NURS 143 EXAM#3 REVIEW QUESTIONS WITH
VERIFIED SOLUTIONS
Describe the components general survey?
1. Physical appearance - age, sexual development, LOC, skin, facial features.
2. Body structure - stature, nutrition, symmetry, posture, position, body build, contour
3. Mobility - normal gait, ROM
4. Behaviour - facial expression, mood and affect, speech, dress, personal hygiene
Describe the components of a priority assessment.
1. General appearance - facial expression, body position, LOC, colour, eyes (open), speech,
hearing, hygiene
2. Airway - patency, gurgling, coughing, suction
3. Breathing - rate, rhythm, effectiveness, O2
4. Circulation/movement/sensation - radial pulse (regular/irregular), ability to squeeze fingers,
dorsal pedal, tibial, edema, sensation
5. Discomfort/Disability - O-V, pupil reactivity, facial symmetry, GCS
6. Equipment - IV, O2, drainage, catheters, dressings
7. Measurements - vitals
Describe a focused assessment.
Assessment which is determining the status of a specific problem identified in an initial
assessment.
How do you complete a PCRA?
1. Check for signage outside of the room
2. Scan floor for spills and tripping hazards
3. Assess bed rails and brakes
4. Check necessary equipment
5. ID the patient + complete primary and general survey
6. Pull the curtain for privacy
When does the nurse complete a head-to-toe assessment or a complete health assessment?
A nurse completes a complete health assessment when the patient is being admitted to a facility,
or when they have little information previously on the patient.
In what order is data taken for a focused assessment?
1. Inspection
2. Palpation
3. Percussion
4. Auscultation
,What is involved in a pain assessment?
O-V questions.
1. Onset
2. Provoking/palliating factos
3. Quality
4. Region/radiation
5. Severity
6. Treatment
7. Understanding
8. Values
What are the components of safe administration of medication?
1. Familiarity with the medication (generic/trade names, mechanism of action, classification,
effects, side effects, interactions, contraindications)
2. Identifies patient allergies
3. Checks accuracy of the MAR
4. Performs 10 rights 3x
5. Hand hygiene
6. Appropriate administration
What are some developmental considerations concerning the integumentary system for
newborns?
Lanugo, vernix caseosa, permeability of the skin, risk for fluid loss, and ineffective temperature
regulation.
Define lanugo.
Fine, soft hair of newborns.
Define vernix caseosa.
A cheesy coating on newborn skin.
What are some developmental considerations concerning the integumentary system for
children during puberty?
- Increased sweat gland secretions
- More active sebaceous glands
- Evidence of secondary sex characteristics in the skin
What are some development considerations concerning the integumentary system for
pregnant individuals?
- Linea nigra
- Striae gravidarum
- Chloasma
, - Increased sweat and sebaceous secretions
- Fat deposits
Define linea nigra.
Darkening line down abdomen that can occur during pregnancy.
Define chloasma.
Discoloration changes on the face from increased estrogen levels that stimulates increased
melanin production (hyper pigmentation). This can occur during pregnancy.
Define striae gravidarum.
Stretch marks, which can develop over the abdomen, breast, and thighs during pregnancy.
What are some developmental considerations concerning the integumentary system for
older adults?
- Atrophy of skin structures
- Loss of elasticity, collagen, subcutaneous fat
- Thinning of stratum corneum and dermis
- Decreased sweat and sebaceous glands
- Greater risk for heat stroke
- Senile purpura
- Increased risk for skin disease
- Change in hair distribution
- Psychological impact of visible aging
Define stratum corneum.
The outer, keratinized layer of the skin which can thin with age.
Define senile purpura.
Extravascular irregularly shaped blood discolorations that often appear on arms & backs of
hands. These discolourations can occur with age.
What is involved in inspection of the integumentary system?
- Colour
- General pigmentation
- Presence of freckles, moles, birthmarks
- Widespread colour change
- Pallor
- Erythema
- Cyanosis
- Jaundice
Define pallor.
