NUR 3065 - EXAM 1 QUESTIONS &
ACCURATE ANSWERS UPDATED
100%
assessment - CORRECT ANSWER collection of data about an individual's state of
health to help make a judgement/diagnosis
-an organized assessment is starting point to diagnostic reasoning (group into clusters!)
ex. acute pain may be associated with ↑HR, ↑BP, anxiety
subjective data - CORRECT ANSWER what a patient says about themself
ex. pain rating, family history
"I feel ___"
"Patient reports feelings of ___"
"Patient feels ___"
key words: feels, reports
objective data - CORRECT ANSWER what a nurse observes about patient when
inspecting, palpating, percussing, or auscultating
ex. age, LOC, height, weight, symmetry, vital signs, contusions on body
"Patient is ___"
"Patient appears to be ___"
"Foot inspection reveals ___"
"erythematous larynx"
key words: is, appears to be
what rounds out the concept of health and forms the core of nursing practice? -
CORRECT ANSWER disease prevention and health promotion
-guidelines to prevention link health to personal behavior
-health promotion is based off teaching and choosing a healthier lifestyle
"Guide to Clinical Preventative Services"
diagnostic reasoning and critical thinking - CORRECT ANSWER critical thinking is
needed for diagnostic reasoning and clinical judgement
-diagnostic reasoning: process of analyzing data and drawing conclusions
hypothetico-deductive process - CORRECT ANSWER -diagnostic reasoning for novice
examiners
(1) attending to initial cues (signs/symptoms/lab imaging)
(2) formulating diagnostic hypotheses (the potential explanation for the cues)
(3) gathering data relative to tentative hypotheses
(4) evaluate each hypotheses with new data to find a final diagnosis
,the nursing process (problem-solving approach) - CORRECT ANSWER standards of
practice in nursing, how we want to be thinking. expert nurses use: intuition
(1) assessment: use evidence-based assessment techniques, collect/document data
(2) diagnosis: interpret data, make clusters of cues. Make and test hypotheses, derive a
diagnosis
(3) outcome identification: set realistic outcomes, dvlp a timeline ex. get heart failure pt
off of supplemental O2
-ask the pt for their input so they're likely to follow plan
(4) planning: set priorities, identify interventions, make plan of care
(5) implementation: use evidence-based interventions, use community resources/health
promotion/education, implement your plan
(6) evaluate: progress toward your outcome, disseminate results to patient/family
were the outcomes met or not?
one of primary causes of misdiagnoses - CORRECT ANSWER clinical bias, upwards of
10-15%
(clustering cues and double-checking validity of data can help make correct diagnosis)
levels of priority - CORRECT ANSWER 1. ABCs (airway, breathing, circulation)
ex. trouble swallowing, choking, no heart beat, systolic of 50
C's include: BP, HR, severe bleeding, cardiac status
2. next in urgency -> goal is to prevent further deterioration
ex. mental status changes, risk of infection/safety, acute pain, acute urinary elimination
problems, abnormal lab values
3. interventions to treat these problems are long term, response to treatment expected
to take time
-know expected (eating raw fish, diabetics glucose level is below avg) vs unexpected
(new round of antibiotics resulted in a rash)
evidence based assessments (EBPs) - CORRECT ANSWER -based on notion that
health care is constantly changing and we are always expanding our knowledge
-want our patients to have the most current and best practices
-helps with clinical decision making
-EBPs are HOLISTIC: based on research, clinical expertise/knowledge, patient
values/preferences
-nurses must learn to filter through scientific data and critique findings to decide which
interventions will best help their patients
ex of EBP in action - CORRECT ANSWER -1970-80s, corticosteroids found to
decrease infant mortality rates. However, not implemented in daily practice at the time
so infants continued to die
-after renewal of evidence in '89, corticosteroids decreased mortality by 30-50%
4 types of patient data: complete 1. (total health) database - CORRECT ANSWER -pt
may have many issues or unknown pathology
, -complete health history (current and past health status) and full physical exam
-often in primary care settings (college health services, peds/family practice clinics,
community health agencies)...where healthcare provider is the only one seeing the
patient
-a complete database helps establish and strengthen bond with the patient
-must screen pathology for all well and ill pts and find ways to respond to pathology
-acute hospital care: complete database is performed once pt is admitted
-data specific to pathology collected by physician
4 types of patient data: 2. focused/problem-centered database - CORRECT ANSWER
aka episodic database
-"mini", smaller scope, concerns mainly one problem, one body system, or one-cue
complex
-used in all settings
ex. 2 days post-op, a hospitalized pt has a congested cough, shortness of breath,
fatigue...history and exam focus primarily on respiratory and cardiovasc system
ex. outpatient clinic has a pt with a rash...history follows the direction of this concern
4 types of patient data: 3. follow-up - CORRECT ANSWER -already know the patient,
evaluate at regular, appropriate intervals
-think ab questions like what changes have occurred? problem better or worse? which
coping strats used?
-used in all settings to follow up both short-term and chronic health pts
ex. heart failure pt: follow up with primary practitioner to re-eval. meds, identify changes
in symptoms, coping strats
4 types of patient data: 4. emergency database - CORRECT ANSWER urgent, rapid
collection of data while simultaneously taking lifesaving measures
-diagnosis is swift and sure
-ask Q while assessing ABCs, LOC, disability
-get info ASAP before pt bc unresponsive (if they are...rely on family and friends for
answers)
once person is stable, get a complete database
ex. ED, ask "what did you take, when, how much?"
general survey - CORRECT ANSWER study of the whole person: general health and
any obvious physical characteristics (gives you overall impression of a person)
-start assessment the second you walk through the door, look @ phys appearance first
-what to survey? 4 notes: physical appearance, body structure, mobility/mvmt, behavior
general survey: 1. physical appearance (normal vs abnormal) - CORRECT ANSWER -
age (appears older/younger than said age)
-sex/gender (delayed/precocious puberty)
-LOC (most imp)
-skin color (cyanotic, jaundice, erythema)
-facial symmetry (asymm may be evident of stroke)
ACCURATE ANSWERS UPDATED
100%
assessment - CORRECT ANSWER collection of data about an individual's state of
health to help make a judgement/diagnosis
-an organized assessment is starting point to diagnostic reasoning (group into clusters!)
ex. acute pain may be associated with ↑HR, ↑BP, anxiety
subjective data - CORRECT ANSWER what a patient says about themself
ex. pain rating, family history
"I feel ___"
"Patient reports feelings of ___"
"Patient feels ___"
key words: feels, reports
objective data - CORRECT ANSWER what a nurse observes about patient when
inspecting, palpating, percussing, or auscultating
ex. age, LOC, height, weight, symmetry, vital signs, contusions on body
"Patient is ___"
"Patient appears to be ___"
"Foot inspection reveals ___"
"erythematous larynx"
key words: is, appears to be
what rounds out the concept of health and forms the core of nursing practice? -
CORRECT ANSWER disease prevention and health promotion
-guidelines to prevention link health to personal behavior
-health promotion is based off teaching and choosing a healthier lifestyle
"Guide to Clinical Preventative Services"
diagnostic reasoning and critical thinking - CORRECT ANSWER critical thinking is
needed for diagnostic reasoning and clinical judgement
-diagnostic reasoning: process of analyzing data and drawing conclusions
hypothetico-deductive process - CORRECT ANSWER -diagnostic reasoning for novice
examiners
(1) attending to initial cues (signs/symptoms/lab imaging)
(2) formulating diagnostic hypotheses (the potential explanation for the cues)
(3) gathering data relative to tentative hypotheses
(4) evaluate each hypotheses with new data to find a final diagnosis
,the nursing process (problem-solving approach) - CORRECT ANSWER standards of
practice in nursing, how we want to be thinking. expert nurses use: intuition
(1) assessment: use evidence-based assessment techniques, collect/document data
(2) diagnosis: interpret data, make clusters of cues. Make and test hypotheses, derive a
diagnosis
(3) outcome identification: set realistic outcomes, dvlp a timeline ex. get heart failure pt
off of supplemental O2
-ask the pt for their input so they're likely to follow plan
(4) planning: set priorities, identify interventions, make plan of care
(5) implementation: use evidence-based interventions, use community resources/health
promotion/education, implement your plan
(6) evaluate: progress toward your outcome, disseminate results to patient/family
were the outcomes met or not?
