NURS 171 Unit 1 Exam UPDATED
ACTUAL QUESTIONS AND CORRECT
ANSWERS
Maslow's Hierarchy of needs - CORRECT ANSWER Physiological: water, oxygen,
food, shelter.
Safety and Security: safe from falls and treatment side effects
Love and Belonging: family, social supports
Esteem and Self-esteem: body image, pride in achievements, admiration from others
Cognitive: need for knowledge, understanding, exploration.
Aesthetic: symmetry, order, and beauty.
Self-actualization: need to achieve one's potential: need for growth and change. Role
Performance.
Steps of Nursing Process - CORRECT ANSWER 1. Assessment
2. Diagnosis
3. Planning outcomes/interventions
4. Implementation
5. Evaluating
Assessment - CORRECT ANSWER Collect, validate, organize, and record data.
subjective data - CORRECT ANSWER What the patient says.
aka covert data or symptoms data
information communicated by the patient, family, or community.
objective data - CORRECT ANSWER data gathered by physical assessment and from
laboratory or diagnostic tests.
aka overt data or signs data.
,can be measure or observed by another nurse.
may be used to check subjective data.
Primary data - CORRECT ANSWER the subjective and objective information obtained
directly from the patient in what the patient says or what you observe.
Secondary Data - CORRECT ANSWER Obtained "secondhand".
from the medical record or from another caregiver
Diagnosis - CORRECT ANSWER RN analyzes assessment data to determine actual or
potential diagnoses, problems, and issues.
Describes patients present health status.
Diagnostic Reasoning - CORRECT ANSWER the thinking process that enables you to
make sense of data gathered during a comprehensive patient assessment. AKA diagnostic
process.
Basic two part statement - CORRECT ANSWER Problem - NANFA list - r/t Etiology -
related factors
i.e. Nausea r/t anxiety, Risk for Deficient Fluid Volume r/t excessive vomitting, Possible
Constipation r/t patients statement of no BM for 2 days.
Basic three part statement - CORRECT ANSWER Problem r/t etiology as manifested
by signs or symptoms.
i.e. Constipation r/t inadequate intake of fluids and fiber-rich food as manifested by painful,
hard stool and bowel movement every 3 or 4 days.
Planning Outcomes - CORRECT ANSWER select standardized care plans, create
individualized care plans, identify outcomes and goals.
Formal planning - CORRECT ANSWER is a conscious, deliberate activity involving
decision making, critical thinking, and creativity
, Informal planning - CORRECT ANSWER occurs while you are performing other
nursing process steps.
Initial planning - CORRECT ANSWER begins with the first patient contact. refers to
the development of the initial comprehensive care plan, which should be written asap after
initial assessment.
Ongoing planning - CORRECT ANSWER refers to changes in the plan: 1. as you
evaluate the patient response to care. 2. as you obtain new data and make new diagnoses.
Discharge planning - CORRECT ANSWER the process of planning for self-care and
continuity of care after the patient leaves the healthcare setting
Purpose: promote the patient progress toward health or disease management outside of
facility, and to reduce early readmission to hospital care
Discharge Planning for Older Adults - CORRECT ANSWER Especially important to
start discharge planning at the initial admission assessment.
Functional abilities, cognition, vision, hearing, social support, and psychological well-being
must be a part of the initial assessment so you can identify needed services at discharge.
Planning Interventions - CORRECT ANSWER are actions based on clinical judgement
and nursing knowledge that the nurses perform to achieve patient outcomes.
Direct-care interventions - CORRECT ANSWER are performed through interaction
with the patient: physical care, emotional support, patient teaching
Indirect-care interventions - CORRECT ANSWER are performs away from the patient
but on behalf of patient: advocacy, managing environment, consulting with other members of
healthcare team, and making referrals.
ACTUAL QUESTIONS AND CORRECT
ANSWERS
Maslow's Hierarchy of needs - CORRECT ANSWER Physiological: water, oxygen,
food, shelter.
Safety and Security: safe from falls and treatment side effects
Love and Belonging: family, social supports
Esteem and Self-esteem: body image, pride in achievements, admiration from others
Cognitive: need for knowledge, understanding, exploration.
Aesthetic: symmetry, order, and beauty.
Self-actualization: need to achieve one's potential: need for growth and change. Role
Performance.
Steps of Nursing Process - CORRECT ANSWER 1. Assessment
2. Diagnosis
3. Planning outcomes/interventions
4. Implementation
5. Evaluating
Assessment - CORRECT ANSWER Collect, validate, organize, and record data.
subjective data - CORRECT ANSWER What the patient says.
aka covert data or symptoms data
information communicated by the patient, family, or community.
objective data - CORRECT ANSWER data gathered by physical assessment and from
laboratory or diagnostic tests.
aka overt data or signs data.
,can be measure or observed by another nurse.
may be used to check subjective data.
Primary data - CORRECT ANSWER the subjective and objective information obtained
directly from the patient in what the patient says or what you observe.
Secondary Data - CORRECT ANSWER Obtained "secondhand".
from the medical record or from another caregiver
Diagnosis - CORRECT ANSWER RN analyzes assessment data to determine actual or
potential diagnoses, problems, and issues.
Describes patients present health status.
Diagnostic Reasoning - CORRECT ANSWER the thinking process that enables you to
make sense of data gathered during a comprehensive patient assessment. AKA diagnostic
process.
Basic two part statement - CORRECT ANSWER Problem - NANFA list - r/t Etiology -
related factors
i.e. Nausea r/t anxiety, Risk for Deficient Fluid Volume r/t excessive vomitting, Possible
Constipation r/t patients statement of no BM for 2 days.
Basic three part statement - CORRECT ANSWER Problem r/t etiology as manifested
by signs or symptoms.
i.e. Constipation r/t inadequate intake of fluids and fiber-rich food as manifested by painful,
hard stool and bowel movement every 3 or 4 days.
Planning Outcomes - CORRECT ANSWER select standardized care plans, create
individualized care plans, identify outcomes and goals.
Formal planning - CORRECT ANSWER is a conscious, deliberate activity involving
decision making, critical thinking, and creativity
, Informal planning - CORRECT ANSWER occurs while you are performing other
nursing process steps.
Initial planning - CORRECT ANSWER begins with the first patient contact. refers to
the development of the initial comprehensive care plan, which should be written asap after
initial assessment.
Ongoing planning - CORRECT ANSWER refers to changes in the plan: 1. as you
evaluate the patient response to care. 2. as you obtain new data and make new diagnoses.
Discharge planning - CORRECT ANSWER the process of planning for self-care and
continuity of care after the patient leaves the healthcare setting
Purpose: promote the patient progress toward health or disease management outside of
facility, and to reduce early readmission to hospital care
Discharge Planning for Older Adults - CORRECT ANSWER Especially important to
start discharge planning at the initial admission assessment.
Functional abilities, cognition, vision, hearing, social support, and psychological well-being
must be a part of the initial assessment so you can identify needed services at discharge.
Planning Interventions - CORRECT ANSWER are actions based on clinical judgement
and nursing knowledge that the nurses perform to achieve patient outcomes.
Direct-care interventions - CORRECT ANSWER are performed through interaction
with the patient: physical care, emotional support, patient teaching
Indirect-care interventions - CORRECT ANSWER are performs away from the patient
but on behalf of patient: advocacy, managing environment, consulting with other members of
healthcare team, and making referrals.
