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NUR 310 Health Assessment Exam 1 Information, Health Assessment Test 1 Questions and Answers
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NUR 310 Health Assessment Exam 1 Information, Health Assessment Test 1 Questions and Answers
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NUR 310 Health Assessment Exam 1Information, Health Assessment Test 1
Questions and Answers
What are the different parts of The Nursing Process? - Answer-Assessment,
Diagnosis/Analysis, Planning, Implementation, and Evaluation
What happens in the "Assessment" portion of The Nursing Process? (This is the first
step) - Answer-Nurse collects data, and health assessment data is characterized as
either subjective or objective
What is subjective data? - Answer-Data that includes interpretations and information
provided by an individual about himself or herself
- typically gathered from health history; pt. presents this information to you (ex: "I feel
nauseous")
What is objective data? - Answer-Data that is measurable and observable
- typically obtained through physical examination or lab/diagnostic tests
- can be observed by someone else
**ALWAYS verify information from the patient!!
What is a health database? - Answer-The patient's laboratory and diagnostic studies,
and objective and subjective data collected by the nurse
What happens during the "Diagnosis/Analysis" portion of The Nursing Process? (this is
the second step) - Answer-the nurse analyzes the data collected during the assessment
using clinical judgement; nursing diagnosis is formed here; nurse collaborates with
patient to develop the plan of care and will identify both actual and potential problems
What happens during the "Planning" step of The Nursing Process? (third step) -
Answer-The nurse establishes priorities based on the patient outcomes and starts to
identify interventions that will allow those outcomes to be met within a timeframe
- identifies priorities: 1st, 2nd, 3rd level
First level priority problems - Answer-emergent, life-threatening, and immediate, such
as establishing an airway or supporting breathing
Second-level priority problems - Answer-those that are next in urgency requiring your
prompt intervention to prevent further deterioration. (mental status change, acute pain,
acute urinary elimination problem, untreated medical problems, abnormal lab test
results
,Third-level priority problems - Answer-those that are important to the patient's health but
can be addressed after more urgent health problems are addressed. (Knowledge deficit,
altered family processes, and low self esteem)
What happens during the "Implementation" stage of The Nursing Process? (fourth step)
- Answer-the nurse will DO something
- implement evidence-based interventions in a safe and timely manner using
collaboration and delegation
What happens during the "Evaluation" stage of The Nursing Process? (fourth and final
step) - Answer-The nurse will refer to established outcomes to:
1) evaluation individual's condition and progress toward outcomes
2) identify reasons for failure to achieve expected outcomes
3) take corrective action to modify plan of care
4) Document evaluation in plan of care
medical diagnosis - Answer-has an actual pathophysiology; (ex: broken arm,
depression); the basis on which a nursing diagnosis can be made
nursing diagnosis - Answer-NOT medical; decisions nurses make in response to a
medical diagnosis
Nonmaleficence - Answer-Duty to do no harm
Beneficence - Answer-The "doing of good" ; return to health is the goal for the patient!
Autonomy - Answer-Individuals have the right to determine their own actions and
freedom to make their own decisions
Justice - Answer-treat everyone fairly, regardless of their ability to pay for treatment,
social status, etc
Confidentiality - Answer-respecting the rights of the pt. to maintain privacy
What are the ethical principles of nursing care? - Answer-Nonmaleficence, Beneficence,
Autonomy, Justice, Confidentiality
What does the CDC recommend as the first line of defense to decrease nosocomial
infections and prevent transmission of microorganisms? - Answer-hand washing
Alcohol based hand rub - Answer-kill more organisms more quickly, less damaging to
skin
- use mechanical soap-and-water washing when hands are visibly soiled
Standard precautions - Answer-consider all waste and contact as potentially infectious;
they also ensure that all health care providers treat all patients equally
, What is the intent of standard precautions? - Answer-prevent disease transmission
during contact with non-intact skin, mucous membranes, body substances, and blood-
borne contacts
What can a latex allergy result from? - Answer-repeated exposure to proteins found in
natural rubber latex through skin contact or inhalation
- reaction can occur within minutes or hours
Why should gloves be worn, according to the CDC? - Answer-1) to reduce the risk of
acquiring infections from patients
2) to prevent the transmission of flora from health care workers to patients
3) to reduce transient contamination of the hands of personnel by flora that can be
transmitted from one patient to another
**Gloves should NOT be worn from room out into the hallway
What are the different aspects of The Process of Communication? - Answer-Sending
(nurse conscious of messages sent), Receiving (receiver uses his or her own
interpretations to process sent messages), Internal Factors (nurse maintains respect,
empathy, listening factors, self-awareness), External factors (nurse should make sure
the physical setting is comfortable)
What should be done to prepare for the physical assessment? - Answer-1) organize the
examination
2) prepare the environment
3) prepare the patient
What are the four assessment techniques in order? - Answer-Inspection, Palpation,
Percussion, Auscultation
What is the assessment order for the abdomen? - Answer-Inspection, Auscultation,
Percussion, Palpation
What should be done during the "inspection" portion of the physical assessment? -
Answer-look carefully and thoroughly at the patient; this offers an overall impression of
the patient and severity of the situation
- most revealing and provides a LOT of info
- note symmetry b/w right and left side, skin characteristics, shape of chest, facial
features, patient mood
what should be done during the "Palpation" portion of the physical assessment? -
Answer-touch to assess for findings such as texture, temperature, moisture, tenderness,
and edema
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