poor fitting dentures
- Choose soft, high calorie, low nutritional density
- Constipation - significant problem as the older adults GI tract slows down. This can
create problems like impaction.
- Impact of loneliness on diet
- Dehydration - less body water content
Respiratory Complications Associated with Immobility - ANSWER-- Hypoventilation
- Atelectasis/pneumonia
- Pulmonary embolism (PE)
Hypoventilation - ANSWER-When someone isn't mobile, there is hypoventilation -
the lungs aren't expanded in the way that they normally are and as a consequence
the alveoli end up collapsing and when they collapse in several groups that is called
atelectasis.
Atelectasis/pneumonia - ANSWER-When someone has atelectasis there respiratory
system isn't functioning as well and can go on to develop into an infectious process
like pneumonia
Pulmonary Embolism (PE) - ANSWER-Blocking of a pulmonary artery due to a blood
clot
With a pulmonary embolism, a blood clot from somewhere else in the body gets into
the bloodstream and finds its way to the pulmonary vasculature
Cardiovascular Complications Associated with Immobility - ANSWER-- Orthostatic
hypotension
- Deep Vein Thrombosis (DVT)
Orthostatic Hypotension - ANSWER-Decrease in systolic blood pressure of 20 mm
Hg or a decrease in diastolic blood pressure of 10 mm Hg within three minutes of
standing when compared with blood pressure from the sitting or supine position.
QUESTIONS WITH VERIFIED
ANSWERS
Confidentiality - ANSWER-Requires that information is not shared beyond those who
have a need to know.
The Nursing Process (Definition) - ANSWER-A systematic patient-centered, goal-
oriented method of caring that provides a framework for nursing practice.
Components of the Nursing Process - ANSWER-ADPIE (Assessment, Diagnosis,
Plan, Implementation, Evaluation)
Three Types of Nursing Diagnoses - ANSWER-Actual (problem-focused,
Risk, and Health promotion
Actual Diagnosis - ANSWER-A clinical judgement concerning an undesirable human
response to a health condition/life process that exists in an individual, family, group,
or community.
Risk Diagnosis - ANSWER-A clinical judgement concerning the susceptibility of an
individual, family, group, or community for developing an undesirable human
response to health conditions/life processes.
Health Promotion Diagnosis - ANSWER-A clinical judgement concerning motivation
and desire to increase well-being and to actualize health potential. These responses
are expressed by a readiness to enhance specific health behaviors, and can be used
in any health state. In cases where individuals are unable to express their own
readiness to enhance health behaviors, the nurse may determine that a condition for
health promotions exists and then act on the client's behalf. Health promotion
responses may exist in an individual, family, group or communit
Components of an Actual Diagnosis - ANSWER-3 Parts:
1. Patient's problem
2. "Related to" - related factor, at risk populations, associated conditions
3: "As evidenced by (AEB)" - defining characteristics
Example: Excess Fluid volume related to excess sodium intake AEB edema
(2+lower extremities)
Components of an at Risk Diagnosis - ANSWER-2 Parts (because it hasn't
manifested)
1. Patient's problem
2. "Related to" - related factor, at-risk populations, associated conditions
Example: Risk for falls related to acute illness
,Maslow's Hierarchy of Needs - ANSWER-Helps the nurse prioritize the patient's
problems in order to decide the appropriate order of treatment.
Components of Maslow's Hierarchy of Needs - ANSWER-- Physiological (breathing,
food, water, sex, sleep, homeostasis, excretion)
- Safety (security of body, employment, resources, mortality, the family
- Need for love, affection, belongings
- Need for Esteem
- Need for Self-actualization
Who is the subject/target of goals? - ANSWER-Patients
7 Guidelines for Writing Patient-Centered Goals - ANSWER-Patient-centered
Specific
Measurable
Attainable
Relevant
Timely
What is the difference between short-term goals and long-term goals? - ANSWER-
Short term goals (STG) are expected within hours to a week, whereas long term
goals (LTG) are behaviors that are expected to be met in days, weeks, or months.
Direct Care - ANSWER-Treatment performed through interactions with patients
Examples: medication administration, insertion of an intravenous (IV) infusion,
counseling during a time of grief
Indirect Care - ANSWER-Treatment performed away from the patient but on behalf
of the patient or group (documentation)
Examples: managing patient's environment, documenting on your patient/ working to
be an advocate (interdisciplinary collaboration)
What is the focus during evaluation phase of the nursing process? - ANSWER-
Evaluation is continuous and ongoing - going back and looking at if what you're
doing is working.
