NSG 3160 Exam 1 Study Guide | 2026 Latest Update
with Complete Solution - Galen College of Nursing
Rapport - a close and harmonious relationship in which the people or groups concerned understand
each other's feelings or ideas and communicate well.
UNIT 1:
Chapter 1 Evidence-Based Assessment
● Assessment is the collection of data about the individual’s health state. The purpose of
assessment is to make a judgment or diagnosis.
○ Subjective Data = What the patient says during history taking.
○ Objective Data = What you as the health professional observe by inspecting, percussing,
palpating, and auscultating during the physical examination.
● Diagnostic Reasoning is the process of analyzing health data and drawing conclusions to identify
diagnoses.
● Cluster or group together assessment data that appear casual or associated.
● A ‘Cue’ is a piece of information, a sign or symptom, or a piece of laboratory or imaging data.
○ For example, elevated heart rate, blood pressure, and respiration may be associated with
anxiety.
● Abductive Reasoning is thinking to determine the best explanation with the information at hand.
This hypothesis is based on incomplete data; therefore, you must complete your assessment and
move to deductive and inductive reasoning.
● In deductive reasoning, you will draw on general principles from physiology and pathology.
● In inductive reasoning, you will use signs and symptoms as a guide. Using logical reasoning,
you will be able to gather the information necessary and use your previous knowledge to
effectively care for patients.
● The nursing process is a five-step process that includes assessment, diagnosis, planning,
implementation, and evaluation.
○ During the assessment phase, you will gather the data from the medical record and
patient and complete an assessment.
○ As you move to the diagnosis phase, clinical findings are interpreted and clinical
judgment is used to determine a diagnosis.
○ In the planning phase, you will formulate goals and outcomes in collaboration with the
patient.
○ Once planning is complete, you will implement the plan and evaluate the results.
● First-level priority problems are those that are emergent, life-threatening, and immediate, such
as establishing an airway or supporting breathing.
○ Airway, breathing, circulation
● Second-level priority problems are those that are next in urgency–those requiring your proper
intervention to forestall further deterioration
○ Mental status change, acute pain, acute urinary elimination problems, untreated medical
problems, abnormal laboratory values, risks of infection, or risk to safety or security
● Third-level priority problems are those that are important to the patient’s health but can be
attended to after more urgent health problems are addressed. Interventions to treat these problems
are long-term, and the response to treatment is expected to take more time. These problems may
require a collaborative effort between the patient and healthcare professionals.
○ Lack of knowledge, mobility problems, and family coping
● Evidence-Based Practice = The conviction that all patients deserve to be treated with the most
current and best-practice techniques.
,Collecting Four Types of Patient Data
● Complete (Total health) Database
○ This includes a complete health history and a full physical examination. It describes the
current and past health state and yields the first diagnoses.
○ The complete database is often collected in a primary care setting. When you work in
these settings, you are the first health professional to see the patient and have primary
responsibility for monitoring the person’s health care.
○ The complete database must screen for pathology and determine the ways people respond
to that pathology or to any health problem.
● Focused or Problem-Centered Database
○ For limited or short-term problems.
○ It concerns mainly one problem, one cue complex, or one body system.
○ For example, a person presents with a rash. The history follows the direction of this
presenting concern such as whether the rash had an acute or chronic onset; was associated
with a fever, new food, pet, or medicine; and was localized or generalized.
● Follow-Up Database
○ The status of any identified problems should be evaluated at regular and appropriate
intervals. What change has occurred? Is the problem getting better or worse? Which
coping strategies are used?
○ For example, a patient with heart failure may follow up with his or her primary care
practitioner at regular intervals to reevaluate medications, identify changes in symptoms,
and discuss coping strategies.
● Emergency Database
○ Urgent, rapid collection of crucial information and often is complied concurrently with
lifesaving measures.
○ For example, a person is brought into an ED with a suspected substance overdose. The
first history question are “What did you take?” “How much did you take?” and “When?”
