NSG 3100 UNIT 2 EXAM QUESTIONS WITH VERIFIED SOLUTIONS LATEST UPDATE 2026
Clinical Judgment - Answers The observed outcome of clinical decision making and critcial thinking
based upon the use of nursnig knowledge to assess, prioritze, generate the best solution, and take
action within the context of patient care
What is the Nursing Process? - Answers a scientific problem solving method that is used to identify
patient problems, and needs, established a plan to address these problems and need and deliver
nursing care
What are the steps to the nursing process? - Answers 1- assessment
2-diagnosis
3-planning
4-implementation
5-evaluation
What is involved in the assessment phase? - Answers -data collection and recognizing cues
What is considered primary data? - Answers the patient and the patient interview
-best source as it describes the patients condition, feelings and what they have done to address their
concerns before seeking professional care
What is secondary data? - Answers -support people
-patients charts
-medial records
-results ( lab , diagnostic)
-vital signs
-handoff report
-literature
What are the 4 types of assessment? - Answers -comprehensive
-emergency
-problem-focused
-time-lapsed
Describe comprehensive assessments - Answers when a nurse checks everything, usually head to toe
Describe an emergency assessment - Answers rapid assessment performed in life threatening
situations (airway, breathing, circulation...)
Describe a problem- focused assessment - Answers focused on the problem the patient came for
Describe a time-lapsed assessment - Answers something that usually occurs annually or at a specific
time such as a physical assessment
Describe a direct interview - Answers Nurse establishes a purpose and controls the interviews, usually
with close ended questions
Describe a indirect interview - Answers nurse establishes rapport and client controls the purpose and
pacing, usually with open ended questions
What are the stages of an interview? - Answers -orientation
-working
-termination
What are some methods of data collection - Answers -systemic
-observation, inspection, auscultation, palpation, percussion
-vital signs, height, and weight
-head to toe approach
-screening examination
What is Subjective data? - Answers Spoken information or symptoms that are typically difficult to
validate and is gathered during the interview process
How should subjective data be documented? - Answers As direct quotes within quotation marks or
summarized and identified as the client's statement that usually express feeling, concerns, and
emotions
What is objective data? - Answers refers to signs that can be measured or observed
What are some examples of objective data? - Answers The nurses senses of sights, hearing, touch and
smell
0usually obtained through observation, physical exam, labs or diagnostic tests (BP, pulse, lab levels,
palpation)
What are some components of nursing health history? - Answers -biographical data
, -history of patient and family illness
-social data
-patterns of healthcare
-chief complaints
-psychological data
What can increase the need for space when interviewing a patient? - Answers -can be based on
patients culture
-anxiety increases need for space
-eye contact increases need for space
What should a nurse do before physically touching a patient ? - Answers physical contact is only used
if it has therapeutic or assessment purposes
-nurse should instruct the client of what needs to be done and then ask the patient for permission
What is an open ended question ? - Answers a question that allows the nurse to get more information
out of a patient
What is a closed ends question? - Answers a question a nurse asks usually with a yes or no response
What is another word for head to toe? - Answers cephal caudal
What are some ways to make a patient feel more comfortable during an interview? - Answers - sit at
the same level
-eye contact unless it makes them uncomfortable for them
-keep a close enough distance
What should you avoid asking when doing an interview? - Answers avoid asking "why" or using
personal examples such as "if I were you "
What are some ways data can be organized? - Answers Most commonly clustered
-conceptual maps/frameworks
-wellness models
-Nonnursing models (Malsow's, body system and head to toe models)
What should a nurse ensure when documenting? - Answers -record client data
-record in a factual manner without stating interpretations
What are the steps for a nurse diagnosis? - Answers 1- Problem
2-etiology
3-defining characteristics
Describe the Problem part of the nursing diagnosis - Answers a diagnostic label from the NANDA-1
-impaired gas exchange etc.
Describe the nursing diagnosis for a patient that is at risk for something - Answers 1-problem
2-etiology
Describe etiology of a nursing diagnosis - Answers related to factors
ex. impaired gas exchange related to crackling in lungs
Describe the defining characteristics of the nursing diagnosis - Answers evidence for the diagnosis (as
evidence by)
-ex. impaired gas exchange related to crackling in lungs as evidence by coughing and SPO88%
Actual diagnosis - Answers A diagnosis of the problem that is present at the time of assessment
-it is associated with signs and symptoms present at the same time as the assessment
Health promotion diagnosis - Answers a diagnosis of preparedness to implement behaviors to
improve their health condition
Risk Nursing diagnosis - Answers a diagnosis when a problem does not yet exist
What is the difference between a nursing diagnosis and a medical diagnosis ? - Answers Medical
diagnoses identify diseases, whereas nursing diagnoses focus on unhealthy responses to health and
illness.
