NSG 316/ NSG316 Exam 1 (NEW 2026/ 2027 Update) Health Assessment Review| Questions & Answers| Grade A| 100% Correct (Verified Solutions)- GCU

…..DLDD NSG 316/ NSG316 Exam 1 (NEW 2026/ 2027 Update) Health Assessment Review| Questions & Answers| Grade A| 100% Correct (Verified Solutions)- GCU Q. When does the general survey begin? ANSWERS The moment you first encounter the person Q. What does the general survey focus on/ consider? ANSWERS physical appearance, body structure, mobility, behavior PBMB Q. Is PBMB subjective or objective? why? ANSWERS Objective, because you are observing them and they are not verbally telling you. Q. What do you look for in physical appearance? ANSWERS age- appears to be stated age sex- appropriate developmental stage for age LOC- alert/ orients & responds to Questions Skin color- appropriate for genetic background facial features- symmetric no signs of acute distress Q. What do you look for in Body Structure? ANSWERS -stature- height in normal rage for age and heritage -nutrition- even body weight distribution -symmetry- body is bilateral -posture- stands comfortably and appropriate for age -position- sits comfortable in chair -body build/ contour: arms span equals height -Obvious deformities- congenital or squired defects Q. What to look for in Mobility? ANSWERS - gait -foot placement- agitate, smooth walking, well balanced -no involuntary movements Q. What to look for in behavior? ANSWERS -facial expression- and sign of pain / distress, expressions are appropriate tot he situation -mood & affect- comfortable and cooperative with examiner -speech- even tased, clear, articulate, communicates in the same language as the interviewee's - dress- appropriate for climate, clean -perosnal hygiene- well groomed and clean Q. What is subjective data? ANSWERS Data that only the subject or "patient" can feel and will tell you. during taking of history Q. IS subjective data signs or symptoms? ANSWERS symptoms Q. What is objective data? ANSWERS What you observe and can measure when inspecting, percussing, palpating, and ausculating during the physical Q. Is objective data the signs or symptoms? ANSWERS signs Q. What is a data base? ANSWERS subjective + objective + patient records + lab studies Q. What is the Complete total health database ANSWERS complete health history + full physical exam current + past health state for a base line Q. What is the Episodic or problem centered database ANSWERS "mini" database one body system/ one probable/ one cue complex hx and exam followed after for short term/ limited problems Q. What is a follow-up database? ANSWERS "after the fact" status of the problem being evaluated at a regular or appropriate time is problem getting better or worse id coping strategies Q. What is Emergency database? ANSWERS Fast collection of data usually only for lifesaving measures rapid and comprehensive - what did you take? How long ago? Who much? Q. Nursing process ANSWERS assessment, diagnosis, outcome identification, planning, implementation, evaluation Q. Assessment: ANSWERS review of record, interview, health hx, physical exam, functional exam, cultural/ spiritual exam, consultation, review of literature Q. Diagnosis ANSWERS interpreting data, comparing clusters of cue to make inference, validation on inference, identify related factors, document the diagnisis Q. Outcome identification? ANSWERS identifying the expected out acmes of the patent (individualized) ensuring realistic and measurable outcomes/goals short term and long term goal criteria Q. Planning ANSWERS establish goal based on patient care goal identify relevant intervention document the plan of care Q. Implementation ANSWERS determine patient readiness in health care process review intervention in a collaborative effort use delegation, mindfulness, supervision, and evaluation counsel person refer for contenting care document the care that was provided Q. Evaluation ANSWERS evaluate individuals condition and compare with expected outcoems summarize identify reasons for failure to achieve outcomes document evaluation in plan of care Q. What is first level priority? ANSWERS Emergent, life threatening, and immediate Q. what is second level priority? ANSWERS Next in urgency, requiring attention so as to avoid further deterioration Q. What is third level priority? ANSWERS Important to patient's health but can be addressed after more urgent problems are addressed Q. evidence-based practice ANSWERS clinical decision making that integrates the best available research with clinical expertise and patient characteristics and preferences Why do you use age specific patient chats? - focus on major risk factors for that age group based on lifestyle, health needs, and problems - positive approach to health aassessment What does HIPPA stand for and what did it implement? HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT implemented patient confidentiality in written, verbal, or electronic communication What type of informaition is protected under HIPPA? - any information that can be linked back tit he patient name, geographic, DOB, addmission, discharge, phone #'s. email, social, medical history, ID #, DL #, any age over 89, full face photo, Health plan beneficiary number Cultural sensitivity goals caregiver possesses basic knowledge and understanding culturally appropriate goals caregiver applies knowledge to improve health outcomes culturally competent goals caregiver apply a universal concept of understanding to all ocntextual aspects of care cultural care goals provision of health care across cultural boundaries in consideration of context What is health? balance of a persons complex, interrelated phenomenon In ones being: physical, mental, spiritual outside world: natural, communal, metaphysical What is illness? the loss of the person's balance, both within one's being and in the outside world Title 6 of the Civil Rights Act of 1964 services can't be denied to people with limited English proficiency What is culture: thoughts, communications, actions, beliefs, values, ans institutions of racial, ethnic, or social groups Characteristics of a culture learned from birth shared by all members, adapted to specific conditions dynamic and chainging Ethnicity is grouped by? -common geographical orgin -migratory status -religion -race -language -shared values, traditions, or symbols -food preferences What is religion? belief in Devine or supernatural powers and and can be obeyed worshiped and beliefs that they are ruler and creator of universie involves practiec What is spirituality? A "journey" that takes place over time and involves the accumulation of life experiences and understanding An attempt to find meaning, value, and purpose in life What is socialization ebbing raised within a culture and having characteristics of that group Acculturation process of adapting to and acquiring another culture assimilation process of developing a new cultural identity and becoming members of domain culture biculturalism dual pattern of identification and often of divided loyalty Biomedical causation theories assume direct cause and effect body is a machine and can be divided into parts germ theory Maturalistic causation theories forces of nature keep in balance ex. yin and yang, hot and cold Magicoreligious Supernatural powers predominate in area of health and illness Examples include voodoo, witchcraft, and faith healing Healing and culture seeking help from folk or religious healer and carried out in the body, mind and spirit Herritage consistency degree to which a persons lifestyle reflects his or her traditional heritage Heritage consistent continumum traditional: living within norms of traditional culture modern: acculturated to norms of dominant society Indicators of heritage conssitancy extended family support of traditional activites family home within ethnic community to which they belong knowledge of language and culture orgin prince in herritage fequent cysts to old country/ neighborhood cultural competence steps? - understand ones own values, beliefs, attitudes, and practices -identify meaning of health to patient -understand how health care system works -acquire knowledge about social backgrounds of patients -become familiar with language, interpretative services, community resources available to nurses and patients Successful interview characteristics? -complete data bout person (health state, description and chronology of symptoms_ -rapport and trust -teach about health state -continue therapeutic realtionship -teach health promotion Elements of the interview process: nonverbal skills, physical appearance, posture, gesture, facial expression, eye contact, voice, touch, closing interview Communication sending: body language: verbal and nonverbal communication receiving: words. gestures interpreted as interviewer seems fit what are open ended questions? begins the interview with new topic or new question section what are close ended questions They require a Yes or a No. These questions are intended to get the most relevant information in the shortest time possible moves the interview faster to know specific information about a health problem (past or present) Empathy the ability to understand and share the feelings of another What is included in the health history? - biographical data, -source of history -reason for seeking care -present health or present illness -past health -family history -review of systmes -functional assessment of daily livings Biographical data: name, adress, phone #, age, DOB, birthplace, sex, marital status, race, wthinci organ, occupation Source: usually the individual but can be a relative or friend wha qualifies someone as a reliable persons: give the same answers when questions are rephrased or repeated letter int he interview Present Health or History of Present Illness Location Character or quality Quantity or severity Timing Setting Aggravating or relieving factors Associated factors Patient's perception HPI for PAIN PQRSTU p- provocative or pallpative Q- Quality or quantity R- Regior or radiation S- ona scale of 1-10 T- timing or onset U- understand the patient perception of the problem Past medical history: Childhood Illnesses (big