NUR 215 MODULE 1-2 EXAM with 100% accurate solutions + rationales 2026-2027

ABC's

airway, breathing, circulation

WHAT TYPES OF THINGS CAN A NURSE DO WITHOUT A DOCTORS ORDER?

-TURNING A PATIENT

-PROVIDNG COMFORT

-GROOMING/BATHING

-PATIENT EDUCATION

-PREVENTING FALLS

-ICEPACKS/HEAT PADS

What can a nurse do if he/she is asked to do something out of their scope?

nurses should refuse to practice beyond their legal scope of practice and use the formal chain of command to verbalize concerns related to these assignments

3 levels of prevention

Primary Prevention

Secondary Prevention

Tertiary Prevention

primary

First or most significant(designed to prevent or slow the onset of disease)

secondary

Screening activities and education for detecting illnesses in the early stages

territory

Focuses on stopping the disease from progressing and returning the individual to the pre-illness phase

5 steps of the nursing process

1. Assessment

2. Diagnosis

3. Planning

4. Implementation

5. Evaluation

Assessment

Involves gathering data about the patient and their health status; Info is related to the physiological, psychological, sociocultural, developmental, and spiritual status of the individual

Analysis/Diagnosis

use information/data from the assessment phase to identify the specific problem

planning

encompasses identifying goals and outcomes, choosing interventions, and creating nursing care plans

Nursing Diagnosis vs Medical Diagnosis

*Nursing Diagnosis: Focus on patient response & Identify potential problems

*Medical Diagnosis:Disease process

Primary emphasis on identifying

the current problem

*Both use physical assessment, interviewing and observing as ways

to derive the diagnosis

*Both are designed for planning patient care

Inital Planning

Begins with the first patient contact; Refers to the development of the initial comprehensive care plan

ongoing planning

Changes made in the plan; Allows you to prioritize the problem(s) the patient has

discharge planning

Process of planning a self-care and continuity of care after the patient leaves the healthcare setting

subjective data and objective data

subjective: what the patient says/tells you

objective: what you see for your self

nursing care plan

includes nursing diagnoses, goals and/or expected outcomes, specific nursing interventions, and a section for evaluation findings so any nurse is able to quickly identify a patient's clinical needs and situation.

Implementation

Involves performing/delegating planned interventions; Carry out the care plan

"It's doing, documenting, and delegating"

evaluation

Last step of the nursing process; Involves making judgements about the patient's progress towards desired health outcomes, the effectiveness of the nursing care plan, and the quality of nursing care in the healthcare setting

structure evaluation

focuses on the environment in which care is provided; also known as an audit

process evaluation

determines whether a program is being implemented as intended

outcomes evaluation

Focuses on observable or measurable changes in the patient's health status that result from the care given

Maslow's Hierarchy of Needs

(level 1) Physiological Needs

(level 2) Safety and Security)

(level 3) Relationships, Love and Affection

(level 4) Self Esteem, (level 5) Self Actualization

HIPAA (passed in 1996)

Health Insurance Portability and Accountability Act

What are examples of nursing attributes?

Nursing Attributes: Qualities that make a nurse good and professional

- fair

- honest

-trust worthy

How can a nurse therapeutically communicate with a patient during a sexual health exam?

Convey a non-judgemental attitude and unbiased approach

Provide privacy

Have others step out of the room

Priorities when discussing sexual health with the patient

Examine your own beliefs/values

Be aware of your nonverbal communication

-Use a relaxed approach

-Maintain eye contact

Modifiable Risk Factors:

changeable or controllable

lifestyle, stress

nonmodifiable risk factors

not changeable

Age

Gender

Family history

Ethnic background

For nursing to be considered a profession, what would be required?

-Technical and scientific knowledge

-Be evaluated by a community of peers

-Have a service orientation and a code of ethics

active listening (SOLAR)

S- sit squarely facing the client

0- observe an open posture

L- lean forward toward the client

E- establish eye contact

R-relax

Therapeutic Communication Techniques

1) ACTIVE LISTENING - Shows clients that they have your undivided attention

2) OPEN-ENDED QUESTIONS - Used initially to encourage clients to tell their story in their own way. Ask questions in a language that a client can understand

3) CLARIFYING - Questioning clients about specific details in greater depth or directing them toward relevant parts of the history.

