NR 329 FINAL EXAM ACTUAL QUESTIONS AND SOLUTIONS
RATED A+
✔✔HITS Screening Tool - ✔✔physically *Hurt you
*Insult or talk down to you
*Threaten you
*Scream at you
✔✔CAGE-AID - ✔✔screening tool for drinking or drugs
(C=cut down, A=annoy, G=guilty, E=Eye-opener, AID=altered to include drugs
✔✔Sexuality Assessment - ✔✔Never make assumption
Ask about perception
Partner(s)
Protective measures
History of STIs or sexual problems during intercourse
✔✔Functional Assessment - ✔✔ADLs (Bathing, Dressing, Eating, Walking, Meal Prep,
Driving)
✔✔Cultural and Spiritual Assessment - ✔✔- Can impact health care practices
- Needed to provide patient centered care/ holistic care
- Ask questions about beliefs, values, spiritual practices
✔✔Review of Systems - ✔✔subjective report of all body systems
designed to identify normal vs. abnormal
patient reports/denies symptoms
head to toe survey
✔✔Mental Health Assessment - ✔✔Observe: general appearance, grooming/hygiene,
posture, behavior/mood, emotion, speech, orientation, memory, signs of depression
✔✔Reliability of Data - ✔✔Includes verbal, non-verbal, and statement of reliability.
"Client sat in a relaxed manner, answered questions without hesitations and gave no
conflicting information. Client is assumed reliable." "Client is reliable as evidenced by..."
Client's reliability is questioned because of..."
✔✔Assessment Techniques - ✔✔Inspection
Palpation
Percussion
Auscultation
✔✔Inspection - ✔✔general observation of the patient as a whole, progressing to
specific body areas
, ✔✔Palpation - ✔✔an examination technique in which the examiner's hands are used to
feel the texture, size, consistency, and location of certain body parts
palpate tender areas last
✔✔Percussion - ✔✔a diagnostic procedure designed to determine the density of a body
part by the sound produced by tapping the surface with the fingers
✔✔Percussion Sounds - ✔✔resonance (hollow) - chest/lungs
hyperresonant (booming) - hyperinflation of lungs/air in pleural space
dull (thud like) - solid organ, fluid filled spaces
flat (dull) - muscle, bones
tympany (drum-like) - air filled: abdomen
✔✔Auscultation - ✔✔listening to sounds within the body
✔✔General Survey - ✔✔study of the whole person, covering the general health state
and any obvious physical characteristics
✔✔Vital Signs - ✔✔temperature, pulse, respirations, blood pressure, oxygenation, and
pain
✔✔Temperature - ✔✔Normal Range 36 to 37.5 C or 97.5 to 99.5 F
Fever: 38 C or 100.5 F
✔✔Pulse Rate - ✔✔Rate, Rhythm, Amplitude/Quality
Normal Range: 60 - 100 bpm
Tachycardia > 100
Bradycardia < 60
Rate 0 to 3 : 0-no pulse, +1-weak/thready, +2-normal, +3-bounding
✔✔pulse deficit - ✔✔the difference between the rate of an apical pulse and the rate of a
radial pulse
✔✔Respiratory rate - ✔✔Rate, Depth, Rythym
normal (eupnea): 12-20
bradypnea < 12
Tachypnea > 20
✔✔Blood Pressure - ✔✔Normal: 100-120/60-80
Hypotension: < 90/60
Hypertension: > 130/80 (various stages)
MAP: (systolic + (diastolic x 2))/3
✔✔Auscultatory Gap - ✔✔a brief period when Korotkoff sounds disappear during
auscultation of blood pressure; common with hypertension
RATED A+
✔✔HITS Screening Tool - ✔✔physically *Hurt you
*Insult or talk down to you
*Threaten you
*Scream at you
✔✔CAGE-AID - ✔✔screening tool for drinking or drugs
(C=cut down, A=annoy, G=guilty, E=Eye-opener, AID=altered to include drugs
✔✔Sexuality Assessment - ✔✔Never make assumption
Ask about perception
Partner(s)
Protective measures
History of STIs or sexual problems during intercourse
✔✔Functional Assessment - ✔✔ADLs (Bathing, Dressing, Eating, Walking, Meal Prep,
Driving)
✔✔Cultural and Spiritual Assessment - ✔✔- Can impact health care practices
- Needed to provide patient centered care/ holistic care
- Ask questions about beliefs, values, spiritual practices
✔✔Review of Systems - ✔✔subjective report of all body systems
designed to identify normal vs. abnormal
patient reports/denies symptoms
head to toe survey
✔✔Mental Health Assessment - ✔✔Observe: general appearance, grooming/hygiene,
posture, behavior/mood, emotion, speech, orientation, memory, signs of depression
✔✔Reliability of Data - ✔✔Includes verbal, non-verbal, and statement of reliability.
"Client sat in a relaxed manner, answered questions without hesitations and gave no
conflicting information. Client is assumed reliable." "Client is reliable as evidenced by..."
Client's reliability is questioned because of..."
✔✔Assessment Techniques - ✔✔Inspection
Palpation
Percussion
Auscultation
✔✔Inspection - ✔✔general observation of the patient as a whole, progressing to
specific body areas
, ✔✔Palpation - ✔✔an examination technique in which the examiner's hands are used to
feel the texture, size, consistency, and location of certain body parts
palpate tender areas last
✔✔Percussion - ✔✔a diagnostic procedure designed to determine the density of a body
part by the sound produced by tapping the surface with the fingers
✔✔Percussion Sounds - ✔✔resonance (hollow) - chest/lungs
hyperresonant (booming) - hyperinflation of lungs/air in pleural space
dull (thud like) - solid organ, fluid filled spaces
flat (dull) - muscle, bones
tympany (drum-like) - air filled: abdomen
✔✔Auscultation - ✔✔listening to sounds within the body
✔✔General Survey - ✔✔study of the whole person, covering the general health state
and any obvious physical characteristics
✔✔Vital Signs - ✔✔temperature, pulse, respirations, blood pressure, oxygenation, and
pain
✔✔Temperature - ✔✔Normal Range 36 to 37.5 C or 97.5 to 99.5 F
Fever: 38 C or 100.5 F
✔✔Pulse Rate - ✔✔Rate, Rhythm, Amplitude/Quality
Normal Range: 60 - 100 bpm
Tachycardia > 100
Bradycardia < 60
Rate 0 to 3 : 0-no pulse, +1-weak/thready, +2-normal, +3-bounding
✔✔pulse deficit - ✔✔the difference between the rate of an apical pulse and the rate of a
radial pulse
✔✔Respiratory rate - ✔✔Rate, Depth, Rythym
normal (eupnea): 12-20
bradypnea < 12
Tachypnea > 20
✔✔Blood Pressure - ✔✔Normal: 100-120/60-80
Hypotension: < 90/60
Hypertension: > 130/80 (various stages)
MAP: (systolic + (diastolic x 2))/3
✔✔Auscultatory Gap - ✔✔a brief period when Korotkoff sounds disappear during
auscultation of blood pressure; common with hypertension