The person is questioned simultaneously while airway, breathing, circulation, LOC, and
disabilities are being assessed.
○ Once the person has been stabilized, a complete database can be compiled.
○ An emergency database may be compiled by questioning the patient, or if the patient is
unresponsive, healthcare providers may need to rely on family and friends.
Comprehensive Health Care
● Holistic Health views the mind, body, and spirit as interdependent and functioning as a whole
within the environment.
○ You must involve your patient throughout the process and work with them as you plan
interventions. Establishing a collaborative relationship is essential.
● Social determinants of health are factors that influence a person’s health and well-being. They
include the environment, access to health care, community, education, and economic stability.
○ For example, you have an outpatient who consistently misses appointments. Instead of
assuming noncompliance or lack of desire to seek health care, talk to the patient about
barriers. Perhaps they lack reliable transportation and your clinic is in an area that is not
serviced by public transportation.
Chapter 3: The Interview
● Subjective Data = What the person says
● Objective Data = What you obtain through physical examination
, ○ Although the purpose of the interview isn’t to collect objective data, you will collect
some objective data as you note the person’s posture, physical appearance, ability to
carry on a conversation, and overall demeanor.
● During the interview, the client remains in charge. The individual knows everything about their
own health state, and you know nothing.
The Process of Communication
● Sending:
○ Non-verbal communication is as important as verbal communication.
○ This is your body language—posture, gestures, facial expression, eye contact, foot
tapping, touch, and even where you place your chair.
○ Because nonverbal communication is under less conscious control than verbal
communication, it may be more reflective of true feelings.
● Receiving:
○ Although you have a specific meaning in mind, the receiver may not understand the
message as it was meant. The receiver interprets your words, and the interpretation may
be different than your intended meaning.
○ It takes mutual understanding by the sender and receiver to have successful
communication.
○ Do not assume. Always confirm that the receiver understands what you are saying.
○ Even greater risk for misunderstanding exists in the health care setting than in a social
setting. The client’s frame of reference is narrowed and focused on illness. It intensifies
the communication because the person feels dependent on you to get better.
● Internal factors are those specific to you. You need to focus on the four inner factors of liking
others, empathy, the ability to listen, and self-awareness.
● Liking Others:
○ An atmosphere of warmth and caring is necessary, and clients must believe that they are
accepted unconditionally.
○ Your goal is to help clients be increasingly responsible for themselves and to promote the
personal growth of clients by providing appropriate resources.
● Empathy:
○ Empathy means viewing the world from the other person’s inner frame of reference while
remaining with you. It is a recognition and acceptance of the other person’s feelings
without criticism.
○ Empathy is described as the ability to understand and be sensitive to the feelings of others
and to recognize how they perceive the world
● The Ability to Listen:
○ Listening requires complete and focused attention. You are not only hearing the person’s
words but also interpreting their meaning, asking follow-up questions, and ensuring a
thorough understanding of what the person is telling you.
○ Be aware of nonverbal communication and ask follow-up questions, but do not interrupt.
● Self-Awareness:
○ Understanding your personal biases, prejudices, and stereotypes is an important part of
developing your skills as an interviewer.
○ By knowing your behaviors and responses, you become aware of how some unintentional
actions can have a negative impact on your communication.
● External Factors include preparing the physical setting. The setting may be in a hospital room,
an examination room in an office or clinic, or the person’s home.
● Ensure Privacy:
, ○ If geographic privacy is unavailable, create “psychological privacy”, using curtained
partitions, but make sure that the person feels comfortable with the privacy provided.
○ Privacy extends to ensuring that the client is comfortable with the people in the room.
● Refuse Interruptions:
○ Most people resent interruptions except in cases of an emergency. An interruption can
destroy in seconds what you have spent many minutes building up.
○ If you anticipate an interruption, let the person know ahead of time. Inform colleagues of
the interview and the need to minimize interruptions.