ones), Accidents or Injuries, Serious or Chronic Illnesses, Hospitalizations, Operations, Obstetric History, Immunizations, Last examination date, Allergies and reaction, Current Medications (prescribed, OTC, Herbal Review of systems: HEAD TO TOE Family hostory age. health, cause of death in realties, health of close family members, various conditions (Heart disease, high BP...) Functional assessment ADL - activities of daily living IADL- instrumental activities of daily living AADLS- advanced activities of daily living self esteem sleep/ rest activities personal/ occupational habits perception of health definition of health, view of situation now, concerns, and health goals what is the CAGE test to test about alcohol consumption What does CAGE stand for? C- Cut down A- annoyed by criticism G0 Guilty about drinking E- Eye opener Enviormental assessments of functional assessment physical environment (safety), falls, elderly driving, sleep, spiritual assessment, special consideration, cultural considerations (impact decision making) Activies of daily living any activity that is performed in one's life on a daily basis eating, bathing, grooming (washing, combing, shaving, cleaning, dressing), toiliteing, walking, transfer bed to chair Instrumental activités of daily living necessary of rindependent community living shopping, meal prep, housekeeping, laundry, managing finance, taking medications, using transportation (historically doe by women) Advanced Activities of daily living performing as a family member, member of society and community, including occupational and recreational activities self care, mobility, work , volunteering, activities/ hobbies, socualization Assessing cognition in functional assessment attention, memory, orientation, language, visuspital skills, higher cognitive function dementia slow onset difficulty with word finding, naming objects, memory Delirium acute changes in cognitions and attention depression A prolonged feeling of helplessness, hopelessness, and sadness memory problems Informal support examples: family, close friends usually free of charge Formal supports: social welfare, social service, health care delivery agencies What is pain stated by a person? what the person says it is What is pain complex and subjective experience that originates form the CNS/ or PSN What are nociceptors? special nerve endings that detect painful sensations where do nociceptors carry the pain signal to CNS Visceral pain in large interior organs deep somatic pain blood vessels, joints, tendons, muscles, and bone injury cutaneous pain skin surface and subcutaneous tissues referred pain radiating pain felt at a particular site but originates from another acute pain short-term, self-limiting, often predictable trajectory; stops after injury heals chronic pain episode of pain that lasts for 6 months or longer; may be intermittent or continuous Malignant related chronic pain parallel pathology created by tumor cells (what the tumor is pushing on) tissue death or stretching of an organ nonmalignant chronic pain with musculoskeletal conditions doesn't stop when injury heals neuropathic pain abnormal processing of pain message; burning, shooting in nature does not adhere to typical phases of nociceptive pain inspection begins with general survey comes first close, and careful scrutiny Needs: - good lighting -adequate exposure - occaitonal uses of instruments palpation using different parts of the hand for assessing different factors fingertips best for palpate fine tactile or skin textures, pulsations and presence of lumps Fingers and thumb best for palpating position, shape, consistency of an organ or mass dora of hands/ fingers best for palapting temperature bc skin is thinner than on the palms base of fingers or ulnar best for palating vibrations Percussion tapping on ones skin with shirt, sharp strokes to assess underlying structures Direct trucking- hand directly contacts body wall indirect striking hand striking hadn't is in contact with the stationary hand on the persons skin Ausculations listening to sounds produced by the body HAND HYGINE wash hands, use alcohol-based hand rub to decrease microorganism transmition when do you preform hand hygiene? before & after physical contact with each patient after inadvertent contact with bod fluids, blood, secretions after contact with equitpment contaminated with body fluids after removing gloves GLOVES not a protective measure or substitute for washing hands decreases contact with body fluids What does HEEDSSS stand for? H- home environment E- education/employment E- eating A- activities peer related D- drugs S- sexuality S- suicide or depression S- safety from injury/violence high levels of independence can cause what in caregivers? burnout, sleep disturbances, depression, morbidity, increased mortality. What things can cause false pallor? Due to vasoconstriction: fear/anger (peripheral vasoconstriction), chilly room (vasoconstriction), cig smoking (vasoconstriction) what causes true pallor? Due to slowed circulation: immobility/inactivity (slowed circulation) Prolonged