CH 16: Nursing Assessment
What are the two main steps of a nursing assessment, and how are they applied in practice?
Answer: Collecting & analyzing data
Rationale: Assessment has 2 steps: gathering information (history/physical exam) and analyzing to identify problems.
When is it appropriate to assess a patient’s vital signs? List two examples.
Answer: On admission; before/after procedures or medications
Rationale: Vital signs provide baseline and ongoing data about patient condition.
How does a nursing diagnosis differ from a medical diagnosis?
Answer: Nursing diagnosis = patient’s response; Medical diagnosis = disease/condition
Rationale: Nursing focuses on human responses; medicine focuses on pathology.
What does the acronym SMART stand for in goal-setting?
Answer: Specific, Measurable, Attainable, Realistic, Timed
Rationale: SMART ensures clear and achievable goals.
What is the Nursing Process?
ADPIE
Assessment, Diagnosis, Planning, Implementation, & Evaluation
Which communication technique is used when a nurse nods and says “go on” during a patient interview?
Answer: Back channeling
Rationale: Using brief cues like nodding or “go on” shows active listening and encourages sharing.
A patient’s temperature is 102°F with increased heart rate and sweating. What physiological change is this?
Answer: Fever (Pyrexia)
Rationale: Fever causes ↑HR, ↑RR, sweating, and vasodilation.
What does the PES format in nursing diagnosis stand for?
Answer: Problem, Etiology, Signs/Symptoms
Rationale: PES is the standard format for diagnostic statements.
Which nursing intervention type requires a physician’s order?
Answer: Dependent interventions
Rationale: Require a physician’s order (e.g., medication administration).
What does FUO stand for?
Fever of Unknown Origin
Give one example of when an emergency assessment would be used.
Answer: During a cardiac arrest or severe trauma
Rationale: Emergency assessments are rapid evaluations in life-threatening situations.
Which condition is indicated by a drop in blood pressure when standing?
Answer: Orthostatic hypotension
Rationale: A drop in BP when moving from lying → standing.
Give one example of a collaborative problem.
Answer: Risk for respiratory complications after surgery
Rationale: Collaborative problems require both nursing and medical interventions.
List two criteria used to prioritize nursing diagnoses.
Answer: ABCs, safety, patient goals
Rationale: Priority-setting criteria prevent harm and address urgent needs.
Is this statement correct?
"BP 146/74, hypotensive"
Answer: No, it is false
Rationale: Hypotensive is low BP, typically below 90/60. Hypertensive is high BP, typically above 130/80.
Why is validating assessment data important in nursing practice?
Answer: To ensure accuracy and identify discrepancies
Rationale: Validating prevents errors and promotes safe clinical judgment.
Name two nursing measures that promote heat conservation.
Answer: Warm blankets, adjusting room temperature
Rationale: These help conserve body heat.
What is the difference between a problem-focused nursing diagnosis and a risk diagnosis?
Answer: Problem-focused = existing issue; Risk = potential future problem
Rationale: Distinguishing between present and potential issues ensures proper care planning.
What is the difference between a standardized care plan and an individualized care plan?
Answer: Standardized = pre-written plans; Individualized = tailored to one patient
Rationale: Both are used, but individualized plans improve person-centered care.
What does "febrile" mean?
Having a fever
A new nurse fails to maintain eye contact and rushes during history-taking. Which principle of professionalism is not being followed?
Answer: Respect & professionalism during history taking
Rationale: Rushing and avoiding eye contact show lack of respect, affecting trust and accuracy.
Name two nursing measures that promote heat conservation.
Answer: Warm blankets, adjusting room temperature
Rationale: These help conserve body heat.
A nurse misinterprets data due to distraction and writes an inaccurate nursing diagnosis. What type of error has occurred?
Answer: Diagnostic error during data interpretation
Rationale: Inaccurate conclusions due to distraction = error in reasoning/analysis.
Why is interprofessional collaboration important in patient care planning?
Answer: It leverages expertise from multiple disciplines for better outcomes
Rationale: Collaboration ensures holistic, effective patient care.
What are the normal vital sign ranges?
HR: 60-100 bpm
RR: 12-20 /min
BP: 120/80 mmHg
T: 98.6F
O2: 95-100%