nur 106 exam 2 study guide UPDATED
ACTUAL Questions and CORRECT
Answers
Head-to-Toe Assessment - CORRECT ANSWER - A head-to-toe assessment is a systematic
examination of the body to identify normal and abnormal findings.
Functional Assessment (ADLs) - CORRECT ANSWER - ADLs evaluate a patient's ability to care
for themselves.
Basic ADLs
Bathing
Dressing
Toileting
Feeding
Transferring
Continence
Why it matters
Determines level of independence
Helps plan nursing care and discharge planning
Identifies risk for injury or decline
Introduction to Assessment - CORRECT ANSWER - The nurse begins with:
Introduction
Identify patient
Explain procedure
Provide privacy
Perform hand hygiene
NCLEX tip: Failure to introduce yourself or identify the patient is considered an unsafe practice.
General Survey - CORRECT ANSWER - First impression of the patient.
, Assess:
Appearance
Hygiene
Nutrition status
Posture
Behavior
Mood
Affect
Orientation
Person
Place
Time
Situation
Signs of distress
Labored breathing
Pain
Anxiety
Sequence of Physical Examination - CORRECT ANSWER - Correct order:
Inspection
Palpation
Percussion
Auscultation
Why this order? It moves from least invasive to more invasive.
Exception: Abdominal Assessment - CORRECT ANSWER - Correct order for abdomen:
Inspection
Auscultation
Percussion
Palpation
ACTUAL Questions and CORRECT
Answers
Head-to-Toe Assessment - CORRECT ANSWER - A head-to-toe assessment is a systematic
examination of the body to identify normal and abnormal findings.
Functional Assessment (ADLs) - CORRECT ANSWER - ADLs evaluate a patient's ability to care
for themselves.
Basic ADLs
Bathing
Dressing
Toileting
Feeding
Transferring
Continence
Why it matters
Determines level of independence
Helps plan nursing care and discharge planning
Identifies risk for injury or decline
Introduction to Assessment - CORRECT ANSWER - The nurse begins with:
Introduction
Identify patient
Explain procedure
Provide privacy
Perform hand hygiene
NCLEX tip: Failure to introduce yourself or identify the patient is considered an unsafe practice.
General Survey - CORRECT ANSWER - First impression of the patient.
, Assess:
Appearance
Hygiene
Nutrition status
Posture
Behavior
Mood
Affect
Orientation
Person
Place
Time
Situation
Signs of distress
Labored breathing
Pain
Anxiety
Sequence of Physical Examination - CORRECT ANSWER - Correct order:
Inspection
Palpation
Percussion
Auscultation
Why this order? It moves from least invasive to more invasive.
Exception: Abdominal Assessment - CORRECT ANSWER - Correct order for abdomen:
Inspection
Auscultation
Percussion
Palpation
