1
NR i304 iFinal iExam iConcepts
Chapter i1:
• Identify isteps iof iNursing iProcess: iEvaluation
o Reassessment iof ipatient
o Have igoals ibeen imet?
• Identify itasks iin iNursing iProcess: iDiagnosis
o Compiling idata ito idetermine iNANDA idiagnosis ifor ipatient
o Cluster idata, idiscard iirrelevant iinformation
• Types iof iDatabases: iProblem iCentered
o Limited ior ishort-term iproblem
o Concerns ione iproblem, icomplex, ior ibody isystem
o Used iin iall isettings
Chapter i9:
• Identify iComponents iof ithe iGeneral iSurvey
o Study iof ithe iwhole iperson
o Begins iupon ientry ito ithe iroom
o Physical iappearance
▪ Age: iperson iappears itheir istated iage
▪ Sex: idevelopment iis iappropriate ifor isex iand iage; iif itransgender inote istage
iof itransformation
▪ Level iof iconsciousness: ialert iand ioriented ito iperson, iplace, itime, iand
isituation
▪ Skin icolor: icolor itone ieven, ipigmentation ivaries, iskin iintact, inote itattoos
iand ipiercings
▪ Facial ifeatures: inote isymmetry
▪ Overall iappearance: iacute idistress?
o Body istructure
▪ Stature: iheight iin inormal irange ifor iage/genetics?
▪ Nutrition: iweight iwithin inormal irange ifor iheight/build?
▪ Symmetry: ibody iparts iequal ibilaterally?
▪ Posture: istand ierect icomfortably? i “plumb iline” ithrough ianterior iear,
ishoulder, ihip, ipatella, iankle
• Exceptions iare itoddler ilordosis iand iaging iperson iwith ikyphosis
▪ Position: isits icomfortably iwith iarms irelaxed iat isides iand ihead itowards
iexaminer
▪ Body ibuild, icontour:
• Arm ispan i= iheight
• Crown ito ipubis i≈ ipubis ito isole
▪ Obvious iphysical ideformities?
o Mobility
, 2
▪Gait: ifeet ishoulder iwidth iapart, ifoot iplacement iaccurate, iwalk ismooth iand
ieven, imaintain ibalance iwithout iassistance, isymmetric iarm iswing ipresent
▪ Range iof imotion: ifull imobility ifor ieach ijoint; imovement iis ideliberate,
iaccurate, ismooth, icoordinated; ino iinvoluntary imovement
o Behavior
▪ Facial iexpression: imaintains ieye icontact i(if iculturally iappropriate),
iexpressions iappropriate ito isituation
▪ Mood iand iaffect: iperson icomfortable iand icooperative, iinteracts ipleasantly
▪ Speech: iarticulation iclear iand iunderstandable
▪ Speech ipattern: ifluent iwith ieven ipace, iconveys iideas iclearly, iword ichoice
iappropriate ifor iculture/education, icommunicates ieasily iby ithemselves ior
iwith iinterpreter
▪ Dress: iclothing iappropriate ito iclimate iand iculture, iclean iand ifits ibody
▪ Personal ihygiene: iclean iand igroomed iappropriately ifor iage, ioccupation,
isocioeconomic igroup
o How idoes ithe ipatient iinteract iwith iothers?
Chapter i10:
• Differentiate ithe igrading iof iPulse iForce
o Three-point iscale
▪ 3+ i= ifull, ibounding ipulse
▪ 2+ i= inormal
▪ 1+ i= iweak, ithready
▪ 0 i= iabsent
• Identify iHypotension iOccurrences iand iRationales
o Acute imyocardial iinfarction i idecreased icardiac ioutput
o Shock i idecreased icardiac ioutput
o Hemorrhage i idecrease iin itotal iblood ivolume
o Vasodilation i idecrease iin iperipheral ivascular iresistance
o Addison idisease i(hypofunction iof iadrenal iglands) i idecrease iin icirculating
ialdosterone
• Recognize ihow ito iCount iRespirations
o Do inot itell ipatient iyou iare icounting irespirations
o Continue ifor i30 iseconds iafter iassessing ipulse
o 30 iseconds imultiply iby i2, ior ifull iminute iif iyou isuspect iabnormality
• Recognize ithe iEffects iof iSmoking ion iBlood iPressure
o Contributes ito ihypertension
Chapter i11:
• Identify iPhysiologic iChanges: iAcute iPain iResponses
o Guarding
o Grimacing
NR i304 iFinal iExam iConcepts
Chapter i1:
• Identify isteps iof iNursing iProcess: iEvaluation
o Reassessment iof ipatient
o Have igoals ibeen imet?
