EXAM Flashcards
What is the first step in the nursing process?
Assessment
How does nursing assessment differ from medical assesment?
a. Focuses on physiological status only
b. includes psycho,socio and spiritual well being
c. limited to physical therapy assessments
d. concerns only with nutrional assessments
B
Which assessment is conducted when a client first enters a healthcare setting
Initial comprehensive assessment
What method is used during an emergency assessment to prioritize treatment?
a. SOAP method
b. ABCDE method
c. HEADSS method
d. PQRST method
B
Which assessment focuses on a thorough examination of a specific health concern
Focused/problem
Which aspect of the nursing process requires critical thinking to identify patient needs based on data collected
a. documentation
b. data analysis
c. data collection
d. implementation
B
How does the role of nurses in HA evolve according to the document
a. remains static
b. shift from focus on acute to community care
c. moves away from patient centered care
d. decreases in importance over time
B
Why is ongoing/partial assesment important?
a. it replaces initial comprehensive assess
b. provides updates on client health status since the initial ass
c. focuses on clients psychological status
d. optional part of nursing process
B
in what scenarios is focused/problem oriented ass most apppropriate?
a. standard proced for new clients
b. when detailed info ab specific health concern is required
c. during emergency situation
B
What is the primary purpose of the nursing process acc to doc?
a. to prescribe med
b. to perform surgeries
c. to provide a structured & effective way to deliver nursing care
d. to diagnose med conditions
C
which phase of interview involves establishing rapport with the client?
a. pre-intro
b. intro
c. working
d. summary and closing phase
B
How does nonverbal communication impact the nursing interview?
a. it can enhance/hinder communication process
b. it is the primary method of gathering data
A
What is the signif of working phase in the nursing interview?
a. to gather comprehensive health history and current health concern
b. summarize interview findings
c. collect data from med record
A
Which type of question is intended to obtain more than a one word response from client?
a. open ended
b. laundry list
c. leading
A
in developing a care plan, why is it important to include both sub and obj data?
a. to ensure a holistic understanding of the clients health status
b. to make the documentation process easier
A
Which communication skill is most crucial for collecting complete and valid data from client
a. speaking skills
b. listening skills
B
what is the primary goal of the preintro phase of nursing interview
a. to collect data from med record and understand reason for seeking care
b. to establish nursing diagnosis
A
How does understanding a client’s lifestyle and healthcare practices contribute to nursing care?
a. helps tailor nursing interventions to the clients unique needs
b. it is a formality wout practical application
A
What is the importance of review of systems in health history?
a. provide list of possible diagnoses
b. document clients family med history
c. elicit detailed info ab curret health prob
d. prescribe treatment base on symptoms
C
Why is it important to assess a clients stress levels & coping styles?
a. to provide entertainment
b. to identify maladaptive behaviours and guide interventions
B
How does the nurse use the COLDSPA mnemonic in the health history interview
a. to conduct a thorough analysis of symptoms
b. to plan nursing interventions witout client input
A
what is the significance of assessing a clients environment in the health history?
a. ensure compliance with hospital policies
b. to identify health hazards & potential risks
B
How does the use of gloves affect hand hygiene practices?
a. gloves are an alternative to using hand sanitizers
b. hand hygiene is required before and after glove use
B
Why is the supine position used during physical examinations?
a. allows for easy examination of abdominal area
b. only suitable for neurological exams
A
Which hand sanitation method is recommended when hands are visibly soiled
a. alcohol based hand sani
b. antiseptic hand rub
c. handwashing w soap and water
d. surgical hand antisepsis
C
when preparing the physical setting for an exam. what is crucial to ensure?
a. high room temp
b. limited lighting for relaxation
c. private and quiet area
C
What does dorsal recumbent pos help w during an examination?
a. best for assessing hip joints
b. restricts access to abdominal muscles
c. it makes easier for patients with back pain
C
integrating auscultation w palpation during an examination allows nurse to
a. decrease the exam time significantly
b. avoid unnecessary patient discomf
c. assess both surface & internal conditions effectively
C
When deciding between palpation and percussion for abdominal assessment. a nurse consider that percussion is better for:
a. determining texture & consistency of surface tissues
b. assessing deep tendon reflex
c. identifiying tenderness and estimating organ size
d. evaluating surface temp variations
B
what is the purpose of indirect percussion in a phys exam?
a. to assess the density and size of organs
b. to test skins sensitivity to touch
c. to provide warmth to examination area
A
When should gloves be changed during a phys exam?
a. after every patient visit, regardless of contact
b. on if visbly soiled
c. before and after contact w patient
B
how should a nurse prepare the examination area to ensure patient comfort and safety?
a. ensuring exam table is correct height
b. limiting use of personal equipment
c. use dim lighting to create a calming atmosph
A
what is the rationale behind using auscultation after inspection in the sequence of physical examination tech?
a. inspection may alter the findings that auscaltation seeks to identify
b. auscultation requires the patient to be in specific position
c. auscultation is more time consuming than inspection
A
which would be most approp for initially assessing a new abdominal mass?
a. auscultation
b. percussion
c. palpation
d. inspection
B
what is the primary purpose of data validation in nursing?
a. to ensure the accuract and reliability of collected data
b. to prescribe appropriate med
A
which method is not a part of data validation?
a. rechecking data through rep assess
b. clarifying data w the client
c. verifying data w another health care prof
d. ignoring discrepancies between sub and obj
D
why is doucmenting sub & obj data crucial in nursing?
a. forms basis of nursing diagnosis and care planning
b. allows for personal opinions to be recorded
c. it is used to evaluate the nurse performance
A
What does HIPPA training ensure in terms of documentation?
a. encourages the use of patient data for marketing purposes
b. it guarantees that patient info is kept confidential and secure
B
How should a nurse correct a documentation error according to best practices?
a. using white out to cover the mistake
b. drawing aline through the error, writing “error and initating
c. erasing error completely
B
when identifying areas where data are missing, what is a crucial step a nurse should take?
a. validate existing data to identify gaps in information
b. only focus on the data that has already been collected
A
what is the impact of discrepancies between sub & obj data on patient care
a. leads to more accurate and effective care plans
b. it can lead to misdiagnosis and inappropriate care
B
how can integrating validated data into patient care enhance outcomes?
a. providing a basis for random care interventions
b. ensuring care is based on accurate and comprehensive data
B
In what way does effective documentation support interdisciplinary communication within healthcare terms?
a. by ensuring patient data is fragmented and inaccessible
b. by providing a clear and accessible record of patient care and needs
B
why is it important to use specific, measurable terms in documenting obj data
a. to ensure detailed & precise communication of patient status
b. to create ambiguity
A
What is the SBAR model used for nursing communication
a. structuring verbal/written communication ab patientcare
b. organizing personal notes
A
What does R in SBAR stand for
Recommendation
What criteria should a nurse use to decide wether to validate patient data?
a. the data is inconsistent or discrepancies
b. the patient insists their info is correct
c. data aligns with the nurse initial assumptions
A
which of the following is considered a collaborative problem?
a. personal health goal
b. physiological complication need monitoring
c. risk for health concerns
d. actual health concern
B
why is clustering cues important in clinical judgement process?
a. to identify patterns indicating possible health issues
b. simplify patient info
A
what does validation of client concerns involve?
a. consulting with healthcare team
b. only using sib data
C. MAKING ASSUMPTIONS WITH OUT FURTHER INVESTIGATION
A
how should nurse act upon idetifying a risk for a helath concern?
a. document the concern wout action
b. implement preventive measures
B
what is a nurses role when opportunities for health promotion are identified?
a. to document
b. to support and guide client towards better health
B
How can nurses use clinical judgement to improve patient care?
a. making judgements based on assumptions
b. integrating assessment data, clinical knowledge and patient input
B
What factor is most important when drawing inferences to hypothesize clinical judgements?
a. most common diagnosis
b. time constraints
c. evidence and data gathered during assessments
C
How do expert nurses differ from novices in making clinical judgements?
a. novices use a broader range of data.
b. novices are more accurate
c. experts integrate knowledge, experience and critical thinking.
d. experts rely on intuition alone
C
which action is a pitfall in the assessment phase?
a. taking time to process data
b. gathering too much/inadequate data
c. consulting with colleagues
d. ignoring patient feedback
B
when should nurse consider a referral
a. when patient requests it, regardless of need.
b. when collab problem/complication arises beyond nurses scope
B
