NSE 103 WEEK 1 EXAM QUESTIONS WITH VERIFIED SOLUTIONS LATEST UPDATE 2026

NSE 103 WEEK 1 EXAM QUESTIONS WITH VERIFIED SOLUTIONS LATEST UPDATE 2026 what is health assessment - Answers the first phase of the nursing process, involves collection of analysis of client data. It is an ongoing process throughout the patients stay Health assessment: related legislation - Answers - Any health assessment performed must fall under the nursing scope of practice and be informed by the appropriate nursing College or associated practice standard - CNO is the legal governing body for nurses, so a health assessment must be performed based within the CNO legislated scope of practice, the practice standard, and based on your individual level of competence (i.e., knowledge and expert practice to perform an action) What is subjective data? - Answers information that a client net or another person shares regarding the clients Questions to ask patients - Answers P provocative (what makes the symptoms worse) Qquality (what does it feel like) quantity ( tell me how bad the pain is) qualification R region (where is it) radiation (does it move anywhere) Sseverity ( on scale) quantification TTiming (when did it start/what were you doing) Treatment (have you treated it with anything) U understanding (what do you think is going on) look at symptoms and signs what is Objective data? - Answers Information the nurse observes when conduction a physical examination (collecting lab and diagnostic results) Measurements in order from 1-5 when taking vital signs on a newborn who is not in distress - Answers 1. Respiration 2. Pulse 3. Oxygen saturation 4. Temperature 5. Blood pressure Consider the following when analyzing vital signs measurements - Answers Knowledge of accurate vital signs ranges for the age of the person (an infant will have a highway pulse than an adult) Knowledge of a person's trends in vital sign measurements (this shows if the person is getting better or deteriorating) Knowledge of a person's baseline vital signs What is the purpose of an health assessment? - Answers To facilitate clinical judgment. ( A determination about a client's health and illness status Their health concerns and needs The capacity to engage in their own care The decision to intervene/act or not if action is required then what action is needed) how do you facilitate clinical judgment? - Answers Determine if the collected data represented are normal findings or abnormal findings clinical judgment process - Answers 1. Recognize cues 2. Analyze cues/ prioritize hypothesis 3. Generate solutions 4. take action 5. Evaluate outcomes Recognize cues - Answers Relevant/important cues/immediate concerns Analyze cues - Answers Why is the cue of concern? How do the cues relate to one another? What other information is important to collect to determine the significance of a cue? Prioritize hypothesis - Answers What explanations are most/least likely? Which explanations are the most serious? Generate solutions - Answers What are the desirable outcomes? What interventions can achieve this outcome? What actions should be avoided? Take action - Answers What actions/interventions are of highest priority? Evaluate outcomes - Answers What signs point to improving/unchanged/declining status? Where the actions/interventions effective? How do you know they were effective? Clinical judgment helps determine - Answers - Health & illness status -Health concern & needs capacity to engage in own care - Decision to act/intervene or not, and if action required, what action - prevent clinical deterioration Starting assessment (Priorities of care) - Answers Primary Survey - Airway -Breathing -Circulation - Disability - Exposure 1. Airway - Answers - Airwflow flow through the upper respiratory system - Patient can talk comfortably with no SOB - Breathing is silent but evident - Colour of the patient can be a cue to obstruction 2. Breathing - Answers -Measure respiratory rate - Evaluate work of breathing -Measure oxygen saturation 3. Circulation - Answers Palpate (pulse rate and rhythm Measure (blood pressure) Assess ( urine output) 4. Disability - Answers - Assess level of consciousness - Evaluate speech - Assess pain 5. Exposure - Answers - Mesure temp - Inspect skin integrity - Inspect and palpate for signs of pressure injury - Observe any wounds, dressings, drains, invasive lines - Observe ability to transfer and mobilize - Assess for bowl movements Why was the Maslows Hierarchy of needs made - Answers - It was developed to consider basic human needs and motivations of healthy individuals what are the 5 needs of Maslows Hierachy of needs? - Answers 1. Physiological needs 2. Safety 3. Social (love) 4. Esteem 5. Self actualization Why is clinical judgment important? How does it guide the provision of care? - Answers Clinical judgment is important to ensure the nurse's actions are based on the client's most important needs. Nurses need to assess and evaluate the priorities of care: priority actions are those that prevent clinical deterioration and death Physiological needs - Answers - Fundamental physical needs required for survival such as air, food/drink, sleep, warmth/clothing/shelter- Are these basic physiological needs being met? Is the client's breathing and circulation supported? Ex (oxygen, fluids, nutrition body temperature, elimination, rest & sleep) include your ABC Safety - Answers - needs related to a secure physical and emotional environment. Does the client feel safe and secure in general in life? - Does the client feel safe and secure in the healthcare environment? - Is the bed lowered to the lowest position when you finish your assessment? - Is the call bell in reach? (make sure the patient is not at risk of harming themselves or others) also educate the patient making sure they know how to minister their medication properly Love and belongingness - Answers - needs related to relationships including