NUR 215 Final Exam
Four types of assessments - answer1. complete (total health)
2. focused/problem centered
3. follow-up
4. emergency
complete assessment - answer new patient/clinic setting
focused/problem centered assessment - answer patient comes in for something specific
follow up assessment - answer revisit/checkup on last visit's reason
emergency assessment - answer accident/ER visit
complete or comprehensive exam - answer consists of complete health history and full
head to toe physical exam
two key parts of a complete health exam - answer objective and subjective
objective data - answerwhat the healthcare provider observes
subjective data - answerwhat the patient tells you as the healthcare provider
what is a general survey? - answer-first impression of a patient
-looking at the whole person
what is included in a general survey? - answerhealth history, appearance, posture, gait,
verbal communication, nonverbal communication, and behaviors
physical exam order - answer1. inspect
2. palpate
3. percuss
4. auscultate
abdominal physical exam order - answer1. inspect
2. auscultate
3. percuss
4. palpate
HR - answer60-100 bpm
BP - answer120/80
,O2 sat - answer95-100%
under 90% is considered hypoxemia
Temperature - answer96.8-100.4 F
RR - answer12-20 breaths/min
sounds heard upon percussion - answerresonance, tympany, dullness,
hyperresonance, flat
where is resonance heard upon percussion? - answerover the lungs
where is dullness heard upon percussion? - answerheard over fluid or solid organs
(liver)
where is flat heard upon percussion? - answerover solid tissue like muscle and bone
where is tympanic heard upon percussion? - answerover air filled bowel loops
pallor - answerpaleness
erythema - answerredness
cyanosis - answerbluish discoloration of the skin
jaundice - answeryellowing of the skin
mottling - answercondition of spotting with patches of irregular color (purplish)
hypopigmentation - answerlack pigmentation
hyperpigmentation - answerover the normal amount of color
stages of ulcers - answerstage 1. redness, no blanching, not broken
stage 2. skin loss involving epidermis
stage 3. involves the epidermis, dermis, and SQ tissue
stage 4. Bone exposed
danger signs of skin lesions - answerABCDE
ABCDE - answerasymmetry
border irregularity
color variation
diameter >6mm
elevation or enlargement
, COLDERR - answer-character & intensity
-onset
-location
-duration
-exacerbation (worsening)
-relief
-radiation
PERRLA - answer-pupils
-equal
-round
-reactive to
-light
-accommodation
AIDET - answeracknowledge/welcome
introduction/identify
duration
explanation
thank you
turgor - answerElasticity of the skin
mobility - answerease in which skin lifts up
braden scale - answerto identify what risk patient has of getting pressure ulcers
clubbing - answerphysical sign characterized by bulbous enlargement of the ends of
one or more fingers or toes
where are hypo and hyperpigmentation found? - answersoles of feet, palms, nails, lips,
freckles, moles, birthmarks
grading edema - answer0 no pitting
1+ mild pitting
2+ moderate pitting
3+ moderate-severe pitting
4+ severe pitting
4 areas where lymph nodes are accessible - answerhead and neck, arms, inguinal area,
axillae
eye exams - answer-visual fields of confrontation
-corneal light reflex
-EOMs (extraocular movements)
Four types of assessments - answer1. complete (total health)
2. focused/problem centered
3. follow-up
4. emergency
complete assessment - answer new patient/clinic setting
focused/problem centered assessment - answer patient comes in for something specific
follow up assessment - answer revisit/checkup on last visit's reason
emergency assessment - answer accident/ER visit
complete or comprehensive exam - answer consists of complete health history and full
head to toe physical exam
two key parts of a complete health exam - answer objective and subjective
objective data - answerwhat the healthcare provider observes
subjective data - answerwhat the patient tells you as the healthcare provider
what is a general survey? - answer-first impression of a patient
-looking at the whole person
what is included in a general survey? - answerhealth history, appearance, posture, gait,
verbal communication, nonverbal communication, and behaviors
physical exam order - answer1. inspect
2. palpate
3. percuss
4. auscultate
abdominal physical exam order - answer1. inspect
2. auscultate
3. percuss
4. palpate
HR - answer60-100 bpm
BP - answer120/80
,O2 sat - answer95-100%
under 90% is considered hypoxemia
Temperature - answer96.8-100.4 F
RR - answer12-20 breaths/min
sounds heard upon percussion - answerresonance, tympany, dullness,
hyperresonance, flat
where is resonance heard upon percussion? - answerover the lungs
where is dullness heard upon percussion? - answerheard over fluid or solid organs
(liver)
where is flat heard upon percussion? - answerover solid tissue like muscle and bone
where is tympanic heard upon percussion? - answerover air filled bowel loops
pallor - answerpaleness
erythema - answerredness
cyanosis - answerbluish discoloration of the skin
jaundice - answeryellowing of the skin
mottling - answercondition of spotting with patches of irregular color (purplish)
hypopigmentation - answerlack pigmentation
hyperpigmentation - answerover the normal amount of color
stages of ulcers - answerstage 1. redness, no blanching, not broken
stage 2. skin loss involving epidermis
stage 3. involves the epidermis, dermis, and SQ tissue
stage 4. Bone exposed
danger signs of skin lesions - answerABCDE
ABCDE - answerasymmetry
border irregularity
color variation
diameter >6mm
elevation or enlargement
, COLDERR - answer-character & intensity
-onset
-location
-duration
-exacerbation (worsening)
-relief
-radiation
PERRLA - answer-pupils
-equal
-round
-reactive to
-light
-accommodation
AIDET - answeracknowledge/welcome
introduction/identify
duration
explanation
thank you
turgor - answerElasticity of the skin
mobility - answerease in which skin lifts up
braden scale - answerto identify what risk patient has of getting pressure ulcers
clubbing - answerphysical sign characterized by bulbous enlargement of the ends of
one or more fingers or toes
where are hypo and hyperpigmentation found? - answersoles of feet, palms, nails, lips,
freckles, moles, birthmarks
grading edema - answer0 no pitting
1+ mild pitting
2+ moderate pitting
3+ moderate-severe pitting
4+ severe pitting
4 areas where lymph nodes are accessible - answerhead and neck, arms, inguinal area,
axillae
eye exams - answer-visual fields of confrontation
-corneal light reflex
-EOMs (extraocular movements)
