NURS 3120 EXAM 1|| 23 QUESTIONS
AND ANSWERS (GRADED A+)
Purpose of health assessment - ANSWER-- Provider of care at bedside: delivery of
therapeutic care
- Manager of care: nurses are making decisions about care
- Member of a profession: member of the healthcare team
Nurse's Role - ANSWER-- health promotion
- illness prevention
- treating human response
- patient advocacy
Nursing Process - ANSWER-- Assessment
- Diagnosis/Concepts
- Outcomes
- Planning
- Implementation
- Define Evaluation
Assessment - ANSWER-data collection
Diagnosis/Concepts - ANSWER-recognizing/analyzing cues
Outcomes - ANSWER-understanding what the patient is doing
Planning - ANSWER-hypothesis
Implementation - ANSWER-execution of the care; planning care
Define Evaluation - ANSWER-if the client met the goals
- make sure goals are measurable
- is the patient making milestones?
- has pain got better?
Clinical Judgement Model - ANSWER-- Recognize cues
- Analyze cues
- Prioritize hypothesis
- Generate solutions
- Take actions
- Evaluate outcomes
Critical Thinking - ANSWER-- Results driven
,- Supported by the best practice/ evidence
- Patient, family, and community centered
- Professional code of conduct
Diagnostic Reasoning: - ANSWER-1. Identify the strengths & abnormalities
2. Take data and cluster it
3. Draw inferences
4. Propose nursing concepts
5. Look for defining characteristics
6. Confirm/remove diagnosis
7. Document conclusion
Clinal judgment - ANSWER-Master critical thinking & diagnostic reasoning
Different types of assessment - ANSWER-1. Emergency
2. Comprehensive
3. Focused
Emergency: ABCDE - ANSWER-- ABCD: Airway, Breathing, Circulation, Disability,
Exposure
- Airway: Ensure patient's airway is open
- Breathing: can't talk (assist w/ breathing)
- Circulation: cardiac rhythm problem or blood pressure
- Disability: mobility problem or fall
- Exposure: occupational hazard; exposed to environmental agent cause harm
safety alert
Health Assessment Frameworks - ANSWER--.Functional defined
- head-to-toe
- body systems
Functional defined - ANSWER-- what the patient can physically do
- do they exercise
- can they feed themselves
- dress themselves
- taking care of themselves
- ADLs
Body systems - ANSWER-best when collecting subjective data, questions particular to
body system or what they are complaining about
E.g. Do you have chest pain, difficulty breathing, swelling in your legs?Hard time laying
down? SOB? Palpitations?
How to prioritize care/assessment - ANSWER-- Maslow's Hierarchy of Needs
, - Urgent
- Safety
- Nursing Process
- Survival Potential
- Least restrictive interventions
Comprehensive - ANSWER-entire health history and physical assessment
- Health history = interviewing; subjective and objective, details of patient's history,
medications history, surgical history
- Physical assessment: comprehensive and annual physical examination, health,
functionally abilities, how they take care of themselves, do they have a good support
system, full head-toe assessment
- can occur during admissions or yearly check ups
Focused - ANSWER-directed to the complaint
E.g complain of a headache so will do a focus assessment
- SOB: focus on heart & lung assessment
- Life Threatening issue
- Two systems being compromised
Lifespan & Cultural Variations - ANSWER-Lifespan Variations: growth, changes in
height, motor skills
Cultural competence: knowledge, attitudes, skills, delivers care based on person's
cultural background
Components of the Health Assessment - ANSWER-- Demographics: patient's name,
DOB, contact information, address
- Subjective cues: feelings, perceptions, expectations, what the patient tells you
(focuses on patient's perception)
- Objective cues: actual physical exam, what you are seeing as the nurse (data
collected by physical assessment)
- SBAR: documentation
Situation background assessment recommendations
Maslow's hierarchy of needs - ANSWER-physiological problems, Urgent versus acute
versus chronic: ABCDE
Physiological Needs: breathing, food, water, shelter, clothing, sleep
AND ANSWERS (GRADED A+)
Purpose of health assessment - ANSWER-- Provider of care at bedside: delivery of
therapeutic care
- Manager of care: nurses are making decisions about care
- Member of a profession: member of the healthcare team
Nurse's Role - ANSWER-- health promotion
- illness prevention
- treating human response
- patient advocacy
Nursing Process - ANSWER-- Assessment
- Diagnosis/Concepts
- Outcomes
- Planning
- Implementation
- Define Evaluation
Assessment - ANSWER-data collection
Diagnosis/Concepts - ANSWER-recognizing/analyzing cues
Outcomes - ANSWER-understanding what the patient is doing
Planning - ANSWER-hypothesis
Implementation - ANSWER-execution of the care; planning care
Define Evaluation - ANSWER-if the client met the goals
- make sure goals are measurable
- is the patient making milestones?
