NUR 514 Exam 1 Study Questions With Correct Answers Latest UPDATED 2024/2025 (100% SOLVED)

NUR 514 Exam 1 Study Questions With Correct Answers Latest UPDATED 2024/2025 (100% SOLVED) What are the 5 steps of the nursing process & an example of each? - answers Assessment - Collecting subjective & objective data from the patient Diagnosis -Data is collected & analyzed in order to make a nursing judgment Planning - Nurse decides the best plan while considering data Implementation -Carrying out the plan Evaluation -Determining whether plan was successful & what can be improved Write an example of an initial comprehensive assessment -ongoing/partial assessment - focused assessment & emergent assessment - answers Initial comprehensive: seeing a new patient for the first time at that practice Ongoing/partial: a check up/follow up Emergent: Pt coming into ER w/ gunshot wound Focused: Pt broke arm or is having stomach pains How can the nurse prepare for the assessment? - answers Review pt record Review pt previous & current health status w/ other healthcare professionals Take time to educate themselves about pt diagnosis & tests performed What is a nursing diagnosis? Give an example. - answers Data analyzed and by definition of NANDA "a clinical judgment concerning a human response to health conditions/life processes, or vulnerability for that response by an individual, family, group or community." It serves as a basis for nursing interventions w/ achievable outcomes by nursing staff Example: Pt came back from surgery → "Risk for infection r/t new incision & increased WBC from possible inflammation" What is the health belief model? When would we use it? - answers The health belief model is based on 3 concepts: the existence of sufficient motivation the belief that one is susceptible or vulnerable to a serious problem the belief that change following a health recommendation would be beneficial to the individual at a level of acceptable cost. Nur 514 Exam 1 Study Questions With Correct Answers Latest UPDATED 2024/2025 (100% SOLVED) This model would be used to analyze health promotion and disease prevention. What are some examples of subjective data? - answers Anything patient states Does not involve measured, numeric data Examples: sensations/symptoms, feelings, perceptions, desires, preferences, beliefs, ideas, values, personal information What are the 3 phases of the interview? Define them. - answers Pre Introductory: Review medical record Introductory: Nurse introduces themselves Explain purpose of the interview, what type of questions will be asked, and why they will be taking notes Nurses makes sure pt is comfortable and ensures their privacy Working phase: Nurse listens to patients comments on biographical data, reasons for seeking care, history of present health concern, past health history, family history, review of body systems for current health problems, lifestyle & health practices Nurse & patient together determine pt problem & goal Summary & Closing: Nurse summarizes information obtained during working phase & validates pt problems and goals They discuss possible plans to resolve the problem Nurse asks if there are any other questions or concerns Give examples of nonverbal communication & what to avoid when interviewing a patient - answers Nonverbal communication pertains to anything & everything that is not communicated directly using your voice to speak Examples: silence, stands (hands folded over chest), body language (standing vs. sitting, too much eye contact vs. not enough) Nurse interviewer should avoid silence & having an aggressive stance/body language, maintain an appropriate amount of eye contact Give examples of verbal communication tactics - answers Open ended questions Close ended questions Laundry listing Giving options: "is pain sharp, radiating, pulsing, etc." Rephrasing the question Well-placed phrases Inferring Providing information What are some examples of cultural - emotional & age related considerations when conducting an assessment? - answers Example: Assessment on Indian girl No male presence in the room, even if it is her father Have mom there for emotional support For age, do not ask any questions related to personal matters in front of her mom Age related example: hearing abilities of pt. Cultural example: space b/w you and pt. What mnemonic is used to explore pt symptoms? What does each letter in the mnemonic stand for? - answers COLDSPA Character: describe the signs/symptoms (feeling, appearance, smell, sound taste) Onset: when did it begin? Location: where is it? Where does it radiate? Other locations? Duration: how long does it last? Is it continuous or intermittent? Severity: how bad is the pain (0-10)? Pattern: what relieves it? What worsens it? Associated factors: other symptoms that may be related to the main symptom? What kind of information is explored when you review the lifestyle & health practice of the patient? - answers Description of a typical day (AM to PM) Nutrition & weight management 24 hr dietary intake (foods & fluids) Who purchases & prepares meals? Activities on a typical day Exercise patterns & habits Sleep & rest patterns Use of medications and other substances (caffeine, nicotine, alcohol, recreational drugs) Self concept Self care responsibilities Social activities for fun & relaxation Relationships w/ family, significant others, pets Values, religious affiliation, spirituality Past, current, & future plans for education Type of work, level of job satisfaction, work stressors Finances Stressors in life, coping strategies Residency, type of environment, neighborhood Environmental risks What are some examples of objective data? - answers Presence of a wound Vital signs Ht/wt General appearance Level of consciousness Anything the nurse can see with their own eyes What are the 4 physical exam techniques that you must do in order? - answers Inspection Palpation Percussion Auscultation Always inspect before touching pt so you don't change appearance of the skin What are the different types of palpation and when you would use them? - answers Types of palpation Light: place hand lightly on surface, very little or no depression, feel using circular motion Use for pulses, tenderness, skin texture, temperature, moisture Moderate Depress skin 1-2 cm w/ hand Use circular motion Use for feeling easily palpable body organs and masses Can note size, consistency, mobility of structures Deep Place dominant hand on skin, nondominant hand on top to apply pressure Depress b/t 2.5-5 cm Used for feeling very deep organs or structures covered by thick muscle Bimanual palpation Use 2 hands, place one on each side of body Use one hand to apply pressure, other hand to feel structure Use for noting size, shape, consistency, mobility of structures Used in OB settings often (breast & uterus exams) Why do we use percussion? - answers Eliciting pain Determining location, size & shape Determining density Detecting abnormal masses Eliciting reflexes What are standard precautions during an exam? - answers Standard precautions during an exam include hand hygiene, PPE such as gloves, gowns, masks, goggles, and face shields (this depends on the type of exam p. 33), patient placement, patient care equipment and instruments/devices, care of the environment, linen, and safe injection practices What are methods of validating your data? - answers Asking client additional questions for clarification Ask another healthcare provider to concur data Confirming data with a repeat assessment Examine subjective and objective discrepancies What is the HITECH act? What are the abbreviations used for medical records that are kept electronically? - answers Encourages use of health information technology (EHR) What does SBAR stand for? When and why would you use it? - answers Situation Background Assessment Recommendation Used to communicate assessment data, improves quality & safety outcomes when used by health team members to communicate or hand off client information (ex. report to next shift), decreases errors