one of primary causes of misdiagnoses - CORRECT ANSWER clinical bias, upwards of
10-15%
(clustering cues and double-checking validity of data can help make correct diagnosis)
levels of priority - CORRECT ANSWER 1. ABCs (airway, breathing, circulation)
ex. trouble swallowing, choking, no heart beat, systolic of 50
C's include: BP, HR, severe bleeding, cardiac status
2. next in urgency -> goal is to prevent further deterioration
ex. mental status changes, risk of infection/safety, acute pain, acute urinary elimination
problems, abnormal lab values
3. interventions to treat these problems are long term, response to treatment expected
to take time
-know expected (eating raw fish, diabetics glucose level is below avg) vs unexpected
(new round of antibiotics resulted in a rash)
evidence based assessments (EBPs) - CORRECT ANSWER -based on notion that
health care is constantly changing and we are always expanding our knowledge
-want our patients to have the most current and best practices
-helps with clinical decision making
-EBPs are HOLISTIC: based on research, clinical expertise/knowledge, patient
values/preferences
-nurses must learn to filter through scientific data and critique findings to decide which
interventions will best help their patients
ex of EBP in action - CORRECT ANSWER -1970-80s, corticosteroids found to
decrease infant mortality rates. However, not implemented in daily practice at the time
so infants continued to die
-after renewal of evidence in '89, corticosteroids decreased mortality by 30-50%
4 types of patient data: complete 1. (total health) database - CORRECT ANSWER -pt
may have many issues or unknown pathology
, -complete health history (current and past health status) and full physical exam
-often in primary care settings (college health services, peds/family practice clinics,
community health agencies)...where healthcare provider is the only one seeing the
patient
-a complete database helps establish and strengthen bond with the patient
-must screen pathology for all well and ill pts and find ways to respond to pathology
-acute hospital care: complete database is performed once pt is admitted
-data specific to pathology collected by physician
4 types of patient data: 2. focused/problem-centered database - CORRECT ANSWER
aka episodic database
-"mini", smaller scope, concerns mainly one problem, one body system, or one-cue
complex
-used in all settings
ex. 2 days post-op, a hospitalized pt has a congested cough, shortness of breath,
fatigue...history and exam focus primarily on respiratory and cardiovasc system
ex. outpatient clinic has a pt with a rash...history follows the direction of this concern
4 types of patient data: 3. follow-up - CORRECT ANSWER -already know the patient,
evaluate at regular, appropriate intervals
-think ab questions like what changes have occurred? problem better or worse? which
coping strats used?
-used in all settings to follow up both short-term and chronic health pts
ex. heart failure pt: follow up with primary practitioner to re-eval. meds, identify changes
in symptoms, coping strats
4 types of patient data: 4. emergency database - CORRECT ANSWER urgent, rapid
collection of data while simultaneously taking lifesaving measures
-diagnosis is swift and sure
-ask Q while assessing ABCs, LOC, disability
-get info ASAP before pt bc unresponsive (if they are...rely on family and friends for
answers)
once person is stable, get a complete database
ex. ED, ask "what did you take, when, how much?"
general survey - CORRECT ANSWER study of the whole person: general health and
any obvious physical characteristics (gives you overall impression of a person)
-start assessment the second you walk through the door, look @ phys appearance first
-what to survey? 4 notes: physical appearance, body structure, mobility/mvmt, behavior
general survey: 1. physical appearance (normal vs abnormal) - CORRECT ANSWER -
age (appears older/younger than said age)
-sex/gender (delayed/precocious puberty)
-LOC (most imp)
-skin color (cyanotic, jaundice, erythema)
-facial symmetry (asymm may be evident of stroke)
