NRS 204 Exam 1 Questions and Answers
Standards and Scopes of Practice - -Determined by ANA for patient safety.
-Shape out practice, a standard we uphold, guidance as students
-ADPIE - -Assessment
Diagnosis
Planning
Implementation
Evaluation
-Assessment - --Communication
-therapeutic relationship: don't belittle
-Introspection: reflection in/on action, adjustment to attitude
-Documentation: written clearly so next nurse can understand
-Cultural sensibility: the emotional intelligence aspect of a nursing when working with
diverse cultures
-Physical assessment: continuous
-Gathering data - -Inspection: looking
Palpation: touching
Auscultation: listening
Perussion: tapping
Olfaction: smelling
-Organizing data - --general
-initial
-emergency
-ongoing
-functional health
-body systems
-subjective
-objective
-Health History - -- family history
-lifestyle-social data
-psychologic data
-pattern of healthcare use
-past history of:
-illnesses
-immunizations
-allergies
-hospitalizations
-medications and supplements
-complementary and integrative health practices
, -objective data - -can be detected by an observer or can be measured or tested against an
accepted standard
-subjective data - -feelings or perceptions that can be described or verified only by the
patient and their family
-Nursing Diagnosis: ACTUAL - --Problem: human response to illness or injury
-Etiology: what caused the problem/ why is this response occurring
-Signs and symptoms: what are they
-Nursing Diagnosis: RISK FOR - --Problem: what is possible or probable human response
to illness
-Etiology: why might this response occur
-Signs and symptoms: ELIMINATED b/c it suggests that the adverse outcome has
happened, when it hasn't yet
-Planning - -What nurses choose for the patient
-Interventions - -What nurses do for the patient
-Independent - --vital signs
-comfort
-trust
-referral (depends)
-physical assessment
-build trust
-Dependent - --diagnosis, surgery, injection, lab work, IVs, anything invasive (catheters)
-Collaborative - --Spiritual care
-administering medicine
-Temperature - --core temperature measured by hypothalamus
-Peripheral temperature - -Sublingual (mouth): under back corner of tongue
Rectum: less technique needed, less external environment
Axilla: arm pit
Temporal artery: forehead, good for mass temperature
Tympanic membrane: eardrum, 1 degree hotter (also needs to be done properly or else
inaccurate reading)
-Hypothermia - -<36.5 C
-Physiological stres, exposure, alch/drug use, shock, endocrine disorders, infections
-Normothermia - -36.5-37 .3 C
Standards and Scopes of Practice - -Determined by ANA for patient safety.
-Shape out practice, a standard we uphold, guidance as students
-ADPIE - -Assessment
Diagnosis
Planning
Implementation
Evaluation
-Assessment - --Communication
-therapeutic relationship: don't belittle
-Introspection: reflection in/on action, adjustment to attitude
-Documentation: written clearly so next nurse can understand
-Cultural sensibility: the emotional intelligence aspect of a nursing when working with
diverse cultures
-Physical assessment: continuous
-Gathering data - -Inspection: looking
Palpation: touching
Auscultation: listening
Perussion: tapping
Olfaction: smelling
-Organizing data - --general
-initial
-emergency
-ongoing
-functional health
-body systems
-subjective
-objective
-Health History - -- family history
-lifestyle-social data
-psychologic data
-pattern of healthcare use
-past history of:
-illnesses
-immunizations
-allergies
-hospitalizations
-medications and supplements
-complementary and integrative health practices
, -objective data - -can be detected by an observer or can be measured or tested against an
accepted standard
-subjective data - -feelings or perceptions that can be described or verified only by the
patient and their family
-Nursing Diagnosis: ACTUAL - --Problem: human response to illness or injury
-Etiology: what caused the problem/ why is this response occurring
-Signs and symptoms: what are they
-Nursing Diagnosis: RISK FOR - --Problem: what is possible or probable human response
to illness
-Etiology: why might this response occur
-Signs and symptoms: ELIMINATED b/c it suggests that the adverse outcome has
happened, when it hasn't yet
-Planning - -What nurses choose for the patient
-Interventions - -What nurses do for the patient
-Independent - --vital signs
-comfort
-trust
-referral (depends)
-physical assessment
-build trust
-Dependent - --diagnosis, surgery, injection, lab work, IVs, anything invasive (catheters)
-Collaborative - --Spiritual care
-administering medicine
-Temperature - --core temperature measured by hypothalamus
-Peripheral temperature - -Sublingual (mouth): under back corner of tongue
Rectum: less technique needed, less external environment
Axilla: arm pit
Temporal artery: forehead, good for mass temperature
Tympanic membrane: eardrum, 1 degree hotter (also needs to be done properly or else
inaccurate reading)
-Hypothermia - -<36.5 C
-Physiological stres, exposure, alch/drug use, shock, endocrine disorders, infections
-Normothermia - -36.5-37 .3 C
