N220 Foundations Of Nursing: Test 1 With
Complete Solutions
Assessment - ANSWER systematic gathering of info related to physical, mental,
spiritual, socioeconomic, and cultural status of an individual, group, or
community
What are the types of assessments? (5) - ANSWER initial: at first approach
ongoing: through shift
comprehensive: history, physical
focused: checking problem areas
special needs
What are examples of special needs assessments? - ANSWER nutritional,
functional ability, pain, cultural, wellness, family
What is the purpose of the nursing interview? - ANSWER to gather subjective
data
-involves purposeful/structured communication & questions
How to prepare for the nursing interview - ANSWER -read chart
-form goals and opening questions
-schedule uninterrupted time
-have your stuff ready beforehand
How to prepare the interview space - ANSWER privacy, remove distractions,
dont hover
What is a comprehensive assessment? - ANSWER complete nurse history,
physical exam, has subjective/objective data
What are the basic physical assessment techniques? - ANSWER inspection,
palpation, percussion, and auscultation
What is inspection? - ANSWER use of sight to gather data
-can use otoscope, ophthalmoscope, penlight
ex: skin color, gait, appearance, behavior
What is palpation? - ANSWER touch to gather data
-goes from light pressure to deeper
ex: edema, moisture, anatomical landmarks, masses
,What part of the hand do you use for temperature? - ANSWER dosal part (back)
What is percussion? - ANSWER tapping to elicit sound on the skin
-used to assess abdomen, lungs, and structures
ex: distended bladder
What is auscultation? - ANSWER hearing to gather info
ex: heart and lung sounds
What is direct auscultation? - ANSWER listening without an instrument
What is indirect auscultation? - ANSWER listening with stethoscope
Diaphragm: high pitched sounds (BP, lung/heart sounds)
Bell: low pitched sounds (heart murmur, turbulence of blood flow)
What modifications do you do for the physical exam on infants/toddlers? -
ANSWER lets parents hold them
What modifications do you do for the physical exam for elderly? - ANSWER may
need to position differently for mobility, might need rest periods, adapt exam for
hearing and vision issues, assess them for ADL function
What are the basic components of the GENERAL SURVEY of the comprehensive
exam? - ANSWER -starts at first contact
-overall impression
-any deviations here can lead to more focused assessments
ex: looking at appearance, grooming, hygiene, body type, mental state, speech,
vitals, height/weight (BMI)
What is the SOAP (IER) charting? - ANSWER Subjective
Objective
Assessment
Plan
.....
Intervention
Evaluation
Revision
What is contextual awareness? - ANSWER Putting the pieces together already,
being observant, knowing the context
What are the 5 major categories of critical thinking? - ANSWER Contextual
awareness, inquiry, considering alternatives, examining assumptions, reflecting
critically
, What are the 4 types of nursing knowledge? - ANSWER theoretical, practical,
self, and ethical
What is the nursing process? - ANSWER Systematic problem-solving process
that guides nursing actions
What is the purpose of the nursing process? - ANSWER to help the nurse give
goal-directed, patient centered care
What are the nursing process phases? - ANSWER assessment, diagnosis,
planning outcomes, planning interventions, implementation, and evaluation
Describe the phases of the nursing process - ANSWER Assessment: gather the
data
Diagnosis: what are the patients health needs
Planning outcomes: goals to achieve with nursing activities
Planning interventions: what you do to help patient reach the goal
Implementation: actions you do, interventions you do/or the doctor orders
Evaluation: judging if your action was successful or not
What is full spectrum nursing? - ANSWER thinking, doing, and caring for the
purpose of effecting good outcomes for the patient
(concepts: thinking, doing, caring, patient situation)
How does the full spectrum nursing model work? - ANSWER thinking: theoretical
model + critical thinking
doing: practical knowledge + nursing process
caring: self/ethical knowledge
patient situation: patient data/preferences, context
Cafe-au-lait skin variation - ANSWER like a freckle but larger
Stork bite skin variation - ANSWER capillary hemangiomas;; abnormal
overgrowth of blood vessels in babies
Mongolian spots skin variation - ANSWER blueish, irregularly bordered birth
marks
Pallor - ANSWER pale, could be anemic-poor circulation-albinism-shock-cold-BP