ex. if a patient is having symptoms related to cancer, the diagnosis cannot include cancer but can
include "terminal illness"
Describe the planning part of the nursing process - Answers setting priorities, establishing client
goals/desired outcomes (SMART), selecting nursing interventions
Independent nursing interventions - Answers interventions initiated by nurses
dependent nursing interventions - Answers interventions originating from health care providers
orders
Collaborative interventions - Answers require cooperation among healthcare professional and
unlicensed assistive personal
Clinical Judgment - Answers The observed outcome of clinical decision making and critcial thinking
based upon the use of nursnig knowledge to assess, prioritze, generate the best solution, and take
action within the context of patient care
What is the Nursing Process? - Answers a scientific problem solving method that is used to identify
patient problems, and needs, established a plan to address these problems and need and deliver
nursing care
What are the steps to the nursing process? - Answers 1- assessment
2-diagnosis
3-planning
4-implementation
5-evaluation
What is involved in the assessment phase? - Answers -data collection and recognizing cues
What is considered primary data? - Answers the patient and the patient interview
-best source as it describes the patients condition, feelings and what they have done to address their
concerns before seeking professional care
What is secondary data? - Answers -support people
-patients charts
-medial records
-results ( lab , diagnostic)
-vital signs
-handoff report
-literature
What are the 4 types of assessment? - Answers -comprehensive
-emergency
-problem-focused
-time-lapsed
Describe comprehensive assessments - Answers when a nurse checks everything, usually head to toe
Describe an emergency assessment - Answers rapid assessment performed in life threatening
situations (airway, breathing, circulation...)
Describe a problem- focused assessment - Answers focused on the problem the patient came for
Describe a time-lapsed assessment - Answers something that usually occurs annually or at a specific
time such as a physical assessment
Describe a direct interview - Answers Nurse establishes a purpose and controls the interviews, usually
with close ended questions
Describe a indirect interview - Answers nurse establishes rapport and client controls the purpose and
pacing, usually with open ended questions
What are the stages of an interview? - Answers -orientation
-working
-termination
What are some methods of data collection - Answers -systemic
-observation, inspection, auscultation, palpation, percussion
-vital signs, height, and weight
-head to toe approach
-screening examination
What is Subjective data? - Answers Spoken information or symptoms that are typically difficult to
validate and is gathered during the interview process
How should subjective data be documented? - Answers As direct quotes within quotation marks or
summarized and identified as the client's statement that usually express feeling, concerns, and
emotions
What is objective data? - Answers refers to signs that can be measured or observed
What are some examples of objective data? - Answers The nurses senses of sights, hearing, touch and
smell
0usually obtained through observation, physical exam, labs or diagnostic tests (BP, pulse, lab levels,
palpation)
What are some components of nursing health history? - Answers -biographical data
, -history of patient and family illness
-social data
-patterns of healthcare
-chief complaints
-psychological data
What can increase the need for space when interviewing a patient? - Answers -can be based on
patients culture
-anxiety increases need for space
-eye contact increases need for space
What should a nurse do before physically touching a patient ? - Answers physical contact is only used
if it has therapeutic or assessment purposes
-nurse should instruct the client of what needs to be done and then ask the patient for permission
What is an open ended question ? - Answers a question that allows the nurse to get more information
out of a patient
What is a closed ends question? - Answers a question a nurse asks usually with a yes or no response
What is another word for head to toe? - Answers cephal caudal
What are some ways to make a patient feel more comfortable during an interview? - Answers - sit at
the same level
-eye contact unless it makes them uncomfortable for them
-keep a close enough distance
What should you avoid asking when doing an interview? - Answers avoid asking "why" or using
personal examples such as "if I were you "
What are some ways data can be organized? - Answers Most commonly clustered
-conceptual maps/frameworks
-wellness models
-Nonnursing models (Malsow's, body system and head to toe models)
What should a nurse ensure when documenting? - Answers -record client data
-record in a factual manner without stating interpretations
What are the steps for a nurse diagnosis? - Answers 1- Problem
2-etiology
3-defining characteristics
Describe the Problem part of the nursing diagnosis - Answers a diagnostic label from the NANDA-1
-impaired gas exchange etc.
Describe the nursing diagnosis for a patient that is at risk for something - Answers 1-problem
2-etiology
Describe etiology of a nursing diagnosis - Answers related to factors
ex. impaired gas exchange related to crackling in lungs
Describe the defining characteristics of the nursing diagnosis - Answers evidence for the diagnosis (as
evidence by)
-ex. impaired gas exchange related to crackling in lungs as evidence by coughing and SPO88%
Actual diagnosis - Answers A diagnosis of the problem that is present at the time of assessment
-it is associated with signs and symptoms present at the same time as the assessment
Health promotion diagnosis - Answers a diagnosis of preparedness to implement behaviors to
improve their health condition
Risk Nursing diagnosis - Answers a diagnosis when a problem does not yet exist
What is the difference between a nursing diagnosis and a medical diagnosis ? - Answers Medical
diagnoses identify diseases, whereas nursing diagnoses focus on unhealthy responses to health and
illness.
ex. if a patient is having symptoms related to cancer, the diagnosis cannot include cancer but can
include "terminal illness"
Describe the planning part of the nursing process - Answers setting priorities, establishing client
goals/desired outcomes (SMART), selecting nursing interventions
Independent nursing interventions - Answers interventions initiated by nurses
dependent nursing interventions - Answers interventions originating from health care providers
orders
Collaborative interventions - Answers require cooperation among healthcare professional and
unlicensed assistive personal
