NUR 216 Exam 1 Study Guide
,NUR 216 Exam 1 Study Guide
NUR 216 Exam 1 Study Guide: Combined
Questions and Answers
NUR 216 Exam 1 Study Guide
comprehensive assessment - ANSAn assessment that includes a complete health history
and physical assessment; Usually brand new patients
focused assessment - ANSassessment conducted to assess a specific problem; focuses
on pertinent history and body regions
HIPAA - ANSHealth Insurance Portability and Accountability Act
The nursing process - ANSAssessment
Diagnosis
Planning
Implementation
Evaluation
Assessment (ADPIE) - ANSData collection (objective/subjective)
Prioritize Data: Primary (life threatening), Secondary (requires prompt attention), Tertiary
(not urgent)
Planning (ADPIE) - ANSDevelop SMART goals, plan nursing interventions
Implementation (ADPIE) - ANSPerform planned nursing interventions
Evaluation (ADPIE) - ANSWere the goals met? If not, re-assess
assessment skills - ANSInspection
Palpation
Percussion
Auscultation
(Bowels: Inspection, Auscultation, Percussion. Auscultation) Do not want to alter the bowel
sounds
Inspection - ANSObserve for Symmetry, size, color, shape
Direct: Visualize with our eyes
Indirect: Use and instrument
Fingertips/pads: Palpation - ANSFine sensation (texture, swelling, pulsation. lumps)
Dorsa of hands: Palpation - ANSBest for determining temperature
Base of fingers or ulnar surface: - ANSvibrations
Palpation - ANSLight: surface characteristics
,NUR 216 Exam 1 Study Guide
Deep: Organs, masses, tenderness (use intermittent pressure)
Ballpottement: Size/Shape of free floating objects
- Always palpate tender areas last
Percussion - ANStapping on a surface to determine the difference in the density of the un-
derlying structure
Ausculation - ANSlistening to sounds within the body
Bell - ANSlow pitched sounds
(mummers)
Diaphragm - ANShigh pitched sounds
(bowel and lung sounds)
What should we do before leaving the patients room? - ANSPatients safety
Bed to lowest position
Side Rails
Call button and personal belongings in reach
Contextual awareness - ANSUnderstanding the status of the client and the events that led
to their interaction
Analyzing assumptions - ANSEvaluating the client's clinical situation
Exploring alternatives - ANSThe use of holistic approaches for treating the whole person
(physical health, lifestyle choices, culture, living environment, life experiences)
Reflecting and deciding - ANSReflect on the client's goals and decide on the intervention
with client input
Steps for communicating with members of the health care team - ANS1.Identify the mem-
ber by name and title
2.Provide info regarding the current situation
3.Provide info regarding the background situation
4.Give the most recent set of vital signs
5.Provide suggestions that may be helpful to the situation
6.Repeat the orders back that are given to you by the provider
Nonmaleficence - ANSDo no harm
Beneficence - ANSPromote good
Autonomy - ANSthe right to make own choice
Justice - ANSFairness
, NUR 216 Exam 1 Study Guide
Confidentiality - ANSHIPPA
Identify steps to ensure client privacy and safety.
Privacy - ANS-Physical privacy is needed to make the client feel secure.
-Personal privacy: Maintaining confidentiality and ensuring the client has been identified
properly.
-Infection control
-Hand Hygiene
-PPE
5 factors influencing the use of therapeutic communication. - ANS-Maintain professional-
ism
-Maintain a neutral attitude
-Do not impose own values on others
-Practice empathy
-Cultural competence
Therapeutic Communication - ANSan approach to communicate that is both verbal and
nonverbal. Focus on the person and not the problem.
Electronic Records (EHR) - ANSCommunication tools for documenting progress, treat-
ments, interventions, and client responses to care.
Paper Records - ANSMaintain integrity. Properly date and time each entry followed by a
full
signature and title.
9 Types of Nursing Documentation Errors - ANS-Sloppy or illegible handwriting
-Failure to date, time and sign a medical entry
-Lack of documentation
-Incomplete or missing documentation
-Adding entries later on
-Documenting Subjective data
-Not questioning incomprehensive orders
-Using wrong abbreviations
-Entering info into the wrong chart
steps to performing general survey - ANS1.General appearance
2.Behavior
3.Body structure
4.Mobility
5.Measurement
6.Vital signs
7.Pain
approach of the initial survey and assessment - ANSThe initial survey and assessment will
help determine a client's health status. The observation begins right when you step into
the room. While performing the initial
survey be sure to establish trust and build a rapport with the client through therapeutic
communication.
,NUR 216 Exam 1 Study Guide
NUR 216 Exam 1 Study Guide: Combined
Questions and Answers
NUR 216 Exam 1 Study Guide
comprehensive assessment - ANSAn assessment that includes a complete health history
and physical assessment; Usually brand new patients
focused assessment - ANSassessment conducted to assess a specific problem; focuses
on pertinent history and body regions
HIPAA - ANSHealth Insurance Portability and Accountability Act
The nursing process - ANSAssessment
Diagnosis
Planning
Implementation
Evaluation
Assessment (ADPIE) - ANSData collection (objective/subjective)
Prioritize Data: Primary (life threatening), Secondary (requires prompt attention), Tertiary
(not urgent)
Planning (ADPIE) - ANSDevelop SMART goals, plan nursing interventions
Implementation (ADPIE) - ANSPerform planned nursing interventions
Evaluation (ADPIE) - ANSWere the goals met? If not, re-assess
assessment skills - ANSInspection
Palpation
Percussion
Auscultation
(Bowels: Inspection, Auscultation, Percussion. Auscultation) Do not want to alter the bowel
sounds
Inspection - ANSObserve for Symmetry, size, color, shape
Direct: Visualize with our eyes
Indirect: Use and instrument
Fingertips/pads: Palpation - ANSFine sensation (texture, swelling, pulsation. lumps)
Dorsa of hands: Palpation - ANSBest for determining temperature
Base of fingers or ulnar surface: - ANSvibrations
Palpation - ANSLight: surface characteristics
,NUR 216 Exam 1 Study Guide
Deep: Organs, masses, tenderness (use intermittent pressure)
Ballpottement: Size/Shape of free floating objects
- Always palpate tender areas last
Percussion - ANStapping on a surface to determine the difference in the density of the un-
derlying structure
Ausculation - ANSlistening to sounds within the body
Bell - ANSlow pitched sounds
(mummers)
Diaphragm - ANShigh pitched sounds
(bowel and lung sounds)
What should we do before leaving the patients room? - ANSPatients safety
Bed to lowest position
Side Rails
Call button and personal belongings in reach
Contextual awareness - ANSUnderstanding the status of the client and the events that led
to their interaction
Analyzing assumptions - ANSEvaluating the client's clinical situation
Exploring alternatives - ANSThe use of holistic approaches for treating the whole person
(physical health, lifestyle choices, culture, living environment, life experiences)
Reflecting and deciding - ANSReflect on the client's goals and decide on the intervention
with client input
Steps for communicating with members of the health care team - ANS1.Identify the mem-
ber by name and title
2.Provide info regarding the current situation
3.Provide info regarding the background situation
4.Give the most recent set of vital signs
5.Provide suggestions that may be helpful to the situation
6.Repeat the orders back that are given to you by the provider
Nonmaleficence - ANSDo no harm
Beneficence - ANSPromote good
Autonomy - ANSthe right to make own choice
Justice - ANSFairness
, NUR 216 Exam 1 Study Guide
Confidentiality - ANSHIPPA
Identify steps to ensure client privacy and safety.
Privacy - ANS-Physical privacy is needed to make the client feel secure.
-Personal privacy: Maintaining confidentiality and ensuring the client has been identified
properly.
-Infection control
-Hand Hygiene
-PPE
5 factors influencing the use of therapeutic communication. - ANS-Maintain professional-
ism
-Maintain a neutral attitude
-Do not impose own values on others
-Practice empathy
-Cultural competence
Therapeutic Communication - ANSan approach to communicate that is both verbal and
nonverbal. Focus on the person and not the problem.
Electronic Records (EHR) - ANSCommunication tools for documenting progress, treat-
ments, interventions, and client responses to care.
Paper Records - ANSMaintain integrity. Properly date and time each entry followed by a
full
signature and title.
9 Types of Nursing Documentation Errors - ANS-Sloppy or illegible handwriting
-Failure to date, time and sign a medical entry
-Lack of documentation
-Incomplete or missing documentation
-Adding entries later on
-Documenting Subjective data
-Not questioning incomprehensive orders
-Using wrong abbreviations
-Entering info into the wrong chart
steps to performing general survey - ANS1.General appearance
2.Behavior
3.Body structure
4.Mobility
5.Measurement
6.Vital signs
7.Pain
approach of the initial survey and assessment - ANSThe initial survey and assessment will
help determine a client's health status. The observation begins right when you step into
the room. While performing the initial
survey be sure to establish trust and build a rapport with the client through therapeutic
communication.
