NURS 3120 EXAM 1 STUDY GUIDE WITH
COMPLETE SOLUTIONS
Ch. 1 The Nurse's Role in Health Assessment - ANSWER-
Purpose of Health Assessment - ANSWER-Provider of care: care to individuals,
families, populations, communities
Manager of care: taking care of patient, population, community, and their needs
Member of a profession: serve as an advocate for patients
Nursing Process - ANSWER-1. Assessment - gather complete and accurate data from
client through interview, physical exam, and observation to make judgements
2. Diagnosis/Analysis - take info to make a judgement abt patient's condition, including
actual and potential problems
3. Outcomes Identification
4. Planning - use problem-solving and decision-making skills to prioritize outcomes and
goals, targeted nursing intervention/care plan
5. Implementation - perform clinical intervention, use clinical judgement to monitor the
client's progress towards achieving their goals
6. Evaluate - assess the effectiveness of goals and the need for interventions to be
adjusted - did we meet the goal? Is there anything to do differently?
Clinical Judgement Model - ANSWER-1. Assessment
2. Analyze cues
3. Prioritize hypotheses
4. Generate solutions
5. Take action
6. Evaluate outcomes
Code of ethics - ANSWER-autonomy, beneficence, justice, non-maleficence
Autonomy - ANSWER-having self control
Beneficence - ANSWER-helping others in a positive manner
Justice - ANSWER-being open and fair
Non-maleficence - ANSWER-avoiding hurt or harm to others
Primary prevention - ANSWER-interventions designed to prevent the onset of future
incidence of a specific problem
ex. immunization, health diet
,Secondary prevention - ANSWER-an early prevention that decreases the prevalence of
a specific problem
ex. BP screenings, mammograms, scoliosis screenings
Tertiary prevention - ANSWER-treatment designed to improve the quality of life and
reduce the symptoms after a disease or disorder has developed. Does not reduce
incidence or prevalence
ex. mitigate risks associated w an existing condition
Nursing process relies on ___ - ANSWER-evidence based thinking
Body Systems Assessment - ANSWER-Assessment method in which a nurse evaluates
each body system separately to focus on a specific problem
Maslow's Hierarchy of Needs - ANSWER-(from most to least important)
physiological, safety, love/belonging, esteem, self-actualization
Urgent - ANSWER-requiring immediate action or attention
Acute - ANSWER-New, usually of rapid onset and of concern, opposite of chronic
Chronic - ANSWER-continuing for a long time
Survival potential - ANSWER-Priority is given to the client who has a reasonable chance
of survival with immediate intervention. This framework is typically used in situations
where resources are limited, such as with mass casualties and disaster triage.
Least restrictive interventions - ANSWER-
Critical Thinking (7 step process) - ANSWER-1. Identify strengths and abnormal data
2. Cluster data
3. Draw inferences
4. Propose nursing diagnoses
5. Check for defining characteristics
6. Confirm or remove nursing diagnosis
7. Document conclusions - in a progress note or SBAR (Situation background
Assessment and Recommendation)
Diagnostic reasoning - ANSWER-the process of analyzing health data and drawing
conclusions to identify diagnoses
Clinical judgement - ANSWER-nursing process +. critical thinking + diagnostic
reasoning
, Emergency Assessment - ANSWER-life threatening or unstable (A - airway, B -
breathing, C - circulation, D - disability/level of consciousness, E - exposure to
chemical); gather RELEVANT INFO only
Comprehensive Assessment - ANSWER-overall health history and physical
assessment; happens typically once a year
Focused Assessment - ANSWER-focused on one issue/concern; can happen frequently
Lifespan Variations - ANSWER-care for ppl from the moment they're born til the
moment they die
Cultural Variations - ANSWER-consider cultural background, beliefs
Culture - ANSWER-Beliefs, customs, and traditions of a specific group of people.
