NURS 246: TEST 1 (NURSING ASSESSMENT) EXAM QUESTIONS AND ANSWERS 100% CORRECT!!, Exams of Nursing

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NURS 246: TEST 1 (NURSING

ASSESSMENT) EXAM QUESTIONS AND

ANSWERS 100% CORRECT!!

critical thinking five-step process that professional nurses use to apply the best available evidence to caregiving and promoting human functions and responses to health and illness - ANSWER nursing process

a _______________________ care approach is holistic and essential when applying the nursing process - ANSWER patient-centered

a nursing assessment must be what three things in order for the nurse to correctly identify a person's desire to improve their health or identify any health problem? - ANSWER 1) complete

2. relevant to a patient's condition
3. accurate

the nursing process is a form of ________________________ reasoning - ANSWER scientific

deliberate and systematic collection of information about a patient to determine the patient's current and past health and functional status and their present and past coping patterns - ANSWER assessment

two steps of nursing assessment - ANSWER 1) collection of information from a primary source (a patient) and secondary sources (family, friends, health professionals, and the medical record)

2. the interpretation and validation of data to ensure a complete database

five sources of information in a nursing assessment - ANSWER 1) the patient through interview, observations, and physical examination

2. family members or significant others' reports and response to interviews
3. other members of the health care team
4. medical record information (patient history, laboratory work, x-ray film results, multidisciplinary consultations)
5. scientific and medical literature (evidence about disease conditions, assessment techniques, and standards)

true or false: assessment is part of the working phase of a nurse-patient relationship - ANSWER true

assessment identifies what two things that help the nurse develop the nursing care plan? - ANSWER 1) functional (patient strengths) patterns

2. dysfunctional (nursing diagnoses) patterns

three examples of objective data - ANSWER 1) inspecting the condition of a surgical incision

2. describing an observed behavior
3. measuring blood pressure

best source of information (usually) - ANSWER the patient

describe how to communicate with a patient (five ways) - ANSWER 1) use short but not leading questions

2. keep your language uncomplicated
3. listen to a patient's perspective carefully
4. always be attentive and engaged
5. show a caring presence with patients

when are family members and significant others primary sources of information? - ANSWER 1) for children

2. critically ill adults
3. patients who are mentally handicapped or have cognitive impairment
4. cases of severe illness or emergency situations

how are family members secondary sources of information? - ANSWER they confirm findings or identify patterns that a patient provides

an interactive process of passing patient-specific information from one caregiver to another for ensuring patient-centers care and patient safety - ANSWER hand-off

three types of records that often contain significant health care information - ANSWER

1. educational
2. military
3. employment

two main characteristics of a patient-centered interview - ANSWER 1) relationship based

2. an organized conversation focused on learning about the well and the sick as they seek care

technique used often in counseling that allows you to become a helper in the change process; a process that addresses a patient's ambivalence to medically indicated behavior change and supports patients in making health care decisions in cases in which there is more than one reasonable option - ANSWER motivational interviewing

four communication skills involved in effective communication in assessment - ANSWER 1) courtesy

2. comfort
3. connection
4. confirmation

three phases of an interview - ANSWER 1) orientation and setting an agenda

2. working phase- collecting assessment or nursing health history
3. terminating an interview

the nurse should start an assessment or nursing health history with what type of questions? - ANSWER open-ended

six types of interview techniques - ANSWER 1) observation

2. open-ended questions
3. leading question
4. back channeling
5. probing
6. direct, close-ended questions

type of question that prompts a patient to describe a situation in more than one or two words - ANSWER open-ended

what is the goal of a patient-centered interview? - ANSWER to find out, in the patient's words, their health goals and any concerns or problems that exist and their probable cause

true or false: an open-ended question presupposes a specific answer - ANSWER false; an open-ended question does not presuppose a specific answer

why are leading questions risky? - ANSWER due to possibly limiting the information provided to that a patient thinks you want to know

examples of back channeling - ANSWER active listening prompts such as "all right", "go on", or "uh-huh."

observations or measurements of a patient's health status - ANSWER objective data

how does a nurse record a patient's response? - ANSWER in quotations to indicate the subjective response

what does the acronym PQRST stand for? - ANSWER 1) provokes

2. quality
3. radiate
4. severity
5. time

symptoms that accompany other symptoms - ANSWER concomitant symptoms

purpose of a health history - ANSWER 1) provides a holistic view of a patient's health are experiences and current health habits