- has pain got better?
Clinical Judgement Model - ANSWER-- Recognize cues
- Analyze cues
- Prioritize hypothesis
- Generate solutions
- Take actions
- Evaluate outcomes
Critical Thinking - ANSWER-- Results driven
,- Supported by the best practice/ evidence
- Patient, family, and community centered
- Professional code of conduct
Diagnostic Reasoning: - ANSWER-1. Identify the strengths & abnormalities
2. Take data and cluster it
3. Draw inferences
4. Propose nursing concepts
5. Look for defining characteristics
6. Confirm/remove diagnosis
7. Document conclusion
Clinal judgment - ANSWER-Master critical thinking & diagnostic reasoning
Different types of assessment - ANSWER-1. Emergency
2. Comprehensive
3. Focused
Emergency: ABCDE - ANSWER-- ABCD: Airway, Breathing, Circulation, Disability,
Exposure
- Airway: Ensure patient's airway is open
- Breathing: can't talk (assist w/ breathing)
- Circulation: cardiac rhythm problem or blood pressure
- Disability: mobility problem or fall
- Exposure: occupational hazard; exposed to environmental agent cause harm
safety alert
Health Assessment Frameworks - ANSWER--.Functional defined
- head-to-toe
- body systems
Functional defined - ANSWER-- what the patient can physically do
- do they exercise
- can they feed themselves
- dress themselves
- taking care of themselves
- ADLs
Body systems - ANSWER-best when collecting subjective data, questions particular to
body system or what they are complaining about
E.g. Do you have chest pain, difficulty breathing, swelling in your legs?Hard time laying
down? SOB? Palpitations?
How to prioritize care/assessment - ANSWER-- Maslow's Hierarchy of Needs
, - Urgent
- Safety
- Nursing Process
- Survival Potential
- Least restrictive interventions
Comprehensive - ANSWER-entire health history and physical assessment
- Health history = interviewing; subjective and objective, details of patient's history,
medications history, surgical history
- Physical assessment: comprehensive and annual physical examination, health,
functionally abilities, how they take care of themselves, do they have a good support
system, full head-toe assessment
- can occur during admissions or yearly check ups
Focused - ANSWER-directed to the complaint
E.g complain of a headache so will do a focus assessment
- SOB: focus on heart & lung assessment
- Life Threatening issue
- Two systems being compromised
Lifespan & Cultural Variations - ANSWER-Lifespan Variations: growth, changes in
height, motor skills
Cultural competence: knowledge, attitudes, skills, delivers care based on person's
cultural background
Components of the Health Assessment - ANSWER-- Demographics: patient's name,
DOB, contact information, address
- Subjective cues: feelings, perceptions, expectations, what the patient tells you
(focuses on patient's perception)
- Objective cues: actual physical exam, what you are seeing as the nurse (data
collected by physical assessment)
- SBAR: documentation
Situation background assessment recommendations
Maslow's hierarchy of needs - ANSWER-physiological problems, Urgent versus acute
versus chronic: ABCDE
Physiological Needs: breathing, food, water, shelter, clothing, sleep