4) SUMMARIZING - Validates the accuracy of the story.

Non-therapeutic communication

Usually blocks the development of a trusting and therapeutic relationship

Nonmaleficence

do no harm

automony

a person's right to choose and act on that choice

Justice

fairness; rightfulness

Beneficence

doing good

Nonmaleficence

duty to do no harm

veracity

truthfulness

fidelity

loyalty

what does the state board of nursing do?

determines the boundaries of practice of nursing

what is the nursing practice act?

Delegation, standards of professional accountability, scaope of nursing practice, and protection

(regulated by each state of nursing)

culture awareness

Having an understanding of another culture's values and perspective

culture and sensitivity

An awareness/knowledge of the uniqueness of other cultures

culture competence

the ability to interact effectively with people of different cultures

negotiation

The patient's perspective may differ from yours about the effects of a particular practice; Negotiation acknowledges that gap

Repatterning/Restructuring

Attempt to change your actions or the clients lifestyle

wellness-illness continuum

A gradient that helps describe the varied and dynamic nature of human health

what immunizations are recommended for an older adult 35-65 and older

Annual influenza, tetanus, diphtheria, zoster, pneumococcal, and pertussis

What is Healthy People 2020?

A NATIONAL agenda that communicates a vision for improving health and achieving health equity. AND

A set of specific measurable objectives with targets to be achieved over the decade.

What are the differences in interventions that are least restrictive or invasive vs most restrictive or invasive

Least Restrictive/Invasive: Always used first; Ensures safety of the patient

-Use toileting schedule VS putting in an indwelling catheter

-Get a sitter VS applying restraints

-Use non-pharmacological measures VS giving opiates for mild pain

-Healthy diet VS weight loss surgery

what is delegation?

When the RN, who holds the authority for nursing care delivery, transfers responsibility for the performance of a task to a nursing assistive personnel while still retaining accountability for a safe outcome

-Delegating is NOT the same as assigning

what are the 5 rights of delegation?

1. Right task- can it be delegated

2. Right Circumstance- Should it be delegated

3. Right person- can this person do the task

4. Right direction/ communication- is the task being conveyed in a clear manner

5. Right supervision- is the task being followed up on once complete.

What types of things can you delegate to assistive personnel?

-Vital signs on a stable patient

Feeding/grooming/bathing/toileting a patient

-Turning a patient

-Ambulating a patient

-Stocking supplies

-Secretarial tasks

*Other types of tasks can be delegated depending on the UAP, facility, and facility policies

What does being a client advocate mean?

-A function of a nurse; supporting patients' right to make healthcare decisions when they are able to voice their opinions and protecting patients from harm when they are unable to make decisions

what would we attempt to develop a definition of nursing ?

-Helps the public understand the value of nursing

-Helps differentiate the activities of nursing from those of medicine

-Helps students understand what is expected of them

direct intervention

Performed through interactions with the patient

Physical care, Emotional support, Patient teaching

indirect interventions

Performed away from the patient but on behalf of the patient

what is self- concept?

Overall view of self; forms out of a person's evaluation of his/her/their characteristics

What is the ANA Code of Ethics?

ANA provides guidelines of acceptable and unacceptable behaviors for how nurses should conduct themselves in their day-to-day practice

what is the purpose of health screenings?

Motivated by the desire to increase well-being (health promotion); meant to detect disease at an early stage

how do people typically define illness?

Illness: A change in the way they feel/a disruption of their typical life

Usually described in terms of how it makes a person feel

What are the characteristics of vulnerable populations?

Groups that are more likely to develop health problems and experience poorer outcomes due to limited access to care, high-risk behaviors, and/or multiple and cumulative stressors (experiencing homelessness, mental illness, economic instability, etc.)

morse fall scale

A rapid and simple method of assessing a patient's likelihood of falling

When to do a fall risk assessment?

