Nursing 143 || with Error-free Answers.
What are the components of the nursing process? correct answers ADPIE:
Assessment (collection of data)
Diagnosis (determine key issues)
Planning (formal plan)
Implementation (action)
Evaluation (response to interventions/next steps)
What is the Fundamentals of Care Framework? correct answers - A trusting therapeutic
relationship between care recipient and care provider
- Integrating and meeting a persons' physical, psychosocial and relational needs
- A context of care that is supportive of relationship development and care integration
What are the 3 sources of health assessment data? correct answers Primary: Client (best source
of information if cognition is unimpaired)
Secondary: Family members/significant others, health care team, client chart/medical records
Tertiary: Scientific/medical literature, nurse's experience
Subjective Data correct answers Subjective Data: client's verbal descriptions of their health
concerns; obtained through health history; the individual's own perception of their health;
quoting is best method of documenting; OPQRSTU (onset, provoke/palliate, quality,
region/radiation, severity, timing, understanding); a symptom
Objective Data correct answers Objective Data: observations or measurements of a client's health
status; gathered through technical measurements/observations by health care practitioner; vital
signs, lab tests, diagnostics; inspect, percuss, palpate, auscultation; a sign
,List the 4 skills required for a physical examination correct answers Inspection, Palpation,
Percussion, Auscultation
Inspection correct answers The use of vision and hearing to distinguish normal from abnormal
findings (concentrated watching)
Palpation correct answers Involves the use of the hands to touch body parts to make sensitive
assessments (sense of touch)
Percussion correct answers Involves tapping the body with the fingertips using short, sharp
strokes to produce a vibration that travels through body tissues; character of the sound
determines the location, size, and density of underlying structures to verify abnormalities
assessed by palpation and auscultation
Auscultation correct answers Involves listening to sounds the body makes to detect variations
from normal (most sounds will require the aid of a stethoscope)
What are some of the key fundamentals in a head-to-toe examination? correct answers - Head-to-
toe approach includes all body systems
- Begins by assessing the head and neck structures and progressing methodically down the body
- Compare both sides of the body for symmetry
- If a patient is seriously ill, first assess the systems of the body more at risk for abnormalities
- If a patient is fatigued, offer rest periods between assessments
- Perform painful procedures at the end of the examination
- Record assessments in specific terms on a physical assessment form
- Use common/accepted medical abbreviations
- Record quick notes during the examination to minimize time patient is waiting
,Systematic Assessment Process correct answers A method for collecting data on all body systems
(integumentary, ocular, auditory, respiratory, etc.)
Comprehensive Assessment Process correct answers Includes identifying data, source of health
history, reason for interview, current state of health, developmental variables, psychological
variables, spiritual variables, sociocultural variables, physiological variables, history of past
illnesses/injuries, current medications, and a review of the body systems
Examination Position and Preparation for Infants correct answers Infants
- For very young, position supine on padded table
- If baby can sit, position on parent's lap
- Prepare examination 1-2 hours after baby has fed
- Maintain a warm environment
Examination Position and Preparation for Toddlers correct answers Toddlers
- Sit on parent's lap
- Enlist parent for aid during invasive procedure
- Toddler can use security object (teddy bear/blanket) to ease anxiety
- Focus most of communication on parent to begin
Examination Position and Preparation for Preschool Age correct answers Preschool Age
- Can be on parent's lap, or on exam table
- Verbal communication is helpful, but use simple terms
Examination Position and Preparation for School Age correct answers School-Age
- Sitting on examination table
- Break ice with small talk
- Children should undress on their own
, Examination Position and Preparation for Adolescents correct answers Adolescent
- Sit on examination table
- Typically examined alone, without a parent
- Be sensitive to body image awareness at this age
Examination Position and Preparation for Older Adults correct answers Older Adults
- Sit on examination table; older adults may need to lie supine
- Allow position changes and rests
- Pace of exam may need to be slowed
- Use physical touch
What are some documentation/charting best practices? correct answers - Do not document
critical or retaliatory comments about a patient (or personal opinions)
- Correct all errors promptly (and cross-out/initial errors instead of erasing or using White Out)
- Record all facts
- Document as close to the time of the event as possible
- If an order was questioned, record that clarification was sought
- Document only for yourself
- Use "quotations" when directly quoting a patient
- Begin each entry with date/time and end with signature/credentials
- Avoid precharting (documenting entry before care has been provided)
- Do not leave blanks spaces or lines in notes
- Use correct terminology and approved acronyms
What is narrative charting? correct answers - Recording patient data in a "story" format that
describes a specific event in chronological order
- Used to document a patient's status, care, events, treatments, interventions, and response
