Assessment
Data that the patient tells the nurse, such as "I have a headache," is called what?
Subjective data
When prioritizing an emergency patient, what three letters should immediately come to mind?
ABC — Airway, Breathing, Circulation
What type of communication is purposeful and used to build trust, obtaininformation, and support the patient?
Therapeutic communication
A patient refuses a treatment. Does the nurse have the right to forcethe treatment?
No.
A competent patient has the right to refuse care.
The nurse should provide education, explain risks/benefits, respect the decision, document, and notify the provider when appropriate.
What does ADPIE stand for?
A — Assessment
D — Diagnosis
P — Planning
I — Implementation
E — Evaluation
A nurse records a patient's temperature as 38.5°C. Is this subjective or objective data?
Objective data
Which patient should the nurse see first?
A. Patient requesting discharge instructions
B. Patient reporting pain of 5/10
C. Patient with an oxygen saturation of 84% and difficulty breathing
D. Patient requesting assistance with bathing
C — Patient with an oxygen saturation of 84% and difficulty breathing
The patient says:
"I'm really scared about my surgery."
The nurse says:
"Tell me more about what concerns you."
What therapeutic communication technique is this?
Broad opening
It allows the patient to decide what they want to discuss.
What is the best resource to use when a patient has a significant language barrier?
A. Their young child
B. A friend
C. Another patient
D. A qualified medical interpreter
D — A qualified medical interpreter
The nurse collects the patient's vital signs, health history, symptoms, and physical examination findings. Which step of ADPIE is this?
Assessment
The nurse is seeing a patient for the first time and needs to establish a comprehensive baseline of the patient's health. What type of database/assessment should be performed?
Complete/comprehensive assessment
Place these in priority order:
The patient says:
"My medication makes me feel funny."
The nurse responds:
"What do you mean when you say it makes you feel funny?"
What technique is being used?
The nurse is asking the patient to explain an unclear statement
A patient falls while getting out of bed. Where does the incident report go?
A. In the patient's medical record
B. In the patient's room
C. To the hospital/risk management according to policy
D. Nowhere because falls don't require reports
C
The incident report is not part of the patient's medical record.
The patient's chart should contain objective documentation about thepatient's condition and care.
The nurse determines that a patient has acute pain and establishes a goal that the patient's pain will decrease to 3/10. Which part of ADPIE is this?
Planning
The nurse identifies goals/outcomes and plans appropriate interventions.
A patient reports chest pain. Instead of performing a full head-to-toe assessment first, the nurse concentrates on the patient's cardiovascular and respiratory status. What type of assessment is this?
Focused assessment
Two nurses are caring for several patients. One patient is unstable and requires frequent assessments, while another is stable and needs routine care. How should assignments be made?
Assignments should be based on patient acuity, stability, nursing needs, and nurse competency, not simply the number of patients.
The unstable/high-acuity patient requires the appropriate skilled nurse.
The patient says:
"I don't think I can manage all these medications."
The nurse says:
"You don't feel confident that you can manage your medications."
What technique is this?
Restating
The nurse repeats the patient's main idea using different words.
A standardized care plan exists for patients undergoing C-sections. Can the nurse simply follow it exactly for every patient?
No.
Standardized care plans are a starting framework. The nurse must individualize the plan based on each patient's assessment, needs, preferences, and response to care.
After giving a pain medication, the nurse reassesses the patient's pain. The patient reports that pain decreased from 8/10 to 3/10. Which part of ADPIE is this?
Evaluation
The nurse determines whether the intervention achieved the desired outcome.
The nurse obtains a blood pressure of 210/110 mmHg. The patient is talking comfortably and has no symptoms. Before making a clinical judgment, the nurse repeats the blood pressure using appropriate technique. What assessment principle is being demonstrated?
Validation of findings
You have four patients:
Patient C.
A sudden change in mental status plus tachypnea may indicate an acutedeterioration. This patient needs immediate assessment before routine care, teaching, or chronic pain management.
A patient says:
"I'm scared. I don't know what's going to happen."
Which response is most therapeutic?
A. "Don't worry. Everything will be fine."
B. "Why are you scared?"
C. "You'll feel better once the procedure is over."
D. "Tell me more about what you're afraid might happen."
D — "Tell me more about what you're afraid might happen."
This encourages the patient to explore their feelings without giving false reassurance or judgment.
A patient and their family disagree about the patient's ability to function independently at home. The patient says, "I can walk to the bathroom by myself," while the family says, "She can't even get out of bed."
What should the nurse do?
Assess the patient's actual functional ability.
Don't simply choose the patient's statement or the family's statement. Use objective assessment to determine what the patient can safely do and what support is needed at home.
The nurse receives this report:
"Mr. Jones is having increasing shortness of breath. He was admitted yesterday with pneumonia. His respiratory rate is 32/min, oxygen saturation is 86%, and he has increased work of breathing. I think he needs to be evaluated immediately."
Identify the S, B, A, and R in this report.
S — Situation: Increasing shortness of breath.
B — Background: Admitted yesterday with pneumonia.
A — Assessment: RR 32, oxygen saturation 86%, increased work of breathing; nurse believes the patient is deteriorating.
R — Recommendation: Patient needs immediate evaluation.