NSE 103- MIDTERM EXAM QUESTIONS ANSWERED CORRECTLY LATEST UPDATE 2026

NSE 103- MIDTERM EXAM QUESTIONS ANSWERED CORRECTLY LATEST UPDATE 2026 Week 1- Introduction to assessment - Answers What is Health Assessment? - Answers - first phase of the nursing process and involves collection and analysis of client data What is Data collection categorized in? - Answers Subjective and Objective Subjective Data - Answers - info client or other person (fam, caregiver) share with nurse - shares in two ways; spontaneously or in response to question example: A client says, "I have had a rash on my ankle and leg for the last two weeks. - contains info about symptoms and signs sign - Answers observable - rash, bruising symptoms - Answers something client feels - nausea, pain Objective Data - Answers - info that nurse observes when conducting physical examination and collecting lab/diagnostic results example: The nurse observes the client sitting upright, leaning forward, breathing fast with eyes wide open. Closing the Objective Assessment - Answers • Brief summary • Next steps • Inquire • Questions trauma informed approach - Answers - physical touch - trauma - trauma informed approach Age ranges important when - Answers determining normal and abnormal finding during health assessment New borns and neonates - Answers birth to a few hours old and neonate is up to 28 days young children - Answers 5 years and younger including: - infants (28 days-1 year) - toddlers (1-2 years) - preschoolers(3-5 years) Older children and adolescents: - Answers 6-17 years including: - older children/school age (6-12 years) - adolescent (13-17 years) Adults and older adults - Answers 18 years and older including: - adults (18 years and older) - older adults (65 and older) Related legislation specific to health assessment - Answers - any health assessment performed must fall within nursing scope of practice - must be informed by appropriate nursing college or association practice standards Nurses must perform health assessment within - Answers CNO legislated scope of practice, the practice standards and also based on individual level of competence example: knowledge and expert practice to perform action It is important to be aware of controlled acts, which are activities that are considered ________ if performed by someone who is _______ as per _________ - Answers harmful, unqualified, Regulated health professionals act (RHPA) As per the RHPA, a controlled act must only be performed with _____ or when permitted by specific regulations and you must be _______ to perform the skill/procedure - Answers an order, competent Example: it is within scope of practice to perform health assessments that involve putting your finger/hands or an instrument beyond "the external ear canal - Answers When performing assessment it is important to ____ the client what you are assessing - Answers inform - share some findings that are within scope of practice why can nurses not tell a client a diagnosis? - Answers - this is considered a controlled act and outside of the registered nursing specific controlled acts who can communicate a diagnosis - Answers physician or nurse practionor when is the only time you can communicate a diagnosis - Answers delegated to do so by physician or nurse practitioner Common practice standards that apply to health assessment include - Answers - information related to consent - permission to touch - privacy and confidentiality - therapeutic nurse-client relationship - documentation Nurses are not permitted to communicate a - Answers Diagnosis Clinical judgment - Answers C.J; involves critical thinking and reasoning while engaging in n.p --important to detect and prevent clinical deterioration priorities of care - Answers - action most important to take first primary survey: - airway - breathing - circulation - disability - exposure When collecting subjective and objective data, you need to consider - Answers clinical judgment purpose of health assessment is to - Answers facilitate clinical judgement What is clinical judgment - Answers - A determination about a client's health and illness status. - Their health concerns and needs. - The capacity to engage in their own care. AND - The decision to intervene/act or not - if action is required, what action clinical judgement is more - Answers comprehensive, action-oriented and guided by philosophy of client safety why important to learn when to act to prevent - Answers clinical deterioration - worsening clinical state related to physiological decompensation To facilitate clinical judgment, you must determine - Answers if the collected data represent normal findings or abnormal findings When findings are abnormal - Answers must act on these cues as they signal a potential concern and require action what happens if you fail to recognize abnormal cues - Answers can lead to negative consequences including sub-optimal health and wellness - and more importantly, clinical deterioration Some abnormal findings