During the evaluation step of the Nursing Process, identify if the outcome/goal was
met, taking corrective action.
Young Old Subgroup Ages - ANSWER-65 to 74 years
Middle Old Subgroup Ages - ANSWER-75 to 84 years
Old Old Subgroup Ages - ANSWER-85 to 99 years
Senescence - ANSWER-Normal age-related changes
,Sclerosis - ANSWER-Hardening
Stenosis - ANSWER-Narrowing
Atrophy - ANSWER-Loss of substance
Depression in the Elderly - ANSWER-- Early morning insomnia
- Daytime sleeping
- Poor appetite
- Lack of energy
- Unwillingness to participate in social or recreational activities
Primary Treatment
- Drug therapy/psychotherapy→ SSRI are the first drug choice
- Distraction & engagement→ volunteering, working, identifying a purpose
Dementia - ANSWER-- Slowly progressive cognitive decline (chronic confusion)
- Usually chronic
- Global impairment of intellectual function and is generally chronic and progressive.
- Types of Dementia:
- Alzheimer's Disease
- Multi-infarct dementia- vascular disorders and can cause infarcts and patient will
become more and more confused (20-25% of dementia)
Delirium - ANSWER-- Acute state of confusion
- Often Short Term and Reversible
- Occurs in up to 50% of older adults who are hospitalized so where they are not
familiar
Types of Delirium - ANSWER-- Hyperactive- restless, aggressive, etc.
- Hypoactive- quiet, empathetic, withdrawn
- Mixed
- Unclassified
Causes of Delirium - ANSWER-- Medications (anticholinergics/psychoactive)
- Electrolyte Imbalance
- Infections
- Fecal Impaction/Severe Diarrhea
- Surgery
- Metabolic disorders
- Neurologic disorders
- Circulatory disorders
- Renal function
- Nutritional deficiencies
- Hypoxia
- Major Loss
Activities of Daily Living (ADLs) - ANSWER-Day-in-day-out elements that a person
takes to care for themselves (bathing, dressing, etc.)
, Examples of ADLs - ANSWER-Bathing, dressing, toileting, transfers, grooming,
feeding
Instrumental Activities of Daily Living (IADLs) - ANSWER-The higher level activities
that someone must be able to maintain to live independently.
Examples of IADLs - ANSWER-Administering own medication, grocery shopping,
preparing meals, using the telephone, driving and transportation, handling own
finances, housekeeping, laundry
Identify issues that impact the nutrition and hydration of the older adult. - ANSWER--
Disrupted ability to store, use and absorb (Specifically Vitamin D and Calcium
become needed)
- Sedentary lifestyle & reduced metabolic rate
-Diminished taste and smell
- Tooth loss & poor fitting dentures
- Choose soft, high calorie, low nutritional density
- Constipation - significant problem as the older adults GI tract slows down. This can
create problems like impaction.
- Impact of loneliness on diet
- Dehydration - less body water content
Respiratory Complications Associated with Immobility - ANSWER-- Hypoventilation
- Atelectasis/pneumonia
- Pulmonary embolism (PE)
Hypoventilation - ANSWER-When someone isn't mobile, there is hypoventilation -
the lungs aren't expanded in the way that they normally are and as a consequence
the alveoli end up collapsing and when they collapse in several groups that is called
atelectasis.
Atelectasis/pneumonia - ANSWER-When someone has atelectasis there respiratory
system isn't functioning as well and can go on to develop into an infectious process
like pneumonia
Pulmonary Embolism (PE) - ANSWER-Blocking of a pulmonary artery due to a blood
clot
With a pulmonary embolism, a blood clot from somewhere else in the body gets into
the bloodstream and finds its way to the pulmonary vasculature
Cardiovascular Complications Associated with Immobility - ANSWER-- Orthostatic
hypotension
- Deep Vein Thrombosis (DVT)
Orthostatic Hypotension - ANSWER-Decrease in systolic blood pressure of 20 mm
Hg or a decrease in diastolic blood pressure of 10 mm Hg within three minutes of
standing when compared with blood pressure from the sitting or supine position.