lowering-dehydrated
Complete Solutions
Assessment - ANSWER systematic gathering of info related to physical, mental,
spiritual, socioeconomic, and cultural status of an individual, group, or
community
What are the types of assessments? (5) - ANSWER initial: at first approach
ongoing: through shift
comprehensive: history, physical
focused: checking problem areas
special needs
What are examples of special needs assessments? - ANSWER nutritional,
functional ability, pain, cultural, wellness, family
What is the purpose of the nursing interview? - ANSWER to gather subjective
data
-involves purposeful/structured communication & questions
How to prepare for the nursing interview - ANSWER -read chart
-form goals and opening questions
-schedule uninterrupted time
-have your stuff ready beforehand
How to prepare the interview space - ANSWER privacy, remove distractions,
dont hover
What is a comprehensive assessment? - ANSWER complete nurse history,
physical exam, has subjective/objective data
What are the basic physical assessment techniques? - ANSWER inspection,
palpation, percussion, and auscultation
What is inspection? - ANSWER use of sight to gather data
-can use otoscope, ophthalmoscope, penlight
ex: skin color, gait, appearance, behavior
What is palpation? - ANSWER touch to gather data
-goes from light pressure to deeper
ex: edema, moisture, anatomical landmarks, masses
,What part of the hand do you use for temperature? - ANSWER dosal part (back)
What is percussion? - ANSWER tapping to elicit sound on the skin
-used to assess abdomen, lungs, and structures
ex: distended bladder
What is auscultation? - ANSWER hearing to gather info
ex: heart and lung sounds
What is direct auscultation? - ANSWER listening without an instrument
What is indirect auscultation? - ANSWER listening with stethoscope
Diaphragm: high pitched sounds (BP, lung/heart sounds)
Bell: low pitched sounds (heart murmur, turbulence of blood flow)
What modifications do you do for the physical exam on infants/toddlers? -
ANSWER lets parents hold them
What modifications do you do for the physical exam for elderly? - ANSWER may
need to position differently for mobility, might need rest periods, adapt exam for
hearing and vision issues, assess them for ADL function
What are the basic components of the GENERAL SURVEY of the comprehensive
exam? - ANSWER -starts at first contact
-overall impression
-any deviations here can lead to more focused assessments
ex: looking at appearance, grooming, hygiene, body type, mental state, speech,
vitals, height/weight (BMI)
What is the SOAP (IER) charting? - ANSWER Subjective
Objective
Assessment
Plan
.....
Intervention
Evaluation
Revision
What is contextual awareness? - ANSWER Putting the pieces together already,
being observant, knowing the context
What are the 5 major categories of critical thinking? - ANSWER Contextual
awareness, inquiry, considering alternatives, examining assumptions, reflecting
critically
, What are the 4 types of nursing knowledge? - ANSWER theoretical, practical,
self, and ethical
What is the nursing process? - ANSWER Systematic problem-solving process
that guides nursing actions
What is the purpose of the nursing process? - ANSWER to help the nurse give
goal-directed, patient centered care
What are the nursing process phases? - ANSWER assessment, diagnosis,
planning outcomes, planning interventions, implementation, and evaluation
Describe the phases of the nursing process - ANSWER Assessment: gather the
data
Diagnosis: what are the patients health needs
Planning outcomes: goals to achieve with nursing activities
Planning interventions: what you do to help patient reach the goal
Implementation: actions you do, interventions you do/or the doctor orders
Evaluation: judging if your action was successful or not
What is full spectrum nursing? - ANSWER thinking, doing, and caring for the
purpose of effecting good outcomes for the patient
(concepts: thinking, doing, caring, patient situation)
How does the full spectrum nursing model work? - ANSWER thinking: theoretical
model + critical thinking
doing: practical knowledge + nursing process
caring: self/ethical knowledge
patient situation: patient data/preferences, context
Cafe-au-lait skin variation - ANSWER like a freckle but larger
Stork bite skin variation - ANSWER capillary hemangiomas;; abnormal
overgrowth of blood vessels in babies
Mongolian spots skin variation - ANSWER blueish, irregularly bordered birth
marks
Pallor - ANSWER pale, could be anemic-poor circulation-albinism-shock-cold-BP
lowering-dehydrated