What are the components of the nursing process? correct answers ADPIE:
Assessment (collection of data)
Diagnosis (determine key issues)
Planning (formal plan)
Implementation (action)
Evaluation (response to interventions/next steps)
What is the Fundamentals of Care Framework? correct answers - A trusting therapeutic
relationship between care recipient and care provider
- Integrating and meeting a persons' physical, psychosocial and relational needs
- A context of care that is supportive of relationship development and care integration
What are the 3 sources of health assessment data? correct answers Primary: Client (best source
of information if cognition is unimpaired)
Secondary: Family members/significant others, health care team, client chart/medical records
Tertiary: Scientific/medical literature, nurse's experience
Subjective Data correct answers Subjective Data: client's verbal descriptions of their health
concerns; obtained through health history; the individual's own perception of their health;
quoting is best method of documenting; OPQRSTU (onset, provoke/palliate, quality,
region/radiation, severity, timing, understanding); a symptom
Objective Data correct answers Objective Data: observations or measurements of a client's health
status; gathered through technical measurements/observations by health care practitioner; vital
signs, lab tests, diagnostics; inspect, percuss, palpate, auscultation; a sign
,List the 4 skills required for a physical examination correct answers Inspection, Palpation,
Percussion, Auscultation
Inspection correct answers The use of vision and hearing to distinguish normal from abnormal
findings (concentrated watching)
Palpation correct answers Involves the use of the hands to touch body parts to make sensitive
assessments (sense of touch)
Percussion correct answers Involves tapping the body with the fingertips using short, sharp
strokes to produce a vibration that travels through body tissues; character of the sound
determines the location, size, and density of underlying structures to verify abnormalities
assessed by palpation and auscultation
Auscultation correct answers Involves listening to sounds the body makes to detect variations
from normal (most sounds will require the aid of a stethoscope)
What are some of the key fundamentals in a head-to-toe examination? correct answers - Head-to-
toe approach includes all body systems
- Begins by assessing the head and neck structures and progressing methodically down the body
- Compare both sides of the body for symmetry
- If a patient is seriously ill, first assess the systems of the body more at risk for abnormalities
- If a patient is fatigued, offer rest periods between assessments
- Perform painful procedures at the end of the examination
- Record assessments in specific terms on a physical assessment form
- Use common/accepted medical abbreviations
- Record quick notes during the examination to minimize time patient is waiting
,Systematic Assessment Process correct answers A method for collecting data on all body systems
(integumentary, ocular, auditory, respiratory, etc.)
Comprehensive Assessment Process correct answers Includes identifying data, source of health
history, reason for interview, current state of health, developmental variables, psychological
variables, spiritual variables, sociocultural variables, physiological variables, history of past
illnesses/injuries, current medications, and a review of the body systems
Examination Position and Preparation for Infants correct answers Infants
- For very young, position supine on padded table
- If baby can sit, position on parent's lap
- Prepare examination 1-2 hours after baby has fed
- Maintain a warm environment
Examination Position and Preparation for Toddlers correct answers Toddlers
- Sit on parent's lap
- Enlist parent for aid during invasive procedure
- Toddler can use security object (teddy bear/blanket) to ease anxiety
- Focus most of communication on parent to begin
Examination Position and Preparation for Preschool Age correct answers Preschool Age
- Can be on parent's lap, or on exam table
- Verbal communication is helpful, but use simple terms
Examination Position and Preparation for School Age correct answers School-Age
- Sitting on examination table
- Break ice with small talk
- Children should undress on their own
, Examination Position and Preparation for Adolescents correct answers Adolescent
- Sit on examination table
- Typically examined alone, without a parent
- Be sensitive to body image awareness at this age
Examination Position and Preparation for Older Adults correct answers Older Adults
- Sit on examination table; older adults may need to lie supine
- Allow position changes and rests
- Pace of exam may need to be slowed
- Use physical touch
What are some documentation/charting best practices? correct answers - Do not document
critical or retaliatory comments about a patient (or personal opinions)
- Correct all errors promptly (and cross-out/initial errors instead of erasing or using White Out)
- Record all facts
- Document as close to the time of the event as possible
- If an order was questioned, record that clarification was sought
- Document only for yourself
- Use "quotations" when directly quoting a patient
- Begin each entry with date/time and end with signature/credentials
- Avoid precharting (documenting entry before care has been provided)
- Do not leave blanks spaces or lines in notes
- Use correct terminology and approved acronyms
What is narrative charting? correct answers - Recording patient data in a "story" format that
describes a specific event in chronological order
- Used to document a patient's status, care, events, treatments, interventions, and response
