NS 500 Foundations of Nursing - Exam 1
Newest questions and answers.
What are the premises of Tanner's model of clinical judgement? - ANSNoticing, interpreting,
responding, reflecting
How do we add JEDI into Tanner's model of clinical judgement? - ANSNotice intersectionality,
interpret without bias, respond with sensitivity
What are the two types of reflection and what are examples? - ANSReflection in action and
reflection on action. Reflection in action could be reflecting on past experiences and how to
apply that experience currently. Reflection on action is reflecting at the end of something about
how things went and what could be different.
What is the overall gist of the nursing process? - ANSTo diagnose and treat human responses to
actual or potential health problem.
What are the components of the nursing process? - ANSAssessment, diagnosis, planning,
implementation, evaluation
What comprises the assessment component? - ANSDetermines patient current and past health
status with two steps: collect information and interpret information. This is when you run
through an HPI, ROS, and exam.
What should you do prior to going in and assessing your patient? - ANSReview the EMR, review
isolation precautions, and sanitize your hands just prior to entering the room
What is a focused assessment? - ANSThis assessment is problem-oriented.
,What are some interview techniques? - ANSObservation, open or closed ended questions,
leading questions, back channeling, probing
What is a nursing diagnosis? - ANSA clinical judgement made by an RN to describe a patient
response or vulnerability to health conditions or life events that an RN is licensed and
competent to treat.
What is a collaborative problem? - ANSA problem that requires both medical and nursing
interventions to treat.
What are the three types of nursing diagnoses? - ANSProblem focused, risk, and health
promotion
Write a PES statement for acute infection. - ANSAcute infection r/t wound from a ground level
fall as evidenced by purulent material, warmth, and erythema of the wound site.
What is wrong with this PES statement?
Risk for falls related to recent cerebrovascular accident. - ANSCVA is a medical diagnosis and
should not be included. This could be fixed by changing the statement to "Risk for falls related
to impaired balance."
What are the methods of prioritization? - ANSConsider the type of nursing diagnosis, as
problem focused tend to be of higher importance than others. Acute issues are the most
important. Consider the ABCs and Maslow's hierarchy of needs.
What is a goal? - ANSA goal is a broad statement of a desired change in a patient's condition,
perceptions, or behavior.
, Give an example of a goal statement. - ANSPatient will report no difficulty breathing by the end
of the shift.
What is an expected outcome? - ANSAn expected outcome is a time limited, measurable change
that must be achieved in order to meet the broad goal. SMART. Specific - Measurable -
Achievable - Realistic - Timely
Give an example of an expected outcome. - ANSPatient will demonstrate proper use of an
incentive spirometer 10 times per hour while awake through the shift.
What are some examples of independent actions? - ANSToileting, teaching, activities of daily
living
What are the two types of interventions? - ANSDirect and indirect
What are the five rights of delegation? - ANSRight task, right circumstance, right person, right
communication, right supervision
What occurs in the evaluation step of the nursing process? - ANSSeeing if interventions caused
the patient to meet the expected outcomes/goals. If not, modify the care plan. If yes, then
discontinue the care plan.
Who is accountable for interpreting and collecting vital signs? - ANSThe RN. The task can be
delegated but in the end it is the RN's responsibility.
What is the normal range for temperature? - ANS96.8-100.4 F or 36-38 C
What controls temperature? - ANSthe hypothalamus
Newest questions and answers.
What are the premises of Tanner's model of clinical judgement? - ANSNoticing, interpreting,
responding, reflecting
How do we add JEDI into Tanner's model of clinical judgement? - ANSNotice intersectionality,
interpret without bias, respond with sensitivity
What are the two types of reflection and what are examples? - ANSReflection in action and
reflection on action. Reflection in action could be reflecting on past experiences and how to
apply that experience currently. Reflection on action is reflecting at the end of something about
how things went and what could be different.
What is the overall gist of the nursing process? - ANSTo diagnose and treat human responses to
actual or potential health problem.
What are the components of the nursing process? - ANSAssessment, diagnosis, planning,
implementation, evaluation
What comprises the assessment component? - ANSDetermines patient current and past health
status with two steps: collect information and interpret information. This is when you run
through an HPI, ROS, and exam.
What should you do prior to going in and assessing your patient? - ANSReview the EMR, review
isolation precautions, and sanitize your hands just prior to entering the room
What is a focused assessment? - ANSThis assessment is problem-oriented.
,What are some interview techniques? - ANSObservation, open or closed ended questions,
leading questions, back channeling, probing
What is a nursing diagnosis? - ANSA clinical judgement made by an RN to describe a patient
response or vulnerability to health conditions or life events that an RN is licensed and
competent to treat.
What is a collaborative problem? - ANSA problem that requires both medical and nursing
interventions to treat.
What are the three types of nursing diagnoses? - ANSProblem focused, risk, and health
promotion
Write a PES statement for acute infection. - ANSAcute infection r/t wound from a ground level
fall as evidenced by purulent material, warmth, and erythema of the wound site.
What is wrong with this PES statement?
Risk for falls related to recent cerebrovascular accident. - ANSCVA is a medical diagnosis and
should not be included. This could be fixed by changing the statement to "Risk for falls related
to impaired balance."
What are the methods of prioritization? - ANSConsider the type of nursing diagnosis, as
problem focused tend to be of higher importance than others. Acute issues are the most
important. Consider the ABCs and Maslow's hierarchy of needs.
What is a goal? - ANSA goal is a broad statement of a desired change in a patient's condition,
perceptions, or behavior.
, Give an example of a goal statement. - ANSPatient will report no difficulty breathing by the end
of the shift.
What is an expected outcome? - ANSAn expected outcome is a time limited, measurable change
that must be achieved in order to meet the broad goal. SMART. Specific - Measurable -
Achievable - Realistic - Timely
Give an example of an expected outcome. - ANSPatient will demonstrate proper use of an
incentive spirometer 10 times per hour while awake through the shift.
What are some examples of independent actions? - ANSToileting, teaching, activities of daily
living
What are the two types of interventions? - ANSDirect and indirect
What are the five rights of delegation? - ANSRight task, right circumstance, right person, right
communication, right supervision
What occurs in the evaluation step of the nursing process? - ANSSeeing if interventions caused
the patient to meet the expected outcomes/goals. If not, modify the care plan. If yes, then
discontinue the care plan.
Who is accountable for interpreting and collecting vital signs? - ANSThe RN. The task can be
delegated but in the end it is the RN's responsibility.
What is the normal range for temperature? - ANS96.8-100.4 F or 36-38 C
What controls temperature? - ANSthe hypothalamus
