NUR 216 Final Exam (Answered) 133
Questions and Correct Answers, 100%
Correct. Updated Fall 2024/2025.
Subjective data
anything reported by the patient (Example) pain, nausea, dyspnea, dysuria, anxiety, dizziness, etc
Objective data
anything you personally assess or see E.g., vitals, physical assessment findings (e.g., edema), diagnostics
Brainpower
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Bell vs. diaphragm of stethoscope
*Use diapHragm for High-pitched sounds·
*Includes breath sounds, heart sounds (S1/S2), & bowel sounds
*Use beLL for Low-pitched & vascuLar sounds (e.g., bruits)
Equipment needed for head-to-toe assessment
-Stethoscope
-Penlight-Blood pressure cuff
-Thermometer
,-Watch
-Glove
Organize physical assessment into "head-to-toe" systematic approach
Goal: gather accurate information thoroughly & efficiently
Order of assessment:·
General survey·
Head & neck
· Chest
· Abdomen·
Lower extremities
Therapeutic communication
ask open-ended questions & encourage patient to verbalize feel- ings.
OLDCARTS & PQRST mnemonics
Assess onset, location, duration, characteristics, aggravating/relieving factors, related symptoms,
severity, & treatment
o Do NOT assess any personal history or family history- Focus on present symptom & assess fully before
moving onto different parts of health history.
Gold standard for assessing pain
patient's self-report (use self-report whenever possible)o If patient unable to self-report (e.g., has
cognitive impairment), assess for nonverbal pain indicators (e.g., groaning or grimacing) instead
Acute pain may cause objective symptoms
increased BP & pulse, etc.
General Survey Purpose
to develop an overall first impression of patient & identify obvious needs
General Survey Components:
Physical appearance
Hygiene
Posture
Physical appearance
age, body structure, etc.
, Hygiene
body odor
Posture
sitting or standing up straight, etc.
Heart rate
60-100 beats per minute
Bradycardia
< 60 BPM
Tachycardia
> 100 BPM
Blood pressure
< 120/ < 80
Hypotension
low blood pressure
Avoid placing BP cuff
over a wound or dressing
SpO2
> 95%
Respiratory rate
12-20 breaths per minute
Bradypnea
< 12 breaths per minute
Tachypnea
> 20 breaths per minute
Temperature
Questions and Correct Answers, 100%
Correct. Updated Fall 2024/2025.
Subjective data
anything reported by the patient (Example) pain, nausea, dyspnea, dysuria, anxiety, dizziness, etc
Objective data
anything you personally assess or see E.g., vitals, physical assessment findings (e.g., edema), diagnostics
Brainpower
Read More
Bell vs. diaphragm of stethoscope
*Use diapHragm for High-pitched sounds·
*Includes breath sounds, heart sounds (S1/S2), & bowel sounds
*Use beLL for Low-pitched & vascuLar sounds (e.g., bruits)
Equipment needed for head-to-toe assessment
-Stethoscope
-Penlight-Blood pressure cuff
-Thermometer
,-Watch
-Glove
Organize physical assessment into "head-to-toe" systematic approach
Goal: gather accurate information thoroughly & efficiently
Order of assessment:·
General survey·
Head & neck
· Chest
· Abdomen·
Lower extremities
Therapeutic communication
ask open-ended questions & encourage patient to verbalize feel- ings.
OLDCARTS & PQRST mnemonics
Assess onset, location, duration, characteristics, aggravating/relieving factors, related symptoms,
severity, & treatment
o Do NOT assess any personal history or family history- Focus on present symptom & assess fully before
moving onto different parts of health history.
Gold standard for assessing pain
patient's self-report (use self-report whenever possible)o If patient unable to self-report (e.g., has
cognitive impairment), assess for nonverbal pain indicators (e.g., groaning or grimacing) instead
Acute pain may cause objective symptoms
increased BP & pulse, etc.
General Survey Purpose
to develop an overall first impression of patient & identify obvious needs
General Survey Components:
Physical appearance
Hygiene
Posture
Physical appearance
age, body structure, etc.
, Hygiene
body odor
Posture
sitting or standing up straight, etc.
Heart rate
60-100 beats per minute
Bradycardia
< 60 BPM
Tachycardia
> 100 BPM
Blood pressure
< 120/ < 80
Hypotension
low blood pressure
Avoid placing BP cuff
over a wound or dressing
SpO2
> 95%
Respiratory rate
12-20 breaths per minute
Bradypnea
< 12 breaths per minute
Tachypnea
> 20 breaths per minute
Temperature
