NUR 3121 Health Assessment Exam 1
UPDATED ACTUAL QUESTIONS AND
CORRECT ANSWERS
What is the Nursing Process - CORRECT ANSWER Assessment
Diagnosis
Planning
Implementation
Evaluation
(ADPIE)
Risk-Focused Nursing Diagnosis - CORRECT ANSWER Clinical judgements that a
problem does not yet exist; risk factors are present. The two components include (1) risk
diagnostic label and (2) related factors
Risk for infection as evidenced by prolonged hospitalization, compromised immune system,
invasive procedures.
Problem-Focused Nursing Diagnosis - CORRECT ANSWER The client's problem is
present at the time of assessment. The three components include (1) nursing diagnosis, (2)
related factors, and (3) defining characteristics
ineffective breastfeeding related to maternal anxiety, inadequate family support, and pacifier
use as evidenced by infant crying at breast, infant unable to latch on to maternal breast
correctly, and sustained infant weight loss.
Health Promotion Focused Nursing Diagnosis - CORRECT ANSWER The client
displays a readiness to improve health. The two components are (1) nursing diagnosis and (2)
defining characteristics.
Readiness for enhanced breastfeeding as evidenced by verbalized commitment to
breastfeeding and expressed interest in learning proper latching techniques.
, What are the aspects of clinical decision making? - CORRECT ANSWER best
evidence from literature + patient preference + clinical expertise and experience + physical
exam
Subjective data - CORRECT ANSWER what the patient tells you; symptoms
Objective data - CORRECT ANSWER information that is seen, heard, felt, or smelled
by an observer; signs
Complete health assessment - CORRECT ANSWER Describes current and past health
state and forms the baseline to measure all future changes
Focused or problem-centered database/assessment - CORRECT ANSWER Collect
"mini" database, smaller scope and more focused on current situation than the complete
database
Follow-up database/assessment - CORRECT ANSWER Status of all identified
problems should be evaluated at regular and appropriate intervals
Emergency database/assessment - CORRECT ANSWER Rapid data collection, may be
done along with lifesaving measures
What are the 5 tiers of Maslow's Hierarchy of Needs? - CORRECT
ANSWER Physiological needs, safety needs, belongingness and love needs, esteem
needs, and self actualization
What is first level priority in nursing? - CORRECT ANSWER Emergency, life
threatening, and immediate.
ie. ABCs
UPDATED ACTUAL QUESTIONS AND
CORRECT ANSWERS
What is the Nursing Process - CORRECT ANSWER Assessment
Diagnosis
Planning
Implementation
Evaluation
(ADPIE)
Risk-Focused Nursing Diagnosis - CORRECT ANSWER Clinical judgements that a
problem does not yet exist; risk factors are present. The two components include (1) risk
diagnostic label and (2) related factors
Risk for infection as evidenced by prolonged hospitalization, compromised immune system,
invasive procedures.
Problem-Focused Nursing Diagnosis - CORRECT ANSWER The client's problem is
present at the time of assessment. The three components include (1) nursing diagnosis, (2)
related factors, and (3) defining characteristics
ineffective breastfeeding related to maternal anxiety, inadequate family support, and pacifier
use as evidenced by infant crying at breast, infant unable to latch on to maternal breast
correctly, and sustained infant weight loss.
Health Promotion Focused Nursing Diagnosis - CORRECT ANSWER The client
displays a readiness to improve health. The two components are (1) nursing diagnosis and (2)
defining characteristics.
Readiness for enhanced breastfeeding as evidenced by verbalized commitment to
breastfeeding and expressed interest in learning proper latching techniques.
, What are the aspects of clinical decision making? - CORRECT ANSWER best
evidence from literature + patient preference + clinical expertise and experience + physical
exam
Subjective data - CORRECT ANSWER what the patient tells you; symptoms
Objective data - CORRECT ANSWER information that is seen, heard, felt, or smelled
by an observer; signs
Complete health assessment - CORRECT ANSWER Describes current and past health
state and forms the baseline to measure all future changes
Focused or problem-centered database/assessment - CORRECT ANSWER Collect
"mini" database, smaller scope and more focused on current situation than the complete
database
Follow-up database/assessment - CORRECT ANSWER Status of all identified
problems should be evaluated at regular and appropriate intervals
Emergency database/assessment - CORRECT ANSWER Rapid data collection, may be
done along with lifesaving measures
What are the 5 tiers of Maslow's Hierarchy of Needs? - CORRECT
ANSWER Physiological needs, safety needs, belongingness and love needs, esteem
needs, and self actualization
What is first level priority in nursing? - CORRECT ANSWER Emergency, life
threatening, and immediate.
ie. ABCs
