lOMoAR cPSD| 67756003
NUR 155: Exam 1 Study Guide
Unit 1: The Nursing Process, Health History, and Physical Assessment
The nursing process is a foundational framework used to provide patient-centered care. It
involves critical thinking, clinical reasoning, and judgment. The five phases of the nursing
process are:
1. Assessment – Collection of data through patient history, interviews, observation, and
physical exams. Data can be subjective (what the patient reports) or objective (what the nurse
observes or measures).
2. Diagnosis – A clinical judgment about the patient’s actual or potential health
conditions or needs. Nurses use NANDA-I approved diagnoses to identify problems and guide
care plans.
3. Planning – Prioritization of nursing diagnoses, setting measurable goals/outcomes,and
selecting interventions. Goals should be SMART (Specific, Measurable, Attainable, Realistic,
Time-bound).
4. Implementation – Performing nursing interventions to achieve the patient’s goals. This
includes direct care, education, coordination of care, and documentation.
5. Evaluation – Determining if patient goals were met and reassessing the plan of careif
needed.
Health History and Interview Process
A complete health history includes biographical data, chief complaint, past medical history,
family history, lifestyle factors, and review of systems. It is conducted in three phases:
- Orientation Phase: Introduce yourself, explain the purpose, and establish trust.
- Working Phase: Gather detailed health information through open-ended and closed-ended
questions.
- Termination Phase: Summarize information, validate accuracy, and explain next steps.
Physical Assessment Techniques
Physical assessments follow a head-to-toe approach using four main techniques:
- Inspection: Visual observation including posture, color, and behavior.
- Palpation: Using touch to detect temperature, texture, moisture, tenderness, and masses.
, lOMoAR cPSD| 67756003
- Percussion: Tapping body parts to determine density and detect abnormalities.
- Auscultation: Listening with a stethoscope to heart, lung, and bowel sounds.
General Survey and Full Assessment Overview
The general survey includes assessment of appearance, behavior, mobility, hygiene, affect,
speech, and signs of distress.
Head-to-Toe System Review Includes:
- Skin: Check for lesions, turgor, temperature, color changes (e.g., pallor, cyanosis, jaundice).
- HEENT: Inspect symmetry, use Snellen for visual acuity, assess pupil response (PERRLA), and
perform Weber/Rinne for hearing.
- Respiratory: Observe chest shape and breathing patterns, palpate for tactile fremitus,
auscultate for adventitious sounds.
- Cardiovascular: Inspect jugular veins, auscultate heart sounds (S1, S2), note any murmurs or
bruits, assess peripheral pulses and capillary refill.
- GI: Inspect abdomen, auscultate bowel sounds (note if hyperactive, hypoactive, or absent),
palpate for tenderness or masses.
- Musculoskeletal: Evaluate gait, posture, strength, and range of motion.
- Neurological: Assess orientation, mood, cognition, memory, and reflexes. Use tools like the
Romberg test for balance.
NUR 155: Foundations of Nursing –
Exam 1 Comprehensive Study Guide
Unit 2: Asepsis, Infection Control, Documentation, and Vital Signs
Asepsis and Infection Control
Asepsis refers to the absence of pathogenic microorganisms. It is categorized into two types:
- Medical Asepsis: Clean technique, including hand hygiene and standard precautions to reduce
microorganism transmission.
NUR 155: Exam 1 Study Guide
Unit 1: The Nursing Process, Health History, and Physical Assessment
The nursing process is a foundational framework used to provide patient-centered care. It
involves critical thinking, clinical reasoning, and judgment. The five phases of the nursing
process are:
1. Assessment – Collection of data through patient history, interviews, observation, and
physical exams. Data can be subjective (what the patient reports) or objective (what the nurse
observes or measures).
2. Diagnosis – A clinical judgment about the patient’s actual or potential health
conditions or needs. Nurses use NANDA-I approved diagnoses to identify problems and guide
care plans.
3. Planning – Prioritization of nursing diagnoses, setting measurable goals/outcomes,and
selecting interventions. Goals should be SMART (Specific, Measurable, Attainable, Realistic,
Time-bound).
4. Implementation – Performing nursing interventions to achieve the patient’s goals. This
includes direct care, education, coordination of care, and documentation.
5. Evaluation – Determining if patient goals were met and reassessing the plan of careif
needed.
Health History and Interview Process
A complete health history includes biographical data, chief complaint, past medical history,
family history, lifestyle factors, and review of systems. It is conducted in three phases:
- Orientation Phase: Introduce yourself, explain the purpose, and establish trust.
- Working Phase: Gather detailed health information through open-ended and closed-ended
questions.
- Termination Phase: Summarize information, validate accuracy, and explain next steps.
Physical Assessment Techniques
Physical assessments follow a head-to-toe approach using four main techniques:
- Inspection: Visual observation including posture, color, and behavior.
- Palpation: Using touch to detect temperature, texture, moisture, tenderness, and masses.
, lOMoAR cPSD| 67756003
- Percussion: Tapping body parts to determine density and detect abnormalities.
- Auscultation: Listening with a stethoscope to heart, lung, and bowel sounds.
General Survey and Full Assessment Overview
The general survey includes assessment of appearance, behavior, mobility, hygiene, affect,
speech, and signs of distress.
Head-to-Toe System Review Includes:
- Skin: Check for lesions, turgor, temperature, color changes (e.g., pallor, cyanosis, jaundice).
- HEENT: Inspect symmetry, use Snellen for visual acuity, assess pupil response (PERRLA), and
perform Weber/Rinne for hearing.
- Respiratory: Observe chest shape and breathing patterns, palpate for tactile fremitus,
auscultate for adventitious sounds.
- Cardiovascular: Inspect jugular veins, auscultate heart sounds (S1, S2), note any murmurs or
bruits, assess peripheral pulses and capillary refill.
- GI: Inspect abdomen, auscultate bowel sounds (note if hyperactive, hypoactive, or absent),
palpate for tenderness or masses.
- Musculoskeletal: Evaluate gait, posture, strength, and range of motion.
- Neurological: Assess orientation, mood, cognition, memory, and reflexes. Use tools like the
Romberg test for balance.
NUR 155: Foundations of Nursing –
Exam 1 Comprehensive Study Guide
Unit 2: Asepsis, Infection Control, Documentation, and Vital Signs
Asepsis and Infection Control
Asepsis refers to the absence of pathogenic microorganisms. It is categorized into two types:
- Medical Asepsis: Clean technique, including hand hygiene and standard precautions to reduce
microorganism transmission.
