Nur 265 Final Exam || with Error-free Answers.
Subjective data correct answers what the person says about himself or herself during history
taking
Objective data correct answers what the health professional observes by inspecting, palpating,
percussing, and auscultating during the physical examination
Primary data sources correct answers From the patients or your observations
Secondary data sources correct answers From family members or other healthcare staffG
General survey correct answers study of the whole person, covering the general health state and
any obvious physical characteristics
Complete assessment correct answers complete health history & full physical exam. describes
the current & past health state & forms a baseline. collected by a primary physician
Focused assessment correct answers assessment conducted to assess a specific problem; focuses
on pertinent history and body regions
follow up assessment correct answers it is one that is conducted at regular intervals during care
of the patient; concentrates on identified health problems to monitor positive or negative changes
and evaluate the effectiveness of interventions
insepction correct answers visual examination
Palpation correct answers an examination technique in which the examiner's hands are used to
feel the texture, size, consistency, and location of certain body parts
,ascultation correct answers listening to sounds within the body
Percussion correct answers tapping on a surface to determine the difference in the density of the
underlying structure
Tympany percussion correct answers high-pitched, loud, drum-like sound produced over the
stomach
dullness percussion correct answers Fluid or mass under area being percussed
First level priority correct answers emergent, life-threatening, and immediate, such as
establishing an airway or supporting breathing
Second level priority correct answers Problems next in urgency-those requiring your prompt
intervention to forestall further deterioration.
EX: Mental status change, untreated medical problems, acute pain, acute urinary elimination
problems, abnormal lad values, or risk of infection.
Third level priority correct answers Health problems that don't fit into more severe categories.
Such as lack of activity, rest or family coping.
Therapeutic communication correct answers Verbal and nonverbal communication techniques
that encourage patients to express their feelings and to achieve a positive relationship.
Pressure Injury Stage 1 correct answers intact skin, non-blanchable redness
Pressure Injury Stage 2 correct answers skin loss (partial-thickness); may see a blister or shallow
reddish-pink ulcer; the blister may be intact or open
, Pressure Injury Stage 3 correct answers skin loss (full-thickness); skin gone; may see
subcutaneous fat; slough (dead soft tissue, often moist and varies in color - white, yellow, green,
or tan) may be present; could be attached or stringy loose
Pressure Injury Stage 4 correct answers full-thickness skin and tissue loss with muscle, tendon,
and bone exposure; slough and eschar (thick, leathery dead tissue that may be loose or attached
to skin); often black or brown
unstageable pressure injury correct answers Full-thickness skin and tissue loss in which the
extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or
eschar.
Deep tissue injury correct answers Purple or maroon localized area of discolored intact skin or
blood-filled blister due to damage of underlying soft tissue from pressure and/or shear.
Interventions to prevent pressure injuries correct answers Inspect skin daily
Manage mositure
Skin care
Minimize pressure
Avoid friction to skin
Optimize nutrition and hydration
Abnormal Lesion Assessment: ABCDE correct answers Asymmetry
Border
Color
Diameter
Elevation & Evolution
Primary lesion correct answers skin lesion caused directly by a disease process; result of specific
triggering agent to change previous intact skin and occur at onset of disease
Subjective data correct answers what the person says about himself or herself during history
taking
Objective data correct answers what the health professional observes by inspecting, palpating,
percussing, and auscultating during the physical examination
Primary data sources correct answers From the patients or your observations
Secondary data sources correct answers From family members or other healthcare staffG
General survey correct answers study of the whole person, covering the general health state and
any obvious physical characteristics
Complete assessment correct answers complete health history & full physical exam. describes
the current & past health state & forms a baseline. collected by a primary physician
Focused assessment correct answers assessment conducted to assess a specific problem; focuses
on pertinent history and body regions
follow up assessment correct answers it is one that is conducted at regular intervals during care
of the patient; concentrates on identified health problems to monitor positive or negative changes
and evaluate the effectiveness of interventions
insepction correct answers visual examination
Palpation correct answers an examination technique in which the examiner's hands are used to
feel the texture, size, consistency, and location of certain body parts
,ascultation correct answers listening to sounds within the body
Percussion correct answers tapping on a surface to determine the difference in the density of the
underlying structure
Tympany percussion correct answers high-pitched, loud, drum-like sound produced over the
stomach
dullness percussion correct answers Fluid or mass under area being percussed
First level priority correct answers emergent, life-threatening, and immediate, such as
establishing an airway or supporting breathing
Second level priority correct answers Problems next in urgency-those requiring your prompt
intervention to forestall further deterioration.
EX: Mental status change, untreated medical problems, acute pain, acute urinary elimination
problems, abnormal lad values, or risk of infection.
Third level priority correct answers Health problems that don't fit into more severe categories.
Such as lack of activity, rest or family coping.
Therapeutic communication correct answers Verbal and nonverbal communication techniques
that encourage patients to express their feelings and to achieve a positive relationship.
Pressure Injury Stage 1 correct answers intact skin, non-blanchable redness
Pressure Injury Stage 2 correct answers skin loss (partial-thickness); may see a blister or shallow
reddish-pink ulcer; the blister may be intact or open
, Pressure Injury Stage 3 correct answers skin loss (full-thickness); skin gone; may see
subcutaneous fat; slough (dead soft tissue, often moist and varies in color - white, yellow, green,
or tan) may be present; could be attached or stringy loose
Pressure Injury Stage 4 correct answers full-thickness skin and tissue loss with muscle, tendon,
and bone exposure; slough and eschar (thick, leathery dead tissue that may be loose or attached
to skin); often black or brown
unstageable pressure injury correct answers Full-thickness skin and tissue loss in which the
extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or
eschar.
Deep tissue injury correct answers Purple or maroon localized area of discolored intact skin or
blood-filled blister due to damage of underlying soft tissue from pressure and/or shear.
Interventions to prevent pressure injuries correct answers Inspect skin daily
Manage mositure
Skin care
Minimize pressure
Avoid friction to skin
Optimize nutrition and hydration
Abnormal Lesion Assessment: ABCDE correct answers Asymmetry
Border
Color
Diameter
Elevation & Evolution
Primary lesion correct answers skin lesion caused directly by a disease process; result of specific
triggering agent to change previous intact skin and occur at onset of disease