elevation (decreased arterial perfusion) skin color due to vasodilation erythema skin color due to vasoconstriction pallor What does ABCDE (F) stand for A- asymmetry B- border C- Color D- Diameter E- Elevation/enlargment Capilary refil normal immediate color return (1-2 seconds) What to check for in nails: shape. contour profile sign (160 degree) consistency color capillary refil Erythema Redness cyanosis blue discoloration of the skin caused by a lack of adequate oxygen in the blood Juandice Yellowing of the skin, can indicate bile in the blood as a result of liver or gallbladder disease What to observe in the skin: moisture texture thickness Edema mobility Tutgor vasculatiry or bruising what do many bruises at different stages indicate? physical absue EDEMA: fluid accumulation in the intersitiaal spaces 1+ of pitting scale mild, slight indentation, no perceptible swelling 2+ of pitting scale moderate, indentation subsides rapidly within 2 seconds 3+ od pitting scale deep indentation, remains for short time, appears swollen (few seconds) 4+ of pitting scale very deep indentation, lasts a long time, appears very swollen Skin Lesions observations color elevation pattern/shape location and distribution exudate (anything coming out of it) odor Hair observations color (melanin production) texture distribution lesions (rash, scaling, bumps ) primary lesions appearing from a direct result of the disease secondary lesions lesions that result in changes in primary lesions due to patient activities Stage 1 of bruising color red/ blue/ purple immediate or within 24 hours Stage 2 of bruising color blue to purple Stage 3 of bruising blue/ green Stage 4 of bruising yellow stage 5 of bruising Brown/ disappearing Tinea pedis (athlete's foot) chronic fungal infection of the foot Candidiasis fungal infection found on the skin, mucous membranes, and vagina Turgor elasticity decreased turgor can result from dehydration Vesicle Elevated circumscribed lesion filled with fluid less than 1 cm ex. Varicella Tumor elevated solid lesion greater than 2 cm in diameter Bulla Vesicle greater than 1 cm in diameter. Ex- Blisters Excoriation loss of epidermis abrasion Uritcaria hives Wheal elevated, irregular-shaped area of cutaneous edema; solid, transient, variable diameter ex. Uticaria Papules Elevated firm circumscribed area less than 1 cm in diameter ex. mole Macules Flat circumscribed area less than 1 cm in diameter Ex. Freckes Keloids Irregular-shaped, elevated scars that occur from during tissue repair petechiae a small red or purple spot caused by bleeding into the skin. cyst fluid-filled sac under the skin postule filled with pus located under the skin crust scab scale dry, scale, itchy fissure a deeper crack in the skin erosion eroding into the skin surface Excoriation Skin sore or abrasion produced by scratching or scraping scar smooth even with surrounding (es. stretch marks) Atrophic scar develop under the skin surface multiple lichenification tightly packed set of papules that thickens skin; caused by prolonged intense scratching excoriation + scaling Ecchymosis Bruising or discoloration associated with bleeding within or under the skin. nodule solid, round or oval elevated lesion 1 cm or more in diameter angioma star shaped making with sold circular center bright red dots develops on face, neck , chest associated with pregnancy, chronic liver disease, estrogen therapy seborrhea oily dandruff (loose white flakes) Xerosis dry skin Alopecia Sudden hair loss that starts with one or more circular bald patches that may overlap. hirituism unwanted male pattern hair on females on the dace, chest, back pallor palleness loss of color from skin and mucos membranes Brown- tan bronzed or tan around the nipple, perineum , genetallia Pressure Ulcer stage 1 non balcnable erythema unbroken, red, change in temp, sensation, firmness Pressure ulcer stage 2 partial thickness skin loss xposed dermis looks like a blister with no visible fat ePressure ulcer stage 3 full thickness skin loss extends to subcutaneous fatty tissue Pressure ulcer stage 4 Full thickness involving all layer of the skin exposed muscle, tendon, bone, tunneling and undermining Annular/ circular ring-shaped Confluent run together ex. hives Discrete separate and individual ex. acne gyrate twisted, coiled spiral, snakelike ex. scabies Grouped clusters of lesions multiple in one section linar in a line target like a target symbol annular/ circular with a darker circle in the middle ex. erythema limes disease zosteriform following a nerve branch sort of linear but not ex. shingles polycyclic elevated and running together ex. psoriasis patch larger macule plaque- congruency of multiple papule What is an example of subjective data? a) bp 124/86 b) vomiting c) a patient states their pain is 3/10 d) coughing blood C When is objective data observed? when inspecting, percussing, palpating, and auscultating patient during physical examination Which database is a rapid collection of data, usually compiled concurrently with life saving measures? emergency database. used in the Emergency department which data base