● Physical Environment:
○ Set the room temp. at a comfortable level.
○ Provide sufficient lighting so that you can see each other clearly, but avoid strong, direct
lighting.
○ Secure a quiet environment.
○ Remove distracting objects or equipment or clutter
○ Place the distance between you and the client at 4 to 5 feet.
○ Arrange equal-status seating. Both you and the client should be comfortably seated, at
eye level. Placing the chairs at 90 degrees is good because it allows the person to either
face you or to look straight ahead from time to time.
○ Make sure you avoid facing a client across a desk.
○ AVOID standing. Standing makes you loom over the client as an authority figure.
○ When interviewing a hospitalized bedridden person, arrange a face-to-face position, and
avoid standing over them.
● Dress:
○ The client should remain in street clothes during the interview except in an emergency. A
hospital gown causes a power differential and may make the person feel exposed and
uncomfortable.
○ Your appearance and clothing should be appropriate to the setting and should meet
conventional professional standards: a uniform or lab coat over conservative clothing, a
name tag, and neat hair. Avoid extremes.
● Note-Taking:
○ Excessive note-taking during the interview has disadvantages:
■ it breaks eye contact too often.
■ it shifts your attention away from the person, diminishing their sense of
importance
■ recording everything a person says may cause you to ask them to slow down, or
the person may slow down to aid in note-taking
■ it impedes your observation of the client’s nonverbal behavior.
■ it is threatening to the client during the discussion of sensitive issues
● EHR:
○ Do not let the computer screen become a barrier between you and the client.
○ Explain the computerized charting, and position the monitor so that the client can see it.
Techniques of Communication
● Unless the client directs you otherwise, avoid using the first name during the interview.
● The working phase is the data-gathering phase. Verbal skills for this phase include your ability to
form questions appropriately and your responses to the answers given by the client. You will
likely use a combination of open-ended and closed questions during the interview.
Open-ended questions and Closed/Direct Questions
with Complete Solution - Galen College of Nursing
Rapport - a close and harmonious relationship in which the people or groups concerned understand
each other's feelings or ideas and communicate well.
UNIT 1:
Chapter 1 Evidence-Based Assessment
● Assessment is the collection of data about the individual’s health state. The purpose of
assessment is to make a judgment or diagnosis.
○ Subjective Data = What the patient says during history taking.
○ Objective Data = What you as the health professional observe by inspecting, percussing,
palpating, and auscultating during the physical examination.
● Diagnostic Reasoning is the process of analyzing health data and drawing conclusions to identify
diagnoses.
● Cluster or group together assessment data that appear casual or associated.
● A ‘Cue’ is a piece of information, a sign or symptom, or a piece of laboratory or imaging data.
○ For example, elevated heart rate, blood pressure, and respiration may be associated with
anxiety.
● Abductive Reasoning is thinking to determine the best explanation with the information at hand.
This hypothesis is based on incomplete data; therefore, you must complete your assessment and
move to deductive and inductive reasoning.
● In deductive reasoning, you will draw on general principles from physiology and pathology.
● In inductive reasoning, you will use signs and symptoms as a guide. Using logical reasoning,
you will be able to gather the information necessary and use your previous knowledge to
effectively care for patients.
● The nursing process is a five-step process that includes assessment, diagnosis, planning,
implementation, and evaluation.
○ During the assessment phase, you will gather the data from the medical record and
patient and complete an assessment.
○ As you move to the diagnosis phase, clinical findings are interpreted and clinical
judgment is used to determine a diagnosis.
○ In the planning phase, you will formulate goals and outcomes in collaboration with the
patient.
○ Once planning is complete, you will implement the plan and evaluate the results.
● First-level priority problems are those that are emergent, life-threatening, and immediate, such
as establishing an airway or supporting breathing.
○ Airway, breathing, circulation
● Second-level priority problems are those that are next in urgency–those requiring your proper
intervention to forestall further deterioration
○ Mental status change, acute pain, acute urinary elimination problems, untreated medical
problems, abnormal laboratory values, risks of infection, or risk to safety or security
● Third-level priority problems are those that are important to the patient’s health but can be
attended to after more urgent health problems are addressed. Interventions to treat these problems
are long-term, and the response to treatment is expected to take more time. These problems may
require a collaborative effort between the patient and healthcare professionals.
○ Lack of knowledge, mobility problems, and family coping
● Evidence-Based Practice = The conviction that all patients deserve to be treated with the most
current and best-practice techniques.
,Collecting Four Types of Patient Data
● Complete (Total health) Database
○ This includes a complete health history and a full physical examination. It describes the
current and past health state and yields the first diagnoses.
○ The complete database is often collected in a primary care setting. When you work in
these settings, you are the first health professional to see the patient and have primary
responsibility for monitoring the person’s health care.
○ The complete database must screen for pathology and determine the ways people respond
to that pathology or to any health problem.
● Focused or Problem-Centered Database
○ For limited or short-term problems.
○ It concerns mainly one problem, one cue complex, or one body system.
○ For example, a person presents with a rash. The history follows the direction of this
presenting concern such as whether the rash had an acute or chronic onset; was associated
with a fever, new food, pet, or medicine; and was localized or generalized.
● Follow-Up Database
○ The status of any identified problems should be evaluated at regular and appropriate
intervals. What change has occurred? Is the problem getting better or worse? Which
coping strategies are used?
○ For example, a patient with heart failure may follow up with his or her primary care
practitioner at regular intervals to reevaluate medications, identify changes in symptoms,
and discuss coping strategies.
● Emergency Database
○ Urgent, rapid collection of crucial information and often is complied concurrently with
lifesaving measures.
○ For example, a person is brought into an ED with a suspected substance overdose. The
first history question are “What did you take?” “How much did you take?” and “When?”
The person is questioned simultaneously while airway, breathing, circulation, LOC, and
disabilities are being assessed.
○ Once the person has been stabilized, a complete database can be compiled.
○ An emergency database may be compiled by questioning the patient, or if the patient is
unresponsive, healthcare providers may need to rely on family and friends.
Comprehensive Health Care
● Holistic Health views the mind, body, and spirit as interdependent and functioning as a whole
within the environment.
○ You must involve your patient throughout the process and work with them as you plan
interventions. Establishing a collaborative relationship is essential.
● Social determinants of health are factors that influence a person’s health and well-being. They
include the environment, access to health care, community, education, and economic stability.
○ For example, you have an outpatient who consistently misses appointments. Instead of
assuming noncompliance or lack of desire to seek health care, talk to the patient about
barriers. Perhaps they lack reliable transportation and your clinic is in an area that is not
serviced by public transportation.
Chapter 3: The Interview
● Subjective Data = What the person says
● Objective Data = What you obtain through physical examination
, ○ Although the purpose of the interview isn’t to collect objective data, you will collect
some objective data as you note the person’s posture, physical appearance, ability to
carry on a conversation, and overall demeanor.
● During the interview, the client remains in charge. The individual knows everything about their
own health state, and you know nothing.
The Process of Communication
● Sending:
○ Non-verbal communication is as important as verbal communication.
○ This is your body language—posture, gestures, facial expression, eye contact, foot
tapping, touch, and even where you place your chair.
○ Because nonverbal communication is under less conscious control than verbal
communication, it may be more reflective of true feelings.
● Receiving:
○ Although you have a specific meaning in mind, the receiver may not understand the
message as it was meant. The receiver interprets your words, and the interpretation may
be different than your intended meaning.
○ It takes mutual understanding by the sender and receiver to have successful
communication.
○ Do not assume. Always confirm that the receiver understands what you are saying.
○ Even greater risk for misunderstanding exists in the health care setting than in a social
setting. The client’s frame of reference is narrowed and focused on illness. It intensifies
the communication because the person feels dependent on you to get better.
● Internal factors are those specific to you. You need to focus on the four inner factors of liking
others, empathy, the ability to listen, and self-awareness.
● Liking Others:
○ An atmosphere of warmth and caring is necessary, and clients must believe that they are
accepted unconditionally.
○ Your goal is to help clients be increasingly responsible for themselves and to promote the
personal growth of clients by providing appropriate resources.
● Empathy:
○ Empathy means viewing the world from the other person’s inner frame of reference while
remaining with you. It is a recognition and acceptance of the other person’s feelings
without criticism.
○ Empathy is described as the ability to understand and be sensitive to the feelings of others
and to recognize how they perceive the world
● The Ability to Listen:
○ Listening requires complete and focused attention. You are not only hearing the person’s
words but also interpreting their meaning, asking follow-up questions, and ensuring a
thorough understanding of what the person is telling you.
○ Be aware of nonverbal communication and ask follow-up questions, but do not interrupt.
● Self-Awareness:
○ Understanding your personal biases, prejudices, and stereotypes is an important part of
developing your skills as an interviewer.
○ By knowing your behaviors and responses, you become aware of how some unintentional
actions can have a negative impact on your communication.
● External Factors include preparing the physical setting. The setting may be in a hospital room,
an examination room in an office or clinic, or the person’s home.
● Ensure Privacy:
, ○ If geographic privacy is unavailable, create “psychological privacy”, using curtained
partitions, but make sure that the person feels comfortable with the privacy provided.
○ Privacy extends to ensuring that the client is comfortable with the people in the room.
● Refuse Interruptions:
○ Most people resent interruptions except in cases of an emergency. An interruption can
destroy in seconds what you have spent many minutes building up.
○ If you anticipate an interruption, let the person know ahead of time. Inform colleagues of
the interview and the need to minimize interruptions.
● Physical Environment:
○ Set the room temp. at a comfortable level.
○ Provide sufficient lighting so that you can see each other clearly, but avoid strong, direct
lighting.
○ Secure a quiet environment.
○ Remove distracting objects or equipment or clutter
○ Place the distance between you and the client at 4 to 5 feet.
○ Arrange equal-status seating. Both you and the client should be comfortably seated, at
eye level. Placing the chairs at 90 degrees is good because it allows the person to either
face you or to look straight ahead from time to time.
○ Make sure you avoid facing a client across a desk.
○ AVOID standing. Standing makes you loom over the client as an authority figure.
○ When interviewing a hospitalized bedridden person, arrange a face-to-face position, and
avoid standing over them.
● Dress:
○ The client should remain in street clothes during the interview except in an emergency. A
hospital gown causes a power differential and may make the person feel exposed and
uncomfortable.
○ Your appearance and clothing should be appropriate to the setting and should meet
conventional professional standards: a uniform or lab coat over conservative clothing, a
name tag, and neat hair. Avoid extremes.
● Note-Taking:
○ Excessive note-taking during the interview has disadvantages:
■ it breaks eye contact too often.
■ it shifts your attention away from the person, diminishing their sense of
importance
■ recording everything a person says may cause you to ask them to slow down, or
the person may slow down to aid in note-taking
■ it impedes your observation of the client’s nonverbal behavior.
■ it is threatening to the client during the discussion of sensitive issues
● EHR:
○ Do not let the computer screen become a barrier between you and the client.
○ Explain the computerized charting, and position the monitor so that the client can see it.
Techniques of Communication
● Unless the client directs you otherwise, avoid using the first name during the interview.
● The working phase is the data-gathering phase. Verbal skills for this phase include your ability to
form questions appropriately and your responses to the answers given by the client. You will
likely use a combination of open-ended and closed questions during the interview.
Open-ended questions and Closed/Direct Questions
