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Nursing Assessment Diagnosis Planning and Vital Signs Review
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1
Question
What is the purpose of assessment in the nursing process?
Answer
Collect subjective and objective data to form the nursing diagnosis
2
Question
What are the two types of data used in assessment?
Answer
Subjective data and objective data
3
Question
What should be selected to label the nursing diagnosis?
Answer
NANDA diagnosis
4
Question
How should a nursing goal be written to be measurable?
Answer
Include problem, etiology, and symptoms in a three-part or two-part statement as applicable
5
Question
What are the two main formats for nursing diagnoses?
Answer
Three-part statement (problem, etiology, symptoms) and two-part statement (risk diagnosis, etiology)
6
Question
What does timebound mean in nursing outcomes?
Answer
A designated time frame for achievement of the goal
7
Question
What is the difference between short-term and long-term goals?
Answer
Short-term: immediate behavioral shift; Long-term: objective over a longer period
8
Question
What should discharge planning involve?
Answer
Naming longer goals for the client after discharge
9
Question
What are components of desired outcomes in care plans?
Answer
Goals or desired outcomes, intervention, evaluation, with criteria of performance
10
Question
How should goals be written to reflect client responses rather than nurse activities?
Answer
Use phrases like 'The client will…' to describe client responses
11
Question
What should data collection methods include for writing goals?
Answer
Assessment techniques and data collection methods (physical assessment, health history, interview, medical records, diagnostic studies)
12
Question
What should be considered when determining the feasibility of a goal?
Answer
Client’s resources, capabilities, limitations, and time span of care
13
Question
What is the rationale in nursing care plans?
Answer
Explain why nursing interventions were chosen; link to pathophysiology and theories
14
Question
What should evaluation in the nursing process accomplish?
Answer
Monitor progress toward goals and determine if interventions should continue, modify, or terminate
15
Question
What is the difference between independent and collaborative nursing interventions?
Answer
Independent: nurse-initiated; Collaborative: carried out with other health team members under supervision or orders
16
Question
What are characteristics of appropriate nursing interventions?
Answer
Safe, age-appropriate, feasible, aligned with client values, and based on nursing knowledge
17
Question
What is the role of rationale in nursing plans?
Answer
Provide scientific explanation for chosen interventions; used to educate students and link to theory
18
Question
What is a tympanic thermometer best used for?
Answer
Fast measurement of body temperature via the ear canal
19
Question
What is the normal human body temperature range on oral measurement?
Answer
Approximately 37°C (98.6°F)
20
Question
List four common routes for measuring body temperature and a key trait of each.
Answer
Oral: convenient; Rectal: reliable; Axillary: safe, noninvasive; Tympanic: fast
21
Question
What term describes the daily fluctuation of body temperature that typically occurs with a 1-1.5 degree Fahrenheit variation, often lowest in the morning and highest in the late afternoon to early evening?
Answer
Diurnal variation in body temperature
22
Question
What measurement method is considered the safest and non-invasive for temperature, though it may take longer to obtain a reading?
Answer
Axillary temperature measurement
23
Question
Which temperature reading is commonly used in clinical practice and is taken by the mouth?
Answer
Oral temperature
24
Question
What is the normal adult resting heart rate range?
Answer
60-100 bpm
25
Question
What is the term for the difference between systolic and diastolic blood pressure?
Answer
Pulse pressure
26
Question
What term describes the pause or irregularity in the rhythm of the heartbeat?
Answer
Dysrhythmia
27
Question
What is tachycardia?
Answer
Heart rate above 100 bpm
28
Question
What is bradycardia?
Answer
Heart rate below 60 bpm
29
Question
What is apnea in respiration terms?
Answer
Temporary cessation of breathing
30
Question
What phase of respiration is characterized by chest movement and is more associated with intercostal muscle use?
Answer
Costal (thoracic) breathing