VERIFIED SOLUTIONS
Describe the components general survey?
1. Physical appearance - age, sexual development, LOC, skin, facial features.
2. Body structure - stature, nutrition, symmetry, posture, position, body build, contour
3. Mobility - normal gait, ROM
4. Behaviour - facial expression, mood and affect, speech, dress, personal hygiene
Describe the components of a priority assessment.
1. General appearance - facial expression, body position, LOC, colour, eyes (open), speech,
hearing, hygiene
2. Airway - patency, gurgling, coughing, suction
3. Breathing - rate, rhythm, effectiveness, O2
4. Circulation/movement/sensation - radial pulse (regular/irregular), ability to squeeze fingers,
dorsal pedal, tibial, edema, sensation
5. Discomfort/Disability - O-V, pupil reactivity, facial symmetry, GCS
6. Equipment - IV, O2, drainage, catheters, dressings
7. Measurements - vitals
Describe a focused assessment.
Assessment which is determining the status of a specific problem identified in an initial
assessment.
How do you complete a PCRA?
1. Check for signage outside of the room
2. Scan floor for spills and tripping hazards
3. Assess bed rails and brakes
4. Check necessary equipment
5. ID the patient + complete primary and general survey
6. Pull the curtain for privacy
When does the nurse complete a head-to-toe assessment or a complete health assessment?
A nurse completes a complete health assessment when the patient is being admitted to a facility,
or when they have little information previously on the patient.
In what order is data taken for a focused assessment?
1. Inspection
2. Palpation
3. Percussion
4. Auscultation
,What is involved in a pain assessment?
O-V questions.
1. Onset
2. Provoking/palliating factos
3. Quality
4. Region/radiation
5. Severity
6. Treatment
7. Understanding
8. Values
What are the components of safe administration of medication?
1. Familiarity with the medication (generic/trade names, mechanism of action, classification,
effects, side effects, interactions, contraindications)
2. Identifies patient allergies
3. Checks accuracy of the MAR
4. Performs 10 rights 3x
5. Hand hygiene
6. Appropriate administration
What are some developmental considerations concerning the integumentary system for
newborns?
Lanugo, vernix caseosa, permeability of the skin, risk for fluid loss, and ineffective temperature
regulation.
Define lanugo.
Fine, soft hair of newborns.
Define vernix caseosa.
A cheesy coating on newborn skin.
What are some developmental considerations concerning the integumentary system for
children during puberty?
- Increased sweat gland secretions
- More active sebaceous glands
- Evidence of secondary sex characteristics in the skin
What are some development considerations concerning the integumentary system for
pregnant individuals?
- Linea nigra
- Striae gravidarum
- Chloasma
, - Increased sweat and sebaceous secretions
- Fat deposits
Define linea nigra.
Darkening line down abdomen that can occur during pregnancy.
Define chloasma.
Discoloration changes on the face from increased estrogen levels that stimulates increased
melanin production (hyper pigmentation). This can occur during pregnancy.
Define striae gravidarum.
Stretch marks, which can develop over the abdomen, breast, and thighs during pregnancy.
What are some developmental considerations concerning the integumentary system for
older adults?
- Atrophy of skin structures
- Loss of elasticity, collagen, subcutaneous fat
- Thinning of stratum corneum and dermis
- Decreased sweat and sebaceous glands
- Greater risk for heat stroke
- Senile purpura
- Increased risk for skin disease
- Change in hair distribution
- Psychological impact of visible aging
Define stratum corneum.
The outer, keratinized layer of the skin which can thin with age.
Define senile purpura.
Extravascular irregularly shaped blood discolorations that often appear on arms & backs of
hands. These discolourations can occur with age.
What is involved in inspection of the integumentary system?
- Colour
- General pigmentation
- Presence of freckles, moles, birthmarks
- Widespread colour change
- Pallor
- Erythema
- Cyanosis
- Jaundice
Define pallor.
