Final clinical skills

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Questions and Answers

The first step of the nursing process is assessment. What action do you perform during assessment?

Acquire and validate information about the patient’s health (correct)

Collaborate with the patient and family to prioritize interventions

Identify a pattern to reach a diagnostic conclusion

Provide direct care

During the interview, the patient provides information about his or her symptoms and health status. What is this data called?

Invalid data

Objective data

Perceptual data

Subjective data (correct)

During the patient interview, the patient shows signs of acute respiratory distress. What should you do next?

Continue the interview so you can get the whole picture before taking action.

Immediately assess the affected body system. (correct)

Reassure the patient that everything will be all right.

Refer the patient to his or her primary health care provider.

What is it called when you reinforce your interest in what a patient has to say by using active listening prompts such as “go on” or “uh-huh”?

Back channeling Signup and view all the answers

Which of the following is an example of a direct, closed-ended question?

“How many times in the last month have you slipped and fallen?” Signup and view all the answers

The second step of the nursing process is diagnosis. What action do you perform during diagnosis?

Identify a pattern to reach a diagnostic conclusion. Signup and view all the answers

What type of nursing diagnosis applies when a patient has an increased likelihood of developing a problem or complication?

Risk nursing diagnosis Signup and view all the answers

What type of nursing diagnosis applies when a patient has an interest in improving his or her health status by making behavioral changes?

Health promotion nursing diagnosis Signup and view all the answers

Which of the following is an example of a problem-focused nursing diagnostic statement?

Impaired nutritional status: deficient food intake related to inability to absorb nutrients. Signup and view all the answers

When formulating a nursing diagnosis, which of these should you do first?

Cluster assessment data into meaningful patterns. Signup and view all the answers

The fifth step of the nursing process is evaluation. What action do you perform during evaluation?

Determine whether goals and outcomes have been achieved. Signup and view all the answers

You are assessing a patient’s pain-relief goal. The patient self-reports his pain as a 1 on a scale of 0 to 10. You note that the patient is grimacing, bracing his incision site, and is reluctant to move. Additional pain medication is available on request, but the patient has not requested it. What is your next step?

Investigate his obvious discomfort. Signup and view all the answers

ne of the patient’s goals is for her surgery incision to remain free of infection. At her follow up, the wound looks good but has not completely healed yet. As a result, the goal of remaining free of infection should be ___________ on the care plan.

Continued Signup and view all the answers

Which of these methods could be used to determine a patient’s expectations of care?

Asking the patient if she received all the information she needed to care for her surgery incision. Signup and view all the answers

You determine that a patient is not meeting a nutritional goal because he is not following the mutually agreed-upon dietary plan. What is your next step?

Understand why the patient is not following the plan Signup and view all the answers

In which position should the patient be placed in order to palpate the popliteal pulse?

Have the patient lie prone with the knee flexed. Signup and view all the answers

Hearing a bruit in an artery is a sign of which of the following conditions?

An obstruction Signup and view all the answers

What is a depression that is left after pressing a finger or thumb on swollen tissue called?

Pitting edema Signup and view all the answers

Normal capillary refill is less than 2 seconds and is assessed by:

Pressing on the nail bed until it blanches, and observing how quickly full color returns Signup and view all the answers

When should you check the patient’s blood pressure to assess for orthostatic hypotension?

While the patient is sitting and standing Signup and view all the answers

Study Notes

Nursing Process

Assessment: The first step of the nursing process, where you gather information about a patient's health status.
Subjective Data: Patient-reported information, including symptoms and health history.
Objective Data: Observable and measurable information obtained during physical assessments.
Acute Respiratory Distress: Requires immediate attention and action.
Active Listening Prompts: Encouraging a patient to share information by using verbal cues like "Go on" or "Uh-huh."
Direct, Closed-Ended Question: A question that requires a short, specific answer.

Nursing Diagnosis

Diagnosis: The second step of the nursing process, where you analyze assessment data and formulate nursing diagnoses.
Risk Nursing Diagnosis: A diagnosis that identifies a potential problem or complication.
Health-Promotion Nursing Diagnosis: A diagnosis that reflects a patient's desire to improve their health through behavioral changes.
Problem-Focused Nursing Diagnostic Statement: A statement that identifies a specific problem experienced by the patient.
Prioritize Nursing Diagnoses: Identify the most urgent or important problems to address first.

Nursing Interventions

Interventions: Actions taken by the nurse based on the nursing diagnosis to meet the patient's needs.

Evaluation

Evaluation: The fifth step of the nursing process, where you assess the effectiveness of interventions and adjust the care plan as needed.
Patient Self-Report: The most reliable source for determining a patient's level of pain.
Modify Goals: When a patient's condition or progress varies from the initial goal.

Patient Expectations and Preferences

Patient Expectations: Understanding what a patient expects from their healthcare providers and experience.
Communication and Education: Clearly explain care plans and provide opportunities for patients to ask questions and express concerns.

Physical Assessment Techniques

Palpate Popliteal Pulse: Position the patient prone or with their knee flexed to access the pulse.
Bruit: A whooshing sound heard through auscultation, suggesting blood flow turbulence and potentially narrowing of the artery.
Pitting Edema: A depression that remains after pressing a finger or thumb on swollen tissue.
Capillary Refill: Assesses the circulation in the extremities.
Orthostatic Hypotension: A drop in blood pressure when standing up, which may cause dizziness or lightheadedness.

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Description

Test your understanding of the first step in the nursing process: assessment. This quiz will cover key actions performed during the assessment phase and its importance in patient care. Enhance your nursing knowledge with these assessment-related questions.