are considered - Answers critical findings that place the client at further risk if the nurse does not act immediately process leading to clinical judgment is described as - Answers clinical reasoning clinical reasoning involves: - Answers - considering all client data as whole - recognizing and analyzing cues - interpreting problems - determining, implementing and evaluating appropriate actions clinical reasoning process is encompassed by - Answers critical thinking critical thinking - Answers when engaging in the process of clinical reasoning, you should systematically analyze your own thinking so that the outcomes are clear, rational, creative, and objective with limited risk of judgment and error What steps are involved in clinical judgement? - Answers 1. Recognize cues 2. Analyze cues 3. Prioritize hypotheses 4. Generate solution 5. Take action 6. Evaluate outcomes Recognize cues - Answers - identifying finding that require action because they are abnormal Analyze cue - Answers - interpreting and making sense of collected data - what does it mean - how may it relate to possible pathophysiological processes Prioritize hypotheses - Answers - figuring out where to start - how to prioritize care - responding to collected data Generate solutions - Answers - identifying the various options (action/intervention) to address problem or abnormal finding interventation types - Answers - effective - ineffective - unrelated - contraindicated Take actions - Answers - identifying the action that should be taken Examples of actions are specific but could be related to notifying the physician or nurse practitioner Evaluate outcomes - Answers - determining if action taken is effective - may include identifying outcome considered improved, unchanged or worsened Guiding approaches to health assessment - Answers - refer to specific conventions when and what type of health assessment to perform Example: how often you should perform an assessment on client or type of assessment to perform - Approaches always depend on the context of the situation Health Assessment Frequency - Answers - determined by setting (ex. primary care, acute care) and the health and clinical status of client Frequency of Primary Care - Answers - depends on client's age and health status and needs - ex. guidelines have been established for the frequency of well-baby and childhood visits and maternal health visits - clients with complex healthcare needs will need to see primary care practitioner more often then healthy adult Frequency of Assessment in Long-term care - Answers - determined by concerns voiced by client, PSW, RN - PSW and RPN have 1:1 contact with client in LTC -- draw more attention to concerns like further assessments Frequency of Assessment in Acute Care - Answers - in critical care; freq. increased to usually every 1-2 hours at least - clients usually on (constant) monitor (heart rhythm and vital signs) - there maybe standard freq. of assessment based on unique population - must be aware that escalation of care and increased freq. maybe needed based on nurse assessment + client clinical status Example: at times clients may require constant observation (e.g., post-surgery, in critical care environments, a client who is unstable or may show signs of deterioration, or a client in mental health distress with suicide ideation or post-attempt) Health Assessment Types - Answers 1. Primary Survey 2. Focused Assessment 3. Head to toe assessment (abbreviated) 4. Complete Health Assessment What is Primary Survey - Answers Airway (patency) Breathing (respiratory rate, work of breathing, oxygen saturation) Circulation (pulse rate/rhythm, BP, urine output) Disability (level of consciousness, speech, pain) Exposure (temperature, skin integrity, pressure injuries, wounds, dressings, drains, lines, ability to transfer/mobilize, bowel movements) Primary survey - Recommendations - Answers - all assessment should begin with primary survey-- structured assessment that help nurse recognize and act on signs - collects data in order of importance - aligned with most in situations - marks a change of tradition (begin with vital sign) - P.S will help with determining urgent intervention is needed or no Complete health assessment - Answers - similar to a head-to-toe assessment - more comprehensive - involves a subjective and objective assessment of all body systems - provides a full overview of the client's current health status Complete health assessment - Answers - take 30-60 min (depends on client and complexity of their health issue) - may be performed for diff reasons (often when client have complex care need) - performed upon admission to LTC or rehabilitation (primary care) - maybe performed at acute care (client = complex health problem/diagnoses problematic) - based on client situation, developmental stage, reason seeking of care/unit Focused assessment - Answers An assessment that is specific to a health concern/reason for seeking care. Focused assessment - Recommedation - Answers - performed in all areas of care - specificity involves a focus on limited number of body system based on health concern -- similar to an episodic database For example, a client's reason for seeking care may be an "achy knee." Thus, the nurse's assessment will be focused on the musculoskeletal system. - follow up assessment Head-to-toe assessment (abbreviated) - Answers A head-to-toe assessment follows a cephalocaudal approach, assessing several body systems, and provides an overview of the client's current health status. Head-to-toe assessment (abbreviated) - Recommedation - Answers - take 10 min - perform beginning of shift - variation of assessment based on situation - includes attention to overall wellbeing/needs, pain, vital signs, specific assessments to body system - Based on the collected data, this type of assessment may influence the need for a more focused examination - complete assessment/head-to-toe may be needed in certain situations when a comprehensive assessment is warranted When conducting assessment important to assess clients level consciousness and orientation decrease/disorientation in level of consciousness important cues that indicate ____ and require _____ - Answers clinical deterioration, immediate intervention what should be done and shared with physician or nurse practitioner for level of consciousness - Answers primary survey Level of consciousness is the client's state of awareness and response to stimuli (voice/sound or physical). Their level of consciousness is described as: - Answers 1. Alert and oriented; awake 2. confused and disoriented; altered cognition (memory) 3. lethargic; slow/sluggish 4. obtunded; significant impairment (requires significant stimuli (loud)) 5. unconsciousness; does not respond to anything Level of orientation is assessed by asking the client questions related to: - Answers - place - time - person - self Health Promotion - Answers - social and environmental intervention to enable people and communities to increase control over health - important component in preventing diseases As part of the Ottawa Charter for Health Promotion, the Government of Canada (1986) specified that health promotion includes attention to the following elements: - Answers - Peace and stable ecosystem along with social justice and equity. - Education, food, income, and healthy living. - Sustainable resources. - Healthier choices and avoidance of harmful products. The following sections describe the three broad approaches to health promotion: - Answers Behavioural. Relational. Structural. Behavioural health promotion - Answers - focuses on lifestyle and behaviours at individual level - ex. healthy eating, reducing alcohol - approach based on ideology of choice - healthcare providers work together with client to build skills and address unhealthy behaviours (educate) - approach to health promotion has come under fire for encouraging victim blaming, which lacks contextual awareness and places an emphasis on agency instead - critiqued for neglecting social context in which people live in Relational Health Promotion - Answers - emphasizes social change at the relational level, meaning the relationships between people, places, environments, spaces, beliefs, meanings, and events - ex. include pesticide restrictions, family-centred interventions, and bike rallies for persons living with HIV/AID - emerges in the relations between social beings and their surrounding environments Structural Health Promotion - Answers - approach focuses on structural aspects of health and wellbeing - addresses policies and practices that affect health at a broader community level, such as systemic discrimination - strategies may include advocating for access to traditional Indigenous healing options in healthcare - important role in health, and that one's participation and access within a community (location) Health Determinants; types - Answers - healthy child development - lifelong learning - absence of racism and discrimination - life free of violence - work opp. - healthy lifestyle - healthy, social relationships - protection from infectious diseases Healthy child development. - Answers - focuses on the physical, cognitive, and emotional development of the child - needs have been met and developmental milestone are being reached Lifelong learning. - Answers - involves the personal and professional pursuit of knowledge - involve developing job skills and improving employability, and thus socioeconomic stability Absence of racism and discrimination associated with culture, gender, and sexual orientation. - Answers - negatively affect a person's health and wellbeing - assess for the presence of these in a client's life and how it affects them A life free of violence. - Answers - influences health and wellbeing - important to be aware of the negative effects of violence on a person's life Work opportunities and adequate income. - Answers - Access to work opportunities supports an