NUR 265 Final Exam
Study online at https://quizlet.com/_d5cpc9
1. subjective data: Things a person tells you about that you cannot observe through your senses; symptoms
2. objective data: information that is seen, heard, felt, or smelled by an observer; signs
3. Primary data source: patient
4. Secondary Data Sources: family members, health records, significant others
5. General Survey: physical appearance, body structure, mobility, behavior
6. Complete database: full physical exam
7. Focused database: focuses on 1 or 2 systems
8. Follow-up database: follow-up after implementation
9. inspection: use of sight to gather data
used throughout PE
tools used to enhance inspection (penlight)
10. palpation: start light to deep
palpate tender areas last
dorsum for temp
palms for pulsations
tips of fingers for texture, moisture, mass, edema
11. percussion: tapping on a surface to determine the difference in the density of the underlying structure
(flatness, dullness, resonance, hyperresonance, tympany)
12. Auscultation: Diaphragm- BP, lungs, BS, heart
Bell- vascular sounds, murmur
Auscultation
13. gender role: a set of expected behaviors for males or for females
14. gender: in psychology, the biologically and socially influenced characteristics by which people define male
and female
15. gender identity: one's sense of being male or female
16. pressure injuries: injuries or wounds that result from skin deterioration and shearing
17. Stage 1 Pressure Injury: non-blanchable erythema of intact skin
18. Stage 2 Pressure Injury: partial-thickness skin loss with exposed dermis
19. Stage 3 Pressure Injury: full-thickness skin loss; not involving underlying fascia
20. Stage 4 Pressure Injury: full-thickness skin and tissue loss
21. Unstageable Pressure Injury: obscured full-thickness skin and tissue loss
22. Deep Tissue Pressure Injury: persistent non-blanchable deep red, maroon, or purple discoloration
, NUR 265 Final Exam
Study online at https://quizlet.com/_d5cpc9
23. prevention of pressure injuries: -good nursing care:
-assessment of skin/pressure points (done on daily basis)
-assist bedfast patient's pressure point every 2 hours
-multiple risk factor for skin break down (check every 2-3 hours)
24. ABCDE: asymmetry, border, color, diameter, evolution
25. primary lesions: lesions arising from previously normal skin
26. secondary lesions: lesions that result in changes in primary lesions
27. skin assessment: color: - general pigmentation, freckles, moles, birthmarks
- widespread color change such as pallor, erythema, cyanosis, or jaundice
28. annular, discrete:
29. linear:
30. Zosteriform:
31. confluent:
32. grouped:
33. gyrate:
34. polycyclic:
35. location of valves: -bicuspid (mitral) valve located on left side
-tricuspid valve located on right side
36. S1 heard loudest at: apex of the heart
37. S2 heard loudest at: base of the heart
38. right sided heart failure: - blood back into the body
- fatigue
- increased peripheral venous pressure
- ascites
- enlarged liver and spleen
- may be secondary to chronic pulmonary problems
- distended jugular veins
- anorexia and complaints of GI distress
- weight gain
- dependent edema
39. Left sided heart failure: - blood backs up into the lungs
- paroxysmal nocturnal dyspnea
Study online at https://quizlet.com/_d5cpc9
1. subjective data: Things a person tells you about that you cannot observe through your senses; symptoms
2. objective data: information that is seen, heard, felt, or smelled by an observer; signs
3. Primary data source: patient
4. Secondary Data Sources: family members, health records, significant others
5. General Survey: physical appearance, body structure, mobility, behavior
6. Complete database: full physical exam
7. Focused database: focuses on 1 or 2 systems
8. Follow-up database: follow-up after implementation
9. inspection: use of sight to gather data
used throughout PE
tools used to enhance inspection (penlight)
10. palpation: start light to deep
palpate tender areas last
dorsum for temp
palms for pulsations
tips of fingers for texture, moisture, mass, edema
11. percussion: tapping on a surface to determine the difference in the density of the underlying structure
(flatness, dullness, resonance, hyperresonance, tympany)
12. Auscultation: Diaphragm- BP, lungs, BS, heart
Bell- vascular sounds, murmur
Auscultation
13. gender role: a set of expected behaviors for males or for females
14. gender: in psychology, the biologically and socially influenced characteristics by which people define male
and female
15. gender identity: one's sense of being male or female
16. pressure injuries: injuries or wounds that result from skin deterioration and shearing
17. Stage 1 Pressure Injury: non-blanchable erythema of intact skin
18. Stage 2 Pressure Injury: partial-thickness skin loss with exposed dermis
19. Stage 3 Pressure Injury: full-thickness skin loss; not involving underlying fascia
20. Stage 4 Pressure Injury: full-thickness skin and tissue loss
21. Unstageable Pressure Injury: obscured full-thickness skin and tissue loss
22. Deep Tissue Pressure Injury: persistent non-blanchable deep red, maroon, or purple discoloration
, NUR 265 Final Exam
Study online at https://quizlet.com/_d5cpc9
23. prevention of pressure injuries: -good nursing care:
-assessment of skin/pressure points (done on daily basis)
-assist bedfast patient's pressure point every 2 hours
-multiple risk factor for skin break down (check every 2-3 hours)
24. ABCDE: asymmetry, border, color, diameter, evolution
25. primary lesions: lesions arising from previously normal skin
26. secondary lesions: lesions that result in changes in primary lesions
27. skin assessment: color: - general pigmentation, freckles, moles, birthmarks
- widespread color change such as pallor, erythema, cyanosis, or jaundice
28. annular, discrete:
29. linear:
30. Zosteriform:
31. confluent:
32. grouped:
33. gyrate:
34. polycyclic:
35. location of valves: -bicuspid (mitral) valve located on left side
-tricuspid valve located on right side
36. S1 heard loudest at: apex of the heart
37. S2 heard loudest at: base of the heart
38. right sided heart failure: - blood back into the body
- fatigue
- increased peripheral venous pressure
- ascites
- enlarged liver and spleen
- may be secondary to chronic pulmonary problems
- distended jugular veins
- anorexia and complaints of GI distress
- weight gain
- dependent edema
39. Left sided heart failure: - blood backs up into the lungs
- paroxysmal nocturnal dyspnea
