Questions and Verified Answers
Indicate when a situation is normal, abnormal or has changed. Get an initial grasp on the
situation - correct answer ✔✔Noticing
Collect: Subjective & objective data
VS, Complaints, self-described symptoms. What nurse notices, such as rashes, swelling, bruising,
etc - correct answer ✔✔Application to thinking noticing
Noticing - correct answer ✔✔Identifying signs and symptoms
Noticing - correct answer ✔✔Gathering Complete and Accurate Data
Noticing - correct answer ✔✔Assessing Systematically and Comprehensively
Noticing - correct answer ✔✔Predicting (and Managing) Potential Complications
Noticing - correct answer ✔✔Identifying Assumptions
Standards Attitudes Competencies Experience Specific Knowledge Base - correct answer ✔✔5
concepts of critical thinking
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 - correct answer ✔✔Nursing
Process
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) - correct answer ✔✔cue
Patient, family and significant other, health care team, medical records, other records and
scientific literature - correct answer ✔✔Sources of Data
(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. - correct answer ✔✔An initial patient-centered interview involves
Health perception-health management pattern - correct answer ✔✔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?
Clinical inference. - correct answer ✔✔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:
A problem-oriented approach - correct answer ✔✔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?
,Working phase - correct answer ✔✔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?
"You have four children; do you have any concerns about going home and caring for them?" -
correct answer ✔✔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?
Patient's level of function. - correct answer ✔✔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:
Self-perception-self-concept pattern - correct answer ✔✔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
Tell me what makes your headaches begin. - correct answer ✔✔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?
Identifying Assumptions
Predicting (and Managing) Potential Complications
Assessing Systematically and Comprehensively
Gathering Complete and Accurate Data
Identifying signs and symptoms - correct answer ✔✔Steps of NOTICING
, a framework for assessing older adults that focuses on six common "marker conditions": sleep
problems, problems with eating and feeding, incontinence, confusion, evidence of falls, and skin
breakdown. These conditions provide a snapshot of a patient's overall health and the quality of
care. - correct answer ✔✔SPICES tool
Ability to identify signs and symptoms indicating a situation is different, changed or not of
normal state. - correct answer ✔✔Noticing-Identifying signs and symptoms
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. - correct answer ✔✔Noticing-Gathering complete and accurate data
Nurses use a systematic method such as body systems, a head to toe approach or focused
assessment so no areas are forgotten. - correct answer ✔✔Noticing-Assessing systematically
and comprehensively
Nurses must look at the big picture to predict potential complications that may exist for
individual patients - correct answer ✔✔Noticing-Predicting and managing potential
complications
Taking something for granted or hastily arriving at a conclusion without supporting evidence. -
correct answer ✔✔Noticing-identifying assumptions
Grouping together information with a common theme to form the basis for problem
identification. - correct answer ✔✔Interpreting-clustering related information
In reviewing data, nurses are cognizant of any inconsistencies that may indicate additional
problems that may not be readily apparent. - correct answer ✔✔Interpreting-recognizing
inconsistencies