VERIFIED AND WELL DETAILED ANSWERS | LATEST EXAM
UPDATE 2026/2027
Noticing - CORRECT ANSWER- Indicate when a situation is normal,
abnormal or has changed. Get an initial grasp on the situation
Application to thinking noticing - CORRECT ANSWER- Collect: Subjective
& objective data
VS, Complaints, self-described symptoms. What the nurse notices, such as
rashes, swelling, bruising, etc.
Identifying signs and symptoms - CORRECT ANSWER- Noticing
Gathering Complete and Accurate Data - CORRECT ANSWER- Noticing
Assessing Systematically and Comprehensively - CORRECT ANSWER-
Noticing
Predicting (and Managing) Potential Complications - CORRECT ANSWER-
Noticing
Identifying Assumptions - CORRECT ANSWER- Noticing
5 concepts of critical thinking - CORRECT ANSWER- Standards Attitudes
Competencies Experience Specific Knowledge Base
,Nursing Process - CORRECT ANSWER- The nursing process is a variation of
scientific reasoning that involves five steps: assessment, nursing diagnosis,
planning, implementation, and evaluation.Assess (collection verification of data
and analysis of data) Diagnose, Plan, Implement, Evaluate
cue - CORRECT ANSWER- obtain information that you obtain through sense.
(Lies still with arms along side: tense. States has not turned in some time.
Reports pain a 7 and on scale of 0-10)
Sources of Data - CORRECT ANSWER- Patient, family and significant other,
health care team, medical records, other records and scientific literature
An initial patient-centered interview involves - CORRECT ANSWER- (1)
setting the stage, (2) gathering information about the patient's problems and
setting an agenda, (3) collecting the assessment or a nursing health history, and
(4) terminating the interview.
A nurse assesses a patient who comes to the pulmonary clinic. "I see that it's
been over 6 months since you've been here, but your appointment was for every
2 months. Tell me about that. Also I see from your last visit that the doctor
recommended routine exercise. Can you tell me how successful you've been in
following his plan?" The nurse's assessment covers which of Gordon's
functional health patterns? - CORRECT ANSWER- Health perception-health
management pattern
The nurse observes a patient walking down the hall with a shuffling gait. When
the patient returns to bed, the nurse checks the strength in both of the patient's
legs. The nurse applies the information gained to suspect that the patient has a
mobility problem. This conclusion is an example of: - CORRECT ANSWER-
Clinical inference.
A 72-year-old male patient comes to the health clinic for an annual follow-up.
The nurse enters the patient's room and notices him to be diaphoretic, holding
,his chest and breathing with difficulty. The nurse immediately checks the
patient's heart rate and blood pressure and asks him, "Tell me where your pain
is." Which of the following assessment approaches does this scenario describe?
- CORRECT ANSWER- A problem-oriented approach
The nurse asks a patient, "Describe for me a typical night's sleep. What do you
do to fall asleep? Do you have difficulty falling or staying asleep? This series of
questions would likely occur during which phase of a patient-centered
interview? - CORRECT ANSWER- Working phase
A nurse is assigned to a 42-year-old mother of 4 who weighs 136.2 kg (300 lbs),
has diabetes, and works part time in the kitchen of a restaurant. The patient is
facing surgery for gallbladder disease. Which of the following approaches
demonstrates the nurse's cultural competence in assessing the patient's health
care problems? - CORRECT ANSWER- "You have four children; do you have
any concerns about going home and caring for them?"
A nurse is checking a patient's intravenous line and, while doing so, notices how
the patient bathes himself and then sits on the side of the bed independently to
put on a new gown. This observation is an example of assessing: - CORRECT
ANSWER- Patient's level of function.
A patient who visits the surgery clinic 4 weeks after a traumatic amputation of
his right leg tells the nurse practitioner that he is worried about his ability to
continue to support his family. He tells the nurse he feels that he has let his
family down after having an auto accident that led to the loss of his left leg. The
nurse listens and then asks the patient, "How do you see yourself now?" On the
basis of Gordon's functional health patterns, which pattern does the nurse assess
- CORRECT ANSWER- Self-perception-self-concept pattern
During a visit to the clinic, a patient tells the nurse that he has been having
headaches on and off for a week. The headaches sometimes make him feel
nauseated. Which of the following responses by the nurse is an example of
probing? - CORRECT ANSWER- Tell me what makes your headaches begin.
, Steps of NOTICING - CORRECT ANSWER- Identifying Assumptions
Predicting (and Managing) Potential Complications
Assessing Systematically and Comprehensively
Gathering Complete and Accurate Data
Identifying signs and symptoms
SPICES tool - CORRECT ANSWER- sleep problems, problems with eating
and feeding, incontinence, confusion, evidence of falls, and skin breakdown.
Noticing-Identifying signs and symptoms - CORRECT ANSWER- Ability to
identify signs and symptoms indicating a situation is different, changed or not of
normal state.
Noticing-Gathering complete and accurate data - CORRECT ANSWER-
When assessing a situation it is important to gather complete and accurate data.
The data is used as the basis for identifying problems, issues and concerns,
solving problems and making decisions.
Noticing-Assessing systematically and comprehensively - CORRECT
ANSWER- Nurses use a systematic method such as body systems, a head to toe
approach or focused assessment.
Noticing-Predicting and managing potential complications - CORRECT
ANSWER- Nurses must look at the big picture to predict potential
complications that may exist for individual patients
Noticing-identifying assumptions - CORRECT ANSWER- Taking something
for granted or hastily arriving at a conclusion without supporting evidence.