friendship and family, intimacy and affection, work, and trust and acceptance. - Does the client feel love and belongingness in general in their relationships? - More specifically, does the client feel cared for by nurses and other healthcare providers? - ( does the patient have good communication skills, you can help support your patient by showing active listening skills) Esteem - Answers - feelings related to self-worth, dignity, respect, and achievement. - Does the client feel respected and valued in general by others? Does the client feel respected and valued within the healthcare environment? - ( want to deliver a proper patient education or any changes the may experience) be considerate of patient perception of change Self-actualization - Answers - a process or action of reaching one's full potential and self-fulfillment. - What is important to the client in terms of what they want to achieve in life in general? - What are the client's goals that they may have for themselves in their own health and healing journey? - Does the client feel satisfied, confident, and accomplished? - ( this would help them reach their full potential, focus on possibilities and strengths, rather than the problem from maximize the patient's life fulfillment this would help them reach their full potential) how to prioritize care - Answers 1. First-level priorities 2. Second- level priorities 3. Third-level priorities First-level priorities - Answers - Life threatening - Require urgent action - Clinical deterioration Second- level priorities - Answers - May lead to clinical deterioration without interventions (worsening conditions) - Prompt action Signs and symptoms - Example ( altered level of orientation, decreased level of consciousness/confusion, elevated temperature, increasing pain levels, and cold extremities) Third level Priorities - Answers - Non urgent, but need addressing when client is stable because not acute in nature - Functional health, client education, and counselling - Post-op education and tips and knowledge - It is essential to consider what is most important to the client. You need to consider tailoring the intervening action to their wishes. 4 Interventions (Action) Types: - Answers 1. Effective (or indicated) 2. Ineffective 3. Unrelated (or non-essential) 4. Contraindicated Effective (or indicated) - Answers - Adequate to produce the intended result and help the client - ex start cp Ineffective - Answers - Not adequate to produce the intended results and therefore will not help the client Unrelated (or non-essential) - Answers - Actions that will not produce and effect (positive or negative) and therefore will not help the client Notify the client's employer Contraindicated - Answers Actions that are not recommended because they have the potential to cause harm A contraindicated intervention is delay resuscitation until a physician is present What are the 4 types of health assessments - Answers 1. Primary Survey 2. Focused assessment 3. Head-to-toe (abbreviated) 4. Complete health assessment Primary Survey - Answers - All assessments should begin with a primary survey because this helps nurses recognize and act on signs of clinical deterioration that are correlated with death. - A primary survey collects data in order of importance, and it is aligned with most institutions rapid response systems 1. (Airway (Patency) 2. Breathing (respiratory rate; WOB; oxygen saturation) 3. Circulation (pulse rate/ rhythm, BP, urine output) 4. Disability (level of consciousness, speech, pain) 5. Exposure (temperature, skin integrity, pressure injuries, mobility, bowl movement) Focused Assessment - Answers Assessment specific to a health/concern/reason for seeking care - Performed in all areas of care ( primary care, emergency, LTC, medical and surgical) - Involves a focus on a limited number of body systems based on the health concern, similar to an episodic database - Example: A client can in for an " achy knee" The nurses assessment will be focused on the musculoskeletal system - Follow up assessment: A client may have been prescribed a new medication for high blood pressure and needs a followup assessment a couple weeks later to determine the effects Head-to-toe assessment - Answers Follows a cephalocaudal approach, assessing several body systems, and provides an overview of the client's current health status ( 10 minutes ) - Should be performed when you first interact with patient - A head-to-toe assessment usually includes attention to overall wellbeing/needs, pain, vital signs, specific assessments related to neurological, cardiovascular, peripheral vascular, skin, respiratory, gastrointestinal, genitourinary, activity/rest, and wounds/dressings, IV sites, drains/tubes, and oxygen. - Can lead to focused assessment Complete health assessment - Answers Similar to a head-to-toe assessment, but it is more comprehensive. It involves a subjective and objective assessment of all body systems. It provides a full overview of the client's current health status. (30-60 mins) - When client has complex care needs *preformed upon admission to a long-term care home or rehabilitation Broad approaches to health promotion - Answers 1. Behavioural 2. Structural 3. Relational 1. Behavioural - Answers - Focuses on lifestyle and behaviours at the individual level - Ex- behavioural health promotion strategies could include healthy eating, smoking cessation, reducing alcohol consumption, or exercise programs. - This approach to health promotion is based on the ideology of choice - An RN working in a diabetic clinic offers educational sessions to clients with Type II Diabetes on healthy eating to promote balanced blood sugar levels. This is considered a behavioural approach because it focuses on the behavior of the individual with no consideration of context. - Example, this approach does not consider contextual factors such as whether the client has access to healthy food.