NUR 203 FINAL EXAM QUESTIONS AND ANSWERS
What 3 parts make up the systematic method of collecting data: - Answers - 1.
Determine the client's current health status
2. Predict health risks
3. Identify health promotion
What is subjective data?
What is objective data? - Answers - Subjective: symptoms that the patient or family tells
you.
Objective: signs that the nurse observe, information that has been gathered from the
physical exam
What are the phases of interviewing: - Answers - Pre-interview: background data
Introduction: small talk, confidential unless harmful
Working phase: obtain information
Termination: summarize important points and discuss a plan
What are the component of the interview: - Answers - Environment
Interviewer
Client
Communication
What three things make up the integumentary system? - Answers - Hair
Skin (16% of body weight/largest organ of the body)
Nails
What are normal integumentary changes with age (changes that we should not look
further into) - Answers - - Skin thinning
- Skin elasticity decreases
- Sebum production decreases
- Perspiration decreases
- Decreases melanin production
- Increase sensitivity to sunlight
- Nail growth slows
What are common skin findings with elderly clients: - Answers - Solar lentigines = liver
spots (flat)
Skin tags
Seborrheic keratosis (raised)
What are common findings of a patient that has been abused: - Answers - Ecchymosis
= bruise
,Hematoma = bruise with a bump
Bites
Burns
Wounds/ulcers
Poor care/hygiene
What are general color changes?
What are local color changes? - Answers - General color change: pallor (pale),
erythema (redness), cyanosis (blueish), jaundice (yellow, suggests liver failure)
Local color change: freckles, nevi (moles), mongolian spots (mostly found on the
buttocks
How do we palpate the skin when assessing temperature? - Answers - We use the
dorsal part of the hand
What is an abnormal finding for skin turgor, and where do we assess skin turgor? -
Answers - We assess skin turgor on the abdomen of patients (especially elderly, you
should not be assessing skin turgor on their hands)
An ABNORMAL finding: takes over 30 seconds for skin to flatten. This may suggest
dehydration.
How do we grade pitting edema? - Answers - 1+ 2+ 3+ 4+
2mm,4mm,6mm,8mm
What is a macule? - Answers - Flat
< 1 cm
What is a patch? - Answers - Flat
> 1 cm
What is a papule? - Answers - Raised
< 1 cm
What is a plaque? - Answers - Raised
> 1 cm
What is a vesicle? - Answers - Fluid filled
< 1 cm
Blister
What is a bulla? - Answers - Fluid filled
> 1 cm
,What is a pustule? - Answers - Fluid filled, filled with puss, infection
What is a cyst? - Answers - Fluid filled (below the skin)
What are the different lesion configurations? - Answers - Annular: round
Linear: straight
Discrete: separate
Confluent: lesions rush together
What are the different vascular lesions? - Answers - Cherry angioma = dot
Spider angioma = dot with legs coming out
What are the purpuric lesions? (2) - Answers - Petechiae: small purple spot
Purpura: rash of purple spots
What are the three cancerous lesions? - Answers - Basal cell carcinoma
Squamous cell carcinoma
Malignant melanoma
Describe the four stages of pressure ulcers: - Answers - Stage 1: red and intact skin -
does not blanch
Stage 2: skin broken or blistered, but no superficial loss
Stage 3: skin broken and deeper loss - deep crater (loss of epidermis, dermis, and
subcutaneous tissue)
Stage 4: skin is broken and deep tissue is lost, massive crater (muscle/bone visible)
Unstageable: full tissue thickness loss, base of ulcer is covered my slough or an eschar
When observing the scalp and hair, what do we inspect? - Answers - Color
Condition
Distribution
Infestations
Lesions
What is alopecia? - Answers - