Practice Questions with Verified Answers(100%Correct)
Nursing diagnosis - Answer –
-Analyze data
-Identify health problems, risks, and strengths
-Formulate diagnostic statements
Planning - Answer –
-Prioritize problems and diagnoses
-Formulate goals and designed health outcomes
-Identify nursing interventions
Implementation - Answer –
-Reassess the patient
-Determine the nurse's need for assistance
-Implement nursing interventions
-Supervise delegated care
-Document nursing activities
Evaluation - Answer –
-Collect data related to outcomes
-Complete data with outcomes
-Relate nursing actions to patient goals/outcomes
-Draw conclusions about problem status
-Continue, modify, or end the patient's care plan
Focused assessment - Answer - -Gathers specific details about the
presenting concern to either confirm or rule out abnormalities
pg. 1
,Time-lapsed assessment - Answer - -To reevaluate the patient's
status and identify whether the condition has improved, worsened, or
stayed the same
Emergency assessment - Answer –
-To ensure the patient has a patent airway, is breathing, and has
adequate circulation
-To identify the primary cause of the problem
Nursing process - Answer –
1. Assessment
2. Diagnosis
3. Planning
4. Implementation
5. Evaluation
Gordon's Functional Health Patterns - Answer –
Health perception-health management pattern
Nutritional-metabolic pattern
Elimination pattern
Activity-exercise pattern
Sleep-rest pattern
Cognitive-perceptual pattern
Self-perception-self-concept pattern
Roles-relationships pattern
Sexuality-reproductive pattern
Coping-stress tolerance pattern
Values-beliefs pattern
Assessment - Answer –
pg. 2
,-Collect data
-Organize data
-Validate data
-Document data
Types of data - Answer –
-Subjective-What the patient says (sometimes patient's family)
-Objective-What the nurse collects or observes (physical assessment,
medical records, patient sometimes)
Health interview - Answer -A health *interview* is a structured
interaction between you and the patient. The *rules* governing this
interaction should be *clearly outlined and agreed on* by you and the
patient at the start of the interview. Your mutual *goal* is the
*patient's optimal health*.
-Provides opportunity for communication, gathering information, and
form a therapeutic relationship with the patient
Assessment tools - Answer –
-Stethoscope
-Blood pressure cuff
-Thermometer
-Etc
-4 of 5 senses
Four senses to use - Answer –
Sight- Colour of patient's skin, presence of abnormal movement,
patient's level of consciousness, patient's response to touch
Smell-Unique smells
Touch-Changes in skin temperature or fluid volume
Sound
pg. 3
, 5 vital signs - Answer –
1. temperature
2. pulse
3. respirations
4. blood pressure
5. oxygen saturation
(6. pain)
Ways to measure temperature - Answer –
-Orally
-Rectally
-Tympanic membrane
-Temporal artery
-Axillary
Causes of clinical alteration in temperature - Answer –
-Infection
-Inflammatory response
-Deteriorating patient status
-Thermoregulatory disorders
Normal respiration rate - Answer -12-20 breaths per minute
Bradypnea - Answer –
-Abnormally slow breathing
-Less than 10 breaths/minute
Tachypnea - Answer –
-Rapid breathing
-More than 24 breaths/minute, shallow
pg. 4