is used for short-term problems? Episodic or problem-centered database. urgent care which data base is usually used in primary care clinics? complete total health database Which database is used to check the status of an issue? follow up database ADPIE A- assessment: collection of data from multiple sources D- diagnosis: interpretation of data by identifying clusters of cues to make inferences. validate inferences based on findings. P- planning:establish priorities based on meeting the patient's care goals. develop outcomes and set time frames to meet outcomes I- implementation: determine patient readiness and involve the patient in health care process. review planned interventions. refer for continuing care E- evaluation: evaluate patient's conditions. summarize results. if outcome not met start adpie all over What are examples of biographical data? name, address, age, dob, sex, marital status, race, ethnic origin, occupation T/F signs and symptoms are the same thing False one is subjective, the other is objective. pg50 what does PQRSTU stand for? a tool used to identify a patient's perception of the problem P- provocative or palliative Q- quality or quantity R- region or radiation S- severity scale T- timing U- understand patient's perception What does HEEDSSS stand for? H- home environment E- education/employment E- eating A- activities peer related D- drugs S- sexuality S- suicide or depression S- safety from injury/violence what are geriatric syndromes? urinary incontinence, fragile skin, confusion, problems with eating or feeding, falls, and sleep disorders The nurse is assessing the patient's ability to bathe and dress herself. The nurse knows this type of assessment is considered: 1. the Mini-Cog. 2. independent activities of daily living 3. dependent activities of daily living. 4. activities of daily living. 4. ADLs what are 3 common cognition disorders in older adults? dementia, delirium, and depression What's informal support? family, close friends, do favors at no cots formal support programs such as social welfare, health care delivery etc high levels of independence can cause what in caregivers? burnout, sleep disturbances, depression, morbidity, increased mortality. culturally sensitive nurse has basic knowledge of and constructive attitudes towards diverse cultural populations. culturally appropriate apply underlying background knowledge necessary to provide best possible health what are the 4 concepts of culture learned, shared, adapted, dynamic What things can cause false pallor? Due to vasoconstriction: fear/anger (peripheral vasoconstriction), chilly room (vasoconstriction), cig smoking (vasoconstriction) what causes true pallor? Due to slowed circulation: immobility/inactivity (slowed circulation) Prolonged elevation (decreased arterial perfusion) how does a dark skinned person appear when they have pallor? ashened or grey **observe mucus membranes, nails, and lips** how does a brown skinned person appear when they have pallor? brown/yellow what are some causes of erythema? -hyperemia polycythemia, carbon monoxide poisoning. What is related to fluorescing lesions? fungus skin color due to vasoconstriction pallor skin color due to vasodilation erythema T/F systemic lupus erythematosus is more common in white women than African American women False it's the other way around what is melasma? mask of pregnancy, discoloration of the face. term for razor bumps or ingrown hairs: Pseudofolliculitis keloids: scars that form @ the site of the wound and grow beyond the normal boundaries of the wound. The nurse is assessing a patient who has been admitted for liver failure.What finding would the nurse expect? 1. Cyanosis 2. Flushing 3. Rubor 4. Jaundice. jaundice, yellowing of the skin white hairline markings near cuticle caused by picking @ it : leukonychia fleabite = erythema toxicum red macule of papule in neonates. keratoses are raised, thickened areas of pigmentation that look crusted, scaly, and warty. ring worm lesions: Annular/circular lesion hives are...? confluent lesions acne and skin tags are...? discrete lesions lesions that are spiral or coil like gyrate lesions vesicles of contact dermatitis are associated with what lesions? grouped lesions herpes zoster appears as what type pf lesion? zosteriform what lesion resembles the iris of an eye? target lesions lichen Plans and psoriasis are what kind of lesions? polycyclic lesions freckles fall under what skin lesions? primary lesion** macule a papule is what type of skin lesion? a xanthoma is a ____ , primary skin lesions nodule which wound would be allowed to heal by secondary intention infected hysterectomy incision A tumor is a primary or a secondary lesion? primary lesions Mosquitos bites call under what type of primary lesion? wheal what is the name of the primary lesion that is a fluid filled cavity in the dermis or subcutaneous layer? cyst which primary lesion has pus init's cavity? pustule, contain turbid fluid. a fissure is what type of lesion? secondary T/F a crust is a primary lesion False What are pustules filled with? turbid fluid aka pus. acne