Module 1 - 4

Question 1

The Use of Nursing Process in Clinical Judgment

Answer 1

ADPIE
Identify Assumptions: take info for granted or see it as fact with no evidence
Validate: Check accuracy of info/data you have collected
Diagnose actual and potential risk problems from the assessment data.

Question 2

Actual Risk Problems

Answer 2

A risk that is occurring or has occurred

sleep deprivation

Question 3

Potential Risk Problems

Answer 3

Identifying possible risks and implementing a plan to prevent it from occurring.

Question 4

First Level Priority Problem

Answer 4

Emergency
Life Threatening
Immediate

ABCV

Question 5

ABCV

Answer 5

Airway
Breathing
Cardiac
Vital Signs

Question 6

Second Level Priority Problems

Answer 6

Next in Urgency that need prompt intervention

Acute pain, infection risks, safety risks, acute urinary elimination problems.

Question 7

Third Level Priority Problems

Answer 7

Important to clients health but can be seen to after more urgent problems.
Social Isolation
Rest
Family Coping.

Question 8

Collaborative Problems

Answer 8

Treatment requires multiple disciplines

Question 9

Medical Diagnosis

Answer 9

Determines the disease or condition that explains a persons symptoms

Question 10

Nursing Diagnosis

Answer 10

Deals with a persons response to the actual potential health problem.
Pain Management.

Question 11

Relational Approach to nursing practice

Answer 11

Health and illness mean different things to people depending on their Culture, Family, gender, age, ability.

Nurses focus should be on what is important to the client in context of their everyday lives.

Question 12

Reflectivity

Answer 12

Continually examining how you view and respond to your clients based on your own assumptions, culture, past experiences etc.
Understanding vs Defensivness
Responsiveness vs Frustration

Question 13

Ethnicity

Answer 13

Implies geographical or national affiliation

Question 14

Inspection as a physical examination technique

Answer 14

Concentrated watching client as a whole then each individual system

Question 15

Palpation

Answer 15

Sense of touch to assess temperature, moisture, organ location, size, swelling, tenderness or pain

Question 16

Light Palpation

Answer 16

Pads of finger tips

surface characteristics

Question 17

Deep Palpation

Answer 17

Blunted or continuous intermittent pressure.

Question 18

Steps for a successful Interview

Answer 18

1) Complete and accurate data: description, timeline of any symptoms.
2) Establish trust, show respect. Help client feel accepted and not judged
3) Share inför with the client about their health state, helps them participate in identifying problems
4) build therapeutic relationship. Helps with future assessments
5) Look for moments to teach about health promotion and illness prevention.

Question 19

Communication Includes

Answer 19

Physical
Mental
Emotional
Verbal and non- Verbal

Question 20

Receiving messages

Answer 20

The meaning is usually determined by experiences social and family context, as well as their current state.

Question 21

Power in Relation to Patients

Answer 21

• More knowledge about the health care system. Influence over clients access to health care
• Diverse in social Contexts, life experiences and knowledge

Question 22

Unconditional Positive Regard

Answer 22

A General optimistic view of people

Question 23

Empathy

Answer 23

Viewing the world from another persons inner frame of reference while remaining yourself.

Question 24

Ten Traps of Interviewing

Answer 24

1) Providing false assurance ( Reassurance)
2) Giving unwanted advice
3) Using Authority
4) Using Avoidance Language
5) Engaging in Distancing
6) Over using professional Jargon or casual language
7) Using leading or Biased questions
8) Talking to much
9) Interrupting
10) Using Why Questions

Question 25

COPD oxygen Stat range

Answer 25

88 - 92%

Question 26

Normal Temp Range and what influences it

Answer 26

35.8 - 37.3
Menstruation Cycle in Women: causes rise in temp
Exercise: increases body temp
Age: Wider normal ranges in children and infants

Question 27

Normal Pulse Range and what influences it

Answer 27

60 - 100 bpm
Exercise
Age
Gender : after puberty girls have a faster heart rate

Question 28

Normal Respiratory Range and what influences it

Answer 28

10 - 20 Breaths per Minute
exercise
anxiety or stress
age

Question 29

Normal BP Range and what influences it

Answer 29

135/85
Age
sex
weight/exercise
Emotions/Stress

Question 30

Hypotension is

Answer 30

95/60

Question 31

PreHypertension is

Answer 31

135-139/ 80-89

Question 32

Stage 1 HyperTension

Answer 32

140-159/90-99

Question 33

Stage 2 Hypertension

Answer 33

160/100

Question 34

Oxygen Saturation Normal Range and what influences it

Answer 34

92% - 100% 
Acceptable range is 95% 
Temperature
Drugs and Medications
Carbon Monoxcide

Question 35

General Survey: Physical Appearance

Answer 35

Age
Sex
Level of Consciousness ( LOC )
Skin colour
facial features
acute stress

Question 36

General Survey: Body Structure

Answer 36

Posture
Nutrition
stature
position
body build

Question 37

General Survey : Mobility

Answer 37

Range of Motion

Gait

Question 38

General Survey: Behaviour

Answer 38

Facial Expressions
Mood
Speech
Dress
Personal Hygiene

Question 39

Measurement would be

Answer 39

Height
weight
BMI
Waist to hip ration

Question 40

In a test when taking vitals what are the steps during the procedure with “cleaning equipment” being one of them

Answer 40

Clean Equipment
Take measurement
State if normal or abnormal
State Normal Range Expectations 
State 3 factors that influence
Document what you actually found on your client in the test.

Question 41

Vitals include …

Answer 41

Blood Pressure
Pulse
Respiratory Rate
Oxygen Saturation
Temperature