Unit 2 - Nursing Process UPDATED
ACTUAL Questions and CORRECT
Answers
Assessment - CORRECT ANSWER - is the systematic and continuous collection of data about a
client for the purpose of determining the client's current and ongoing health status, predicting the client's
risks to health and identifying appropriate health-promotion activities.
Collect, Organize, Validate, and Document Data.
Assessment - Critical Thinking Activities - CORRECT ANSWER - - Making reliable observations
- Distinguishing relevant from irrelevant data
- Distinguishing important from unimportant data
- Validating data
- Organizing data
- Recognizing assumptions
- Identifying gaps in the data
4 Types of Assessments - CORRECT ANSWER - - Initial Assessment
- Problem-Focused Assessment
- Emergency Assessment
- Time-Lapsed Reassessment
Initial (baseline) Assessment - CORRECT ANSWER - - Performed within specific time frame after
admission to a health agency (refer to agency policy and procedure)
- Purpose is to establish a complete baseline for problem identification, reference, and future comparison.
- An example would be a nursing admission assessment
, Problem-Focused (System Specific) Assessment - CORRECT ANSWER - - Ongoing process
integrated with nursing care
- Purpose is to determine the status of a specific problem identified in an earlier assessment.
- Hourly assessments of client's fluid intake and urinary output in an intensive care unit (ICU).
Assessment of a client's ability to perform self-care while assisting a client to bathe.
Emergency Assessment - CORRECT ANSWER - - During any physiologic or psychologic crisis.
- To identify life-threatening problems.
- To identify new or overlooked problems.
- Rapid assessment of a person's airway, breathing status, and circulation during a cardiac arrest.
Assessment of suicidal tendencies or potential for violence.
Ongoing Reassessment - CORRECT ANSWER - - Several months after initial assessment.
- To compare the client's current status to baseline data previously obtained.
- Reassessment of a client's functional health patterns in a home care or outpatient setting or, in a hospital,
at shift change.
Assessment Situation 1 - CORRECT ANSWER - Situation: Client complains of abdominal pain
Physical Assessment: Inspect, auscultate, and palpate abdomen; assess vital signs.
Assessment Situation 2 - CORRECT ANSWER - Situation: Client is admitted with a head injury.
Physical Assessment: assess level of consciousness using the Glasgow Coma Scale; assess pupils for
reaction to light and accommodation; assess vital signs.
Assessment Situation 3 - CORRECT ANSWER - Situation: the nurse prepares to administer a
cardiotonic drug to a client
Physical Assessment: Assess apical pule and compare with baseline data.
ACTUAL Questions and CORRECT
Answers
Assessment - CORRECT ANSWER - is the systematic and continuous collection of data about a
client for the purpose of determining the client's current and ongoing health status, predicting the client's
risks to health and identifying appropriate health-promotion activities.
Collect, Organize, Validate, and Document Data.
Assessment - Critical Thinking Activities - CORRECT ANSWER - - Making reliable observations
- Distinguishing relevant from irrelevant data
- Distinguishing important from unimportant data
- Validating data
- Organizing data
- Recognizing assumptions
- Identifying gaps in the data
4 Types of Assessments - CORRECT ANSWER - - Initial Assessment
- Problem-Focused Assessment
- Emergency Assessment
- Time-Lapsed Reassessment
Initial (baseline) Assessment - CORRECT ANSWER - - Performed within specific time frame after
admission to a health agency (refer to agency policy and procedure)
- Purpose is to establish a complete baseline for problem identification, reference, and future comparison.
- An example would be a nursing admission assessment
, Problem-Focused (System Specific) Assessment - CORRECT ANSWER - - Ongoing process
integrated with nursing care
- Purpose is to determine the status of a specific problem identified in an earlier assessment.
- Hourly assessments of client's fluid intake and urinary output in an intensive care unit (ICU).
Assessment of a client's ability to perform self-care while assisting a client to bathe.
Emergency Assessment - CORRECT ANSWER - - During any physiologic or psychologic crisis.
- To identify life-threatening problems.
- To identify new or overlooked problems.
- Rapid assessment of a person's airway, breathing status, and circulation during a cardiac arrest.
Assessment of suicidal tendencies or potential for violence.
Ongoing Reassessment - CORRECT ANSWER - - Several months after initial assessment.
- To compare the client's current status to baseline data previously obtained.
- Reassessment of a client's functional health patterns in a home care or outpatient setting or, in a hospital,
at shift change.
Assessment Situation 1 - CORRECT ANSWER - Situation: Client complains of abdominal pain
Physical Assessment: Inspect, auscultate, and palpate abdomen; assess vital signs.
Assessment Situation 2 - CORRECT ANSWER - Situation: Client is admitted with a head injury.
Physical Assessment: assess level of consciousness using the Glasgow Coma Scale; assess pupils for
reaction to light and accommodation; assess vital signs.
Assessment Situation 3 - CORRECT ANSWER - Situation: the nurse prepares to administer a
cardiotonic drug to a client
Physical Assessment: Assess apical pule and compare with baseline data.