For all clients at admission and at regular intervals

what is a nurse?

Asses patients, administer meds/treatments, provide education, and modify care plans based on patient's response to treatment

Licensed Practical Nurse (LPN)

A nurse who has completed a 1-year nursing program and has passed a licensing test; called licensed vocational nurse (LVN) in some states

nursing assistant personnel

Unlicensed assistive personnel (nursing assistants, aides, and techs) provide custodial care under the direction of nurses/providers in a variety of settings

physicians

Licensed medical doctors (MD) or doctors of osteopathy (DO); primary role is to diagnose/treat a disease/illness through medical and surgical services

physican's

responsible for diagnosing illness and disease, prescribing treatments, evaluating the response, examine patients, order and interpret diagnostic tests, and counsel patients on necessary health issues

- may be an M.D., or D.O.

- most take 4 years of undergraduate school, 4 years of medical school, and 3-8 years of residency and an internship in a specialty

- all state license physicians must graduate from an accredited medical school, pass a licensing examination, and complete 1-7 years of graduate medical education

- those seeking board certification may spend years in residency training and take a final examination

physican assistant

a licensed professional who works under the supervision of a physician

Home safety measures

Common safety hazards in the home: Poisoning, carbon monoxide exposure, scalds/burns, fires (smoking, heating equipment, home oxygen administration equipment, unsupervised children, unmonitored candles, faulty wiring), falls, firearm injuries, suffocation/asphyxiation, take-home toxins (bugs, dust, dirty clothes)

Hospital safety (RACE)

Rescue: move clients to a safe area

Alarm: Call EMS, pull fire alarm, alert others

Contain: Closing doors, turning off Oxygen

Extinguish: Using fire Extinguishers

SEIZURE PRECAUTIONS

Make sure rescue equipment is available (padding, Oxygen, suction)

Stay with the patient and call for help

Lower to the floor/bed and protect the head

Do NOT restraint

Do NOT place anything into the mouth

FALL PRECAUTIONS

Remove throw rugs/cords/trip hazards

Using a shower chair and grab bars and non-skid bathroom mats

Use mobility aids (canes)

Use non-slip socks

Patient wear "fall risk" band

Place sign on door

Have bed/chair alarm

Who is Florence Nightingale?

she recorded deaths and their causes during the Crimean War and promoted infection control processes

Who is Clara Barton?

Founder of the American Red Cross

WHO IS ANGEL OF MERCY?

Angel of mercy grew from the influence of religion and the risks inherent to the practice

battle ax nurse

Battle-ax emerged as science and philosophy grew popular during the 17th century and religious orders became less common

Handmaiden

portrays male as nurses

Survival Potential Framework

Emergent- class I/highest priority/immediate tx: chance for survival

Urgent- Class II/ serious and extensive injuries/ do not pose immediate threat to life/ potential for survival even with delayed tx

Nonurgent-Class III/ less serious and less extensive/ no threat

Expectant- Class IV/ potential survival does not exist even with tx

how does self-concept impact health and wellness?

Self-concept has the ability to impact overall health and wellness.

If one has a negative self-concept then their health/wellness will likely be negatively impacted in multiple dimensions.

if they have a positive self-concept their overall health/wellness is impacted positively in multiple dimensions.

gender/sexuality bias role in health and wellness?

Sexuality involves body, mind, and spirit, so it is not surprising that health status affects sexuality. Certain health issues can have an impact on both the physical and emotional aspects of sexuality, and you must be open to discuss any sexual issues with your patients.

contact precautions

practices used to prevent spread of disease by direct or indirect contact

Airborne precautions

Methods of infection control that must be used for patients known or suspected to be infected with pathogens transmitted by airborne droplet nuclei. (N95 MASK)

Droplet precautions

Must be followed for a patient known or suspected to be infected with pathogens transmitted by large-particle droplets expelled during coughing, sneezing, talking, or laughing.

(surgical mask)