NUR 310 Health Assessment Exam 1 Information, Health
Assessment Test 1 || with Errorless Solutions 100%.
What are the different parts of The Nursing Process? correct answers Assessment,
Diagnosis/Analysis, Planning, Implementation, and Evaluation
What happens in the "Assessment" portion of The Nursing Process? (This is the first step)
correct answers Nurse collects data, and health assessment data is characterized as either
subjective or objective
What is subjective data? correct answers 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? correct answers 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? correct answers 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) correct answers 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) correct answers
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 correct answers emergent, life-threatening, and immediate, such as
establishing an airway or supporting breathing
Second-level priority problems correct answers 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 correct answers 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) correct
answers 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)
correct answers 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 correct answers has an actual pathophysiology; (ex: broken arm, depression);
the basis on which a nursing diagnosis can be made
nursing diagnosis correct answers NOT medical; decisions nurses make in response to a medical
diagnosis
Nonmaleficence correct answers Duty to do no harm
Beneficence correct answers The "doing of good" ; return to health is the goal for the patient!
Autonomy correct answers Individuals have the right to determine their own actions and freedom
to make their own decisions
Justice correct answers treat everyone fairly, regardless of their ability to pay for treatment,
social status, etc
Confidentiality correct answers respecting the rights of the pt. to maintain privacy
What are the ethical principles of nursing care? correct answers 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? correct answers hand washing
Alcohol based hand rub correct answers kill more organisms more quickly, less damaging to skin
- use mechanical soap-and-water washing when hands are visibly soiled
Standard precautions correct answers 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? correct answers prevent disease transmission during
contact with non-intact skin, mucous membranes, body substances, and blood-borne contacts
, What can a latex allergy result from? correct answers 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? correct answers 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? correct answers 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? correct answers 1) organize the
examination
2) prepare the environment
3) prepare the patient
What are the four assessment techniques in order? correct answers Inspection, Palpation,
Percussion, Auscultation
What is the assessment order for the abdomen? correct answers Inspection, Auscultation,
Percussion, Palpation
What should be done during the "inspection" portion of the physical assessment? correct answers
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? correct answers
touch to assess for findings such as texture, temperature, moisture, tenderness, and edema
what are the finger pads used to palpate for? correct answers - pulses, lymph nodes, small lumps,
skin texture, edema
what are the palmar surfaces of the fingers and finger joints used to palpate for? correct answers
firmness, contour, position size, paint and tenderness
what is the douse (back side) of the hand used to palpate for? correct answers temperature
