Nursing 251 Final Exam
1. Assessment
2. Diagnosis
3. Planning
4. Implementation
5. Evaluation Correct Answer What are the steps in the
nursing process?
1. Independent/Nurse Initiated
2. Delegated
3. Interdependent/Collaborative
4. Physician Initiated Correct Answer What are the types of
interventions?
Actual problem Correct Answer The nursing diagnosis must
be supported by assessment data; clinical signs and symptoms
Acute pain Correct Answer Less than 6 months of pain; rapid
onset following accident or trauma. Have a foreseeable end.
Have to manage by performing interventions such as deep
breathing and turning.
Acute wound Correct Answer A wound that is healing
through the normal wound healing process
Adjunct therapies Correct Answer nerve pain; chronic pain
with no source
Adjuvants Correct Answer Not intended to treat pain but
helps with nerve pain
,Aggressive receiver Correct Answer self-denying, hurt,
defensive, humiliated, does not achieve desired goal
Aggressive sender Correct Answer Self-enhancing at the
expense of another, expressive, chooses for others, achieves
desired goal by hurting others
Analyze data and determine the diagnosis Correct Answer
ANA Standard 2: Diagnosis
Assertive receiver Correct Answer Self-enhancing,
expressive, and may achieve desired goal
Assertive sender Correct Answer Self-enhancing, expressive,
feels good about self, choose for self, and may achieve desired
goal
Assessment Correct Answer ________________ is the first
step in determining priorities to individualize care
Assessment Correct Answer The systematic collection and
verification of data
Atelectasis, hypostatic pneumonia, accumulation of secretions
Correct Answer What are the respiratory changes due to
immobility?
Biological pain Correct Answer Pain that the body is causing
(tumor occupying space and pushing on organs)
, Braden Scale Correct Answer risk assessment tool for
pressure ulcers; composed of six subscales: sensory perception,
moisture, activity, mobility, nutrition, and friction/shear.
brevity Correct Answer Briefness or conciseness in verbal
communication
Cancer pain Correct Answer Life threatening; can be related
to tumor progression, invasive procedures, toxicity of treatment,
or infection due to the decreased immune system. Can be acute
or chronic pain.
Channels Correct Answer How the message is conveyed
Chemical pain Correct Answer Pain from gout, stomach
ulcers, ruptured appendix, and side effects of medication
Chronic pain Correct Answer Greater than 6 months of pain;
no foreseeable end. Ex: arthritis, diabetic neuropathy. Ongoing
and does not necessarily respond to treatment; need to manage
it. Typically not life threatening, however most likely diagnosed
with depression (58%)
Chronic wound Correct Answer Prolonged healing in any
stage complicated by various factors-blood flow issues, edema,
necrotic tissue, bacterial load.
clarity Correct Answer clearness in thought or expression in
verbal communication
1. Assessment
2. Diagnosis
3. Planning
4. Implementation
5. Evaluation Correct Answer What are the steps in the
nursing process?
1. Independent/Nurse Initiated
2. Delegated
3. Interdependent/Collaborative
4. Physician Initiated Correct Answer What are the types of
interventions?
Actual problem Correct Answer The nursing diagnosis must
be supported by assessment data; clinical signs and symptoms
Acute pain Correct Answer Less than 6 months of pain; rapid
onset following accident or trauma. Have a foreseeable end.
Have to manage by performing interventions such as deep
breathing and turning.
Acute wound Correct Answer A wound that is healing
through the normal wound healing process
Adjunct therapies Correct Answer nerve pain; chronic pain
with no source
Adjuvants Correct Answer Not intended to treat pain but
helps with nerve pain
,Aggressive receiver Correct Answer self-denying, hurt,
defensive, humiliated, does not achieve desired goal
Aggressive sender Correct Answer Self-enhancing at the
expense of another, expressive, chooses for others, achieves
desired goal by hurting others
Analyze data and determine the diagnosis Correct Answer
ANA Standard 2: Diagnosis
Assertive receiver Correct Answer Self-enhancing,
expressive, and may achieve desired goal
Assertive sender Correct Answer Self-enhancing, expressive,
feels good about self, choose for self, and may achieve desired
goal
Assessment Correct Answer ________________ is the first
step in determining priorities to individualize care
Assessment Correct Answer The systematic collection and
verification of data
Atelectasis, hypostatic pneumonia, accumulation of secretions
Correct Answer What are the respiratory changes due to
immobility?
Biological pain Correct Answer Pain that the body is causing
(tumor occupying space and pushing on organs)
, Braden Scale Correct Answer risk assessment tool for
pressure ulcers; composed of six subscales: sensory perception,
moisture, activity, mobility, nutrition, and friction/shear.
brevity Correct Answer Briefness or conciseness in verbal
communication
Cancer pain Correct Answer Life threatening; can be related
to tumor progression, invasive procedures, toxicity of treatment,
or infection due to the decreased immune system. Can be acute
or chronic pain.
Channels Correct Answer How the message is conveyed
Chemical pain Correct Answer Pain from gout, stomach
ulcers, ruptured appendix, and side effects of medication
Chronic pain Correct Answer Greater than 6 months of pain;
no foreseeable end. Ex: arthritis, diabetic neuropathy. Ongoing
and does not necessarily respond to treatment; need to manage
it. Typically not life threatening, however most likely diagnosed
with depression (58%)
Chronic wound Correct Answer Prolonged healing in any
stage complicated by various factors-blood flow issues, edema,
necrotic tissue, bacterial load.
clarity Correct Answer clearness in thought or expression in
verbal communication