individual's development over the course of their life and also provides access to adequate income Healthy lifestyles (nutrition, activity/exercise, sleep/rest, coping and stress management, and smoke free). - Answers - range of lifestyle factors can negatively affect health and wellbeing and lead to certain disease processes Healthy, social relationships. - Answers - positive health determinants throughout all life stages Protection from infectious diseases and environmental hazards. - Answers - Living in an environment free from and/or protected from infectious diseases and environmental hazards is important to overall health and wellbeing Integrative Approach to Health Promotion and Assessment - Answers - offer guidance to your clients - An integrative, individualized, and adapted approach to health promotion means that you partner with clients to identify their needs - may apply all three approaches - behavioural, relational, and structural - to health promotion - health promotion approaches and strategies rely on the nurse's assessment skills and their capacity to prioritize what is important to the client - understand the person's day-to-day life and what is important to them Therefore, when collaboratively developing a health promotion intervention with a client, your assessment should include questions like: - Answers Tell me about your day-to-day activities. What does a typical day look like for you? Who is involved in these activities with you? Have you had any recent changes in your day-to-day activities in the past year? In order to be a healthier you, how would you like these day-to-day activities to be different? Example of health promotion steps - Answers - client description, clinical judgment, health promotion Development and concepts of health promotion and its use as a guide to nursing assessment - Answers Health promotion interventions, education, and counseling - Answers Components of a primary survey (airway, breathing, circulation, disability, exposure) and how to combine with a body systems approach - Answers Components of a mental status examination - Answers - appearance - behaviour - cognition - thinking Inspection - Answers - purposeful and systematic - bilateral comparison - client overall and then, specific body area palpation - Answers - using hands and fingers - permission to touch - bilateral comparison Palpation - Dorsal aspect of hands - Answers - temperature; cold or hot - back of hands Palpation - Use of fingertips - Answers texture, thickness, moisture, swelling and masses, pain/tenderness, feel glands, pulpability, crepitus (air becomes trapped) Palpation - Cupping of hand orgrasping of fingers/thumbs - Answers - bone and muscles, trachea and testicles often assessed using a gentle grasping motion of finger/thumbs crepitation - Answers abnormal grating or crunching sound heard over joints Palpation - Metacarpophalangeal joints or ulnar surface of hands - Answers vibration over lungs pulsatility over heart Percussion - Answers Percussion • Tapping the body to elicit sounds • Sounds determined by consistency of underlying structure - Air-filled - Fluid-filled - Dense Indirect percussion technique - Answers - Non-dominant hand - Dominant hand - assess the lungs and the abdomen Auscultation - Answers • Listening to the body with the stethoscope • Sounds - High-pitched - Low-pitched • Steps in using the stethoscope How to ensure the best setting and approach for assessment and practice with proper use of equipment - Answers 3 levels first level: - life threatening - require urgent action second level: - may lead to clinical deterioration - prompt action third-level: - non urgent but need addressing Maslow's Hierarchy of Needs in relation to health assessment - Answers With Maslow's model in mind, health-care workers can assess an individual as a whole person - a physical, intellectual, social, emotional, and moral being whose physicality cannot be separated from psychology and feeling STAT - Answers immediate action, often to treat a life-threatening condition or to prevent further complications bradycardia - Answers heart beats slowly fewer than 60 beats / min tachycardia - Answers beats faster than normal 100 beats per min What are vital signs? - Answers clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure What is pulse - Answers - refers to a pressure wave that expands and recoils the artery when the heart contracts/beats - palpated at many points throughout the body - most common locations to accurately assess pulse as part of vital sign measurement include radial, brachial, carotid, and apical pulse The heart pumps a volume of blood per contraction into the _______ This volume is referred to as ________ - Answers aorta, stroke volume Age is one factor that influences stroke volume, which ranges from _________ from newborns to older adults - Answers 5-80 mL Heart Rate Ranges; Ages new born to one month one month to two year age 2- 6 years age 7-11 year age 12-18 years