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INTRO TO NURSING - EXAM 1 QUESTIONS AND ANSWERS WITH SOLUTIONS 2024
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INTRO TO NURSING - EXAM 1 QUESTIONS AND ANSWERS WITH SOLUTIONS 2024
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INTRO TO NURSING - EXAM 1QUESTIONS AND ANSWERS WITH
SOLUTIONS 2024
The foundation of the nursing profession; is the systematic approach to problem-solving and providing
individualized care? - ANSWER The Nursing Process
The phases of the nursing process? - ANSWER Assessment, Diagnosis, Planning (includes Outcome),
Implementation, Evaluation
What is Assessment? - ANSWER Collection of data to help establish a goal of making a clinical nursing
judgment.
Difference between subjective and objective data? - ANSWER Subjective, from the client; Objective, from
the nurse's senses.
Difference between primary, secondary and tertiary sources? - ANSWER Primary, can only be the patient;
Secondary, info from families, medical records, or other health care professionals; Tertiary, info from
textbooks, nurse's and other health care team responses to patient
What must be done by the nurse on admission to a health care facility? And what does it identify? -
ANSWER In depth nursing history and physical assessment must be done and it identifies the patient's
strengths and weakness/health problems.
When does data collection take place? - ANSWER Through observations, interviews, physical assessment,
and interpreting lab and diagnostic results.
What is diagnosis? - ANSWER The clinical act of identifying problems using the assessment data
collected. This step identifies an individual, family or group response to an actual or potential health
problem.
What is the nursing diagnosis based on? - ANSWER The pathophysiology of the disease process.
Who established the list of nursing diagnosis for classifying nursing problems, standardizing language
and facilitating communication for nurses? - ANSWER North American Nursing Diagnosis Association
(NANDA)
What is included in Outcome? - ANSWER Development of patient focused goals...included in the
planning phase.
What are the guidelines on making goals? - ANSWER Must be patient-focused, specific to the nursing
diagnosis or patient problem, measurable, realistic and have time frame.
What is involved in the Planning phase? - ANSWER Preparing the nursing care plan with patient input in
how to identify goals and interventions to help with the identified problems.
, What is included in the Planning phase? - ANSWER Patient goals/outcomes specific to the problem,
assessment, specific treatments (independent and dependent), medications, teaching, and community
care.
What is a Joint Commission on Accreditation of Healthcare Organizations (JACHO) requirement? -
ANSWER The care plan is a written summary of the care that a patient is to receive.
What is the action phase? - ANSWER Implementatio/Intervention
Why are nursing actions goal oriented? - ANSWER To help the patient reach maximum health potential
What is crucial in the implementation phase? - ANSWER Documentation
What is determined in the Evaluation phase? - ANSWER The patient's reactions to nursing interventions
and judging whether the goals of the plan of care were achieved.
What is ongoing and continuous process performed throughout the process? - ANSWER
Evaluation..."revised or reassessed"
Vital signs are a __________ mechanism? - ANSWER Homeostatic
What is an important component of assessment? - ANSWER It yields info about underlying health status
What is included in vital signs? - ANSWER Temperature, Pulse, Respiration, Blood Pressure, Pain, Pulse
Oximetry
What are normal vital ranges, in adults? - ANSWER Pulse: 60-100; Respirations: 12-20; Temp: 97-99;
Systolic: 90-120; Diastolic: 60-80
When do you assess vital signs? - ANSWER Upon admission, physician order, facility policy; before and
after- surgery, diagnostic procedure, medication administration, nursing interventions, patient becomes
symptomatic
What produces heat in the body? - ANSWER Basal metabolism, muscle activity, hormones and cells
(fever)
What causes loss of heat in body? - ANSWER Radiation, conduction/convection, evaporation... 40% of
heat is lost through head.
What is included in core body temperature? - ANSWER Temp of deep body tissue: abdominal, chest,
pelvic cavities, and cranium
What is included in surface body temperature? - ANSWER Temp of skin, subcutaneous tissue, and fat
What factors affect temperature? - ANSWER Age, environment, time of day, exercise, stress and
hormones. (temp is lowest in am)
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