Adult Health Exam 1 (A+ Guaranteed)
steps of the nursing process correct answers 1. Assessment
2. Diagnosis
3. Planning
4. Implementation
5. Evaluation
Assessment correct answers collects data, Subjective data - what the patient Says or feels,
OBjective data - what the nurse OBserves and measures
Diagnosis correct answers analyze data, identify health problems, risk and strengths, formulates
nursing diagnoses.
Problem-focused diagnosis correct answers 1. NANDA approved
2. r/t what is causing the problem
3. AEB what data supports it
Ineffective airway clearance r/t fatigue AEB dyspnea at rest
Risk diagnosis correct answers 1. NANDA approved
2. AEB what data supports it
Risk for falls AEB steady gait
Health promotion diagnosis correct answers 1. NANDA approved
2. AEB what data supports it
Readiness for enhanced self-care AEB expressed desire to enhance self-care
Planning correct answers prioritize diagnoses, develop outcomes, plan interventions that make
sense for your patient
Implementation correct answers nurse initiated treatments, health care provider-initiated
treatments, direct & indirect care
Evaluation correct answers examine results, see if patients are reaching outcomes, recognize
errors, modify care plan if necessary
SMART goal correct answers Specific, Measurable, Achievable, Realistic, Timely
specific correct answers goal is detailed and exact. Answers who, what, when, where, why and
which
measurable correct answers track your progress and know exactly when your goal is met, usually
involves numbers
, achievable correct answers it is reasonable, not completely out of reach or too easy
realistic correct answers goal is worthwhile, something that is important to you right now
timely correct answers goal will be accomplished in a set time frame such as two weeks, three
months or one year
Prioritization correct answers ABC's (airways, breathing, circulation), Maslow's hierarchy
(ABC's, safety, pain, education, feelings)(basic needs, psychological needs, self-fulfillment
needs)
standard precautions correct answers hand hygiene, gown, gloves, goggles, mask
Hand hygiene correct answers alcohol based, soap and water (MUST use soap and water when
hands are visibly soiled or working with C. Diff)
1. Before touching a patient
2. Before clean/aseptic procedure
3. After body fluid exposure risk
4. After touching a patient
5. After touching patient surroundings
Gloves correct answers use when touching blood, body fluids, secretions, excretions,
contaminated items; for touching mucus membranes and nonintact skin
Gown correct answers use during procedures and patient care activities when contact of clothing/
exposed skin with blood/body fluids, secretions or excretions is anticipated
mask/goggles/face shield correct answers use during patient care activities likely to generate
splashes or sprays of blood, body fluids, secretions or excretions
isolation precautions correct answers contact, droplet and airborne
Contact correct answers private room, gloves, gown
contact examples correct answers VRE, MRSA, C. diff, herpes, scabies, RSV, shigella, major
wound infections, varicella zoster, respiratory syncytial virus, chickenpox
Droplet correct answers private room, mask or respirator
droplet examples correct answers Influenza, RSV, rubella, mumps, pneumonia, pertussis, group
a strep, adenovirus, neisseria meningitidis, rhinovirus, mycoplasma pneumonia, diphtheria,
pneumonia plague, respiratory syncytial virus
Airborne correct answers private room, negative pressure room, n95 mask
steps of the nursing process correct answers 1. Assessment
2. Diagnosis
3. Planning
4. Implementation
5. Evaluation
Assessment correct answers collects data, Subjective data - what the patient Says or feels,
OBjective data - what the nurse OBserves and measures
Diagnosis correct answers analyze data, identify health problems, risk and strengths, formulates
nursing diagnoses.
Problem-focused diagnosis correct answers 1. NANDA approved
2. r/t what is causing the problem
3. AEB what data supports it
Ineffective airway clearance r/t fatigue AEB dyspnea at rest
Risk diagnosis correct answers 1. NANDA approved
2. AEB what data supports it
Risk for falls AEB steady gait
Health promotion diagnosis correct answers 1. NANDA approved
2. AEB what data supports it
Readiness for enhanced self-care AEB expressed desire to enhance self-care
Planning correct answers prioritize diagnoses, develop outcomes, plan interventions that make
sense for your patient
Implementation correct answers nurse initiated treatments, health care provider-initiated
treatments, direct & indirect care
Evaluation correct answers examine results, see if patients are reaching outcomes, recognize
errors, modify care plan if necessary
SMART goal correct answers Specific, Measurable, Achievable, Realistic, Timely
specific correct answers goal is detailed and exact. Answers who, what, when, where, why and
which
measurable correct answers track your progress and know exactly when your goal is met, usually
involves numbers
, achievable correct answers it is reasonable, not completely out of reach or too easy
realistic correct answers goal is worthwhile, something that is important to you right now
timely correct answers goal will be accomplished in a set time frame such as two weeks, three
months or one year
Prioritization correct answers ABC's (airways, breathing, circulation), Maslow's hierarchy
(ABC's, safety, pain, education, feelings)(basic needs, psychological needs, self-fulfillment
needs)
standard precautions correct answers hand hygiene, gown, gloves, goggles, mask
Hand hygiene correct answers alcohol based, soap and water (MUST use soap and water when
hands are visibly soiled or working with C. Diff)
1. Before touching a patient
2. Before clean/aseptic procedure
3. After body fluid exposure risk
4. After touching a patient
5. After touching patient surroundings
Gloves correct answers use when touching blood, body fluids, secretions, excretions,
contaminated items; for touching mucus membranes and nonintact skin
Gown correct answers use during procedures and patient care activities when contact of clothing/
exposed skin with blood/body fluids, secretions or excretions is anticipated
mask/goggles/face shield correct answers use during patient care activities likely to generate
splashes or sprays of blood, body fluids, secretions or excretions
isolation precautions correct answers contact, droplet and airborne
Contact correct answers private room, gloves, gown
contact examples correct answers VRE, MRSA, C. diff, herpes, scabies, RSV, shigella, major
wound infections, varicella zoster, respiratory syncytial virus, chickenpox
Droplet correct answers private room, mask or respirator
droplet examples correct answers Influenza, RSV, rubella, mumps, pneumonia, pertussis, group
a strep, adenovirus, neisseria meningitidis, rhinovirus, mycoplasma pneumonia, diphtheria,
pneumonia plague, respiratory syncytial virus
Airborne correct answers private room, negative pressure room, n95 mask
