DETAILED EXPLANATIONS, AND ESSENTIAL STUDY
NOTES FOR A HIGH-SCORING TEST EXPERIENCE
1. -: What is
the primary purpose of a nursing
assessment?
Answer: The primary purpose of a nursing assessment is to collect
comprehensive data about a patient's physical, psychological, sociocultural,
spiritual, economic, and lifestyle factors to identify actual or potential health
problems, establish a baseline, and develop an appropriate plan of care.
2. Definethe term "homeostasis" and explain its
significance in nursing care.
Answer: Homeostasis refers to the body's ability to maintain internal stability
and balance despite changes in external conditions. It's significant in nursing
care because many diseases represent a disruption in homeostasis, and nursing
interventions often aim to restore or support homeostatic mechanisms.
3. -: What information should
be included in a
thorough patient handoff report?
Answer: A thorough handoff report should include: patient demographics,
diagnosis, current status, vital signs, significant lab/diagnostic results,
medications administered, treatments performed, pain assessment, intake and
output, significant changes in condition, pending tests/procedures, and specific
concerns or priorities for the next shift.
,4. -: What
are the five components of a complete pain
assessment?
Answer: The five components of a complete pain assessment include: Location,
Intensity (using a pain scale), Quality (sharp, dull, burning), Radiation/referral
pattern, and Temporal factors (onset, duration, pattern). This is often
remembered using the acronym PQRST (Provocation/Palliation, Quality,
Region/Radiation, Severity, Timing).
5. -: Differentiate
between objective and
subjective data in nursing assessment
,Answer: Subjective data is information provided by the patient or family based
on feelings, perceptions, and concerns (symptoms). Objective data is observable
and measurable information collected by the nurse through physical
examination and diagnostic tests (signs).
6. -:
What is the purpose of the Glasgow Coma Scale
(GCS) and what three responses does it evaluate?
Answer: The Glasgow Coma Scale evaluates the level of consciousness in
patients with neurological issues. It assesses three responses: eye opening
(scored 1-4), verbal response (scored 1-5), and motor response (scored 1-6). The
total score ranges from 3-15, with lower scores indicating decreased levels of
consciousness.
7. -: Define "nursing
diagnosis" and explain how it
differs from a medical diagnosis.
Answer: A nursing diagnosis is a clinical judgment about individual, family, or
community responses to actual or potential health problems/life processes. It
differs from a medical diagnosis in that it focuses on the patient's response to
health problems rather than the identification of disease processes, and provides
the basis for nursing interventions to achieve specific outcomes.
8. -: What are the components of the nursing process?
Answer: The nursing process consists of five interconnected steps: Assessment
(collecting patient data), Diagnosis (analyzing data to identify problems),
Planning (developing care plans with outcomes), Implementation (performing
interventions), and Evaluation (determining effectiveness of interventions).
9. -: What is
the significance of obtaining a patient's
baseline vital signs?
Answer: Baseline vital signs provide a reference point for comparison to detect
changes in a patient's condition, help evaluate responses to treatments, assist in
determining appropriate interventions, and aid in monitoring disease
progression or recovery.
, 10. -: List five factors that can affect a patient's vital signs.
Answer: Five factors that can affect vital signs include: age, gender,
medications, emotional state (pain, anxiety, stress), physical activity, underlying
medical conditions, time of day, and environmental factors such as temperature.