2. provides a comprehensive record of the client's past and current health status
3. provides documentation of the client's response to actual and potential health concerns

two components of a health history - ANSWER 1) medical records

2. lifestyle patterns and habits

two components of family history - ANSWER 1) data about immediate and blood relatives

2. informations about family structure, interaction, support, and function

systematic approach for collecting subjective information from patients about the presence or absence of health-related issues in each body system - ANSWER review of systems

what does interpreting and validating assessment data ultimately lead the nurse to? - ANSWER the second step of the nursing process, in which you make clinical decisions in your patient's care

three things nurse does when critically interpreting assessment information - ANSWER

1. determine the presence of abnormal findings
2. recognize that further observations are needed to clarify information
3. begin to identify a patient's health problems

true or false: validation opens the door for gathering more assessment data because it involves clarifying vague or unclear data - ANSWER true

a health history includes a ________________________________________ - ANSWER wellness assessment

three examples of categories in a wellness assessment - ANSWER 1) nutrition

2. stress management
3. social interaction

a nursing health history focuses on (functional/dysfunctional) assessment - ANSWER functional

what type of care is the goal of a nursing health history? - ANSWER patient-centered

describe the communication process in nursing - ANSWER sender ---> encode ---> message ---> decode ---> receiver ---> encode ---> response ---> decode ---> sender

two main communication skills in interviewing - ANSWER 1) listening

2. interactional skills

two components of effective listening - ANSWER 1) active

2. undivided attention

six types of interactional skills - ANSWER 1) attending

2. paraphrasing
3. leading
4. questioning (open and closed)
5. reflecting
6. summarizing

giving the client undivided attention - ANSWER attending

four techniques of attending - ANSWER 1) use direct eye contact if appropriate for the culture

2. lean toward the client slightly
3. select a quiet area with no distractions for the interview
4. convey an unhurried manner; avoid fidgeting and looking at your watch

2. ask the client to express feelings about what is being discussed
3. ask questions that help the client gain insight

example of questioning - ANSWER "What did you mean when you said your back was breaking?"

letting the client know that the nurse empathizes with the thoughts, feelings, or experiences expressed - ANSWER reflecting

set of signs and symptoms that you group together in a logical way - ANSWER data clusters

the comparison of data with another source to determine data accuracy - ANSWER validation

who most often validates your assessment information? - ANSWER family and friends of the patient

who else can participate in validation? - ANSWER 1) the patient

2. other health care team members

seven barriers to effective nurse-client communication - ANSWER 1) false reassurance

2. interrupting
3. changing the subject
4. passing judgment
5. cross-examination
6. using technical terminology
7. encountering sensitive issues

seven diversity factors that contribute to the influence of culture on nurse-client interactions - ANSWER 1) body language

2. ethnicity
3. religion
4. education
5. health status
6. level of intelligence
7. health literacy

how could the use of a family member as an interpreter cause potential problems? - ANSWER they could interpret or relay information wrongly

describe the three phases of the client interview - ANSWER 1) pre-interaction (record review)

2. initial interview (planned meeting and formal interaction)
3. focused interview

purpose of the focused interview phase in the client interview - ANSWER to obtain clarification of previous assessment data and gather missing information

six main components of a nursing health history - ANSWER 1) biographical data

2. present health/illness
3. past history
4. family history
5. psychosocial history
6. review of systems

nine examples of biographical data - ANSWER 1) name

2. address
3. age
4. marital status
5. gender
6. religion
7. cultural data
8. occupation
9. insurance coverage

four components in the present health/illness portion of a nursing health history - ANSWER 1) reason for seeking care

2. health beliefs
3. health patterns
4. medications

the reason for seeking care may also be known as what? - ANSWER the chief complaint (why are you here?)

eleven components of a patient's past history - ANSWER 1) childhood illnesses

2. immunizations
3. allergies
4. blood transfusions
5. major illnesses

three techniques of summarizing - ANSWER 1) listen to verbal and nonverbal content throughout the interview

2. summarize feelings, issues, and themes in broad statements
3. repeat them to the client, or ask the client to repeat them to you

example of summarizing - ANSWER "Let's review the health problems you've identified today."