Cultural Competence - ANSWER-using our knowledge and asking individuals about
their preferences without judgement
Components of Health Assessment - ANSWER-Demographics - age, gender, etc
Subjective cues - what the pt tells you
Objective cues - can be measured
SBAR - Situation, Background, Assessment, Recommendation
Functional Assessment - ANSWER-focuses on functional patterns all humans share
ex. sleep, vision, hearing, excretion, stress/coping, sexuality/reproduction, values/beliefs
Head to Toe Assessment - ANSWER-most organized assessment that goes through
each body system
Role of the nurse - ANSWER-health promotion, illness prevention, treating human
response, patient advocacy
Nursing values - ANSWER-caring, diversity, integrity, excellence
ADPIE - clinical judgement measurement model - ANSWER-Assessment
Diagnosis
Planning
Implementation
Evaluation
Critical thinking is ___, ___, and can lead to ___ ___ - ANSWER-EBP, patient centered,
Diagnostic Reasoning
COMPLETE SOLUTIONS
Ch. 1 The Nurse's Role in Health Assessment - ANSWER-
Purpose of Health Assessment - ANSWER-Provider of care: care to individuals,
families, populations, communities
Manager of care: taking care of patient, population, community, and their needs
Member of a profession: serve as an advocate for patients
Nursing Process - ANSWER-1. Assessment - gather complete and accurate data from
client through interview, physical exam, and observation to make judgements
2. Diagnosis/Analysis - take info to make a judgement abt patient's condition, including
actual and potential problems
3. Outcomes Identification
4. Planning - use problem-solving and decision-making skills to prioritize outcomes and
goals, targeted nursing intervention/care plan
5. Implementation - perform clinical intervention, use clinical judgement to monitor the
client's progress towards achieving their goals
6. Evaluate - assess the effectiveness of goals and the need for interventions to be
adjusted - did we meet the goal? Is there anything to do differently?
Clinical Judgement Model - ANSWER-1. Assessment
2. Analyze cues
3. Prioritize hypotheses
4. Generate solutions
5. Take action
6. Evaluate outcomes
Code of ethics - ANSWER-autonomy, beneficence, justice, non-maleficence
Autonomy - ANSWER-having self control
Beneficence - ANSWER-helping others in a positive manner
Justice - ANSWER-being open and fair
Non-maleficence - ANSWER-avoiding hurt or harm to others
Primary prevention - ANSWER-interventions designed to prevent the onset of future
incidence of a specific problem
ex. immunization, health diet
,Secondary prevention - ANSWER-an early prevention that decreases the prevalence of
a specific problem
ex. BP screenings, mammograms, scoliosis screenings
Tertiary prevention - ANSWER-treatment designed to improve the quality of life and
reduce the symptoms after a disease or disorder has developed. Does not reduce
incidence or prevalence
ex. mitigate risks associated w an existing condition
Nursing process relies on ___ - ANSWER-evidence based thinking
Body Systems Assessment - ANSWER-Assessment method in which a nurse evaluates
each body system separately to focus on a specific problem
Maslow's Hierarchy of Needs - ANSWER-(from most to least important)
physiological, safety, love/belonging, esteem, self-actualization
Urgent - ANSWER-requiring immediate action or attention
Acute - ANSWER-New, usually of rapid onset and of concern, opposite of chronic
Chronic - ANSWER-continuing for a long time
Survival potential - ANSWER-Priority is given to the client who has a reasonable chance
of survival with immediate intervention. This framework is typically used in situations
where resources are limited, such as with mass casualties and disaster triage.
Least restrictive interventions - ANSWER-
Critical Thinking (7 step process) - ANSWER-1. Identify strengths and abnormal data
2. Cluster data
3. Draw inferences
4. Propose nursing diagnoses
5. Check for defining characteristics
6. Confirm or remove nursing diagnosis
7. Document conclusions - in a progress note or SBAR (Situation background
Assessment and Recommendation)
Diagnostic reasoning - ANSWER-the process of analyzing health data and drawing
conclusions to identify diagnoses
Clinical judgement - ANSWER-nursing process +. critical thinking + diagnostic
reasoning
, Emergency Assessment - ANSWER-life threatening or unstable (A - airway, B -
breathing, C - circulation, D - disability/level of consciousness, E - exposure to
chemical); gather RELEVANT INFO only
Comprehensive Assessment - ANSWER-overall health history and physical
assessment; happens typically once a year
Focused Assessment - ANSWER-focused on one issue/concern; can happen frequently
Lifespan Variations - ANSWER-care for ppl from the moment they're born til the
moment they die
Cultural Variations - ANSWER-consider cultural background, beliefs
Culture - ANSWER-Beliefs, customs, and traditions of a specific group of people.
Cultural Competence - ANSWER-using our knowledge and asking individuals about
their preferences without judgement
Components of Health Assessment - ANSWER-Demographics - age, gender, etc
Subjective cues - what the pt tells you
Objective cues - can be measured
SBAR - Situation, Background, Assessment, Recommendation
Functional Assessment - ANSWER-focuses on functional patterns all humans share
ex. sleep, vision, hearing, excretion, stress/coping, sexuality/reproduction, values/beliefs
Head to Toe Assessment - ANSWER-most organized assessment that goes through
each body system
Role of the nurse - ANSWER-health promotion, illness prevention, treating human
response, patient advocacy
Nursing values - ANSWER-caring, diversity, integrity, excellence
ADPIE - clinical judgement measurement model - ANSWER-Assessment
Diagnosis
Planning
Implementation
Evaluation
Critical thinking is ___, ___, and can lead to ___ ___ - ANSWER-EBP, patient centered,
Diagnostic Reasoning