• Identify itasks iin iNursing iProcess: iDiagnosis
o Compiling idata ito idetermine iNANDA idiagnosis ifor ipatient
o Cluster idata, idiscard iirrelevant iinformation
• Types iof iDatabases: iProblem iCentered
o Limited ior ishort-term iproblem
o Concerns ione iproblem, icomplex, ior ibody isystem
o Used iin iall isettings
Chapter i9:
• Identify iComponents iof ithe iGeneral iSurvey
o Study iof ithe iwhole iperson
o Begins iupon ientry ito ithe iroom
o Physical iappearance
▪ Age: iperson iappears itheir istated iage
▪ Sex: idevelopment iis iappropriate ifor isex iand iage; iif itransgender inote istage
iof itransformation
▪ Level iof iconsciousness: ialert iand ioriented ito iperson, iplace, itime, iand
isituation
▪ Skin icolor: icolor itone ieven, ipigmentation ivaries, iskin iintact, inote itattoos
iand ipiercings
▪ Facial ifeatures: inote isymmetry
▪ Overall iappearance: iacute idistress?
o Body istructure
▪ Stature: iheight iin inormal irange ifor iage/genetics?
▪ Nutrition: iweight iwithin inormal irange ifor iheight/build?
▪ Symmetry: ibody iparts iequal ibilaterally?
▪ Posture: istand ierect icomfortably? i “plumb iline” ithrough ianterior iear,
ishoulder, ihip, ipatella, iankle
• Exceptions iare itoddler ilordosis iand iaging iperson iwith ikyphosis
▪ Position: isits icomfortably iwith iarms irelaxed iat isides iand ihead itowards
iexaminer
▪ Body ibuild, icontour:
• Arm ispan i= iheight
• Crown ito ipubis i≈ ipubis ito isole
▪ Obvious iphysical ideformities?
o Mobility
, 2
▪Gait: ifeet ishoulder iwidth iapart, ifoot iplacement iaccurate, iwalk ismooth iand
ieven, imaintain ibalance iwithout iassistance, isymmetric iarm iswing ipresent
▪ Range iof imotion: ifull imobility ifor ieach ijoint; imovement iis ideliberate,
iaccurate, ismooth, icoordinated; ino iinvoluntary imovement
o Behavior
▪ Facial iexpression: imaintains ieye icontact i(if iculturally iappropriate),
iexpressions iappropriate ito isituation
▪ Mood iand iaffect: iperson icomfortable iand icooperative, iinteracts ipleasantly
▪ Speech: iarticulation iclear iand iunderstandable
▪ Speech ipattern: ifluent iwith ieven ipace, iconveys iideas iclearly, iword ichoice
iappropriate ifor iculture/education, icommunicates ieasily iby ithemselves ior
iwith iinterpreter
▪ Dress: iclothing iappropriate ito iclimate iand iculture, iclean iand ifits ibody
▪ Personal ihygiene: iclean iand igroomed iappropriately ifor iage, ioccupation,
isocioeconomic igroup
o How idoes ithe ipatient iinteract iwith iothers?
Chapter i10:
• Differentiate ithe igrading iof iPulse iForce
o Three-point iscale
▪ 3+ i= ifull, ibounding ipulse
▪ 2+ i= inormal
▪ 1+ i= iweak, ithready
▪ 0 i= iabsent
• Identify iHypotension iOccurrences iand iRationales
o Acute imyocardial iinfarction i idecreased icardiac ioutput
o Shock i idecreased icardiac ioutput
o Hemorrhage i idecrease iin itotal iblood ivolume
o Vasodilation i idecrease iin iperipheral ivascular iresistance
o Addison idisease i(hypofunction iof iadrenal iglands) i idecrease iin icirculating
ialdosterone
• Recognize ihow ito iCount iRespirations
o Do inot itell ipatient iyou iare icounting irespirations
o Continue ifor i30 iseconds iafter iassessing ipulse
o 30 iseconds imultiply iby i2, ior ifull iminute iif iyou isuspect iabnormality
• Recognize ithe iEffects iof iSmoking ion iBlood iPressure
o Contributes ito ihypertension
Chapter i11:
• Identify iPhysiologic iChanges: iAcute iPain iResponses
o Guarding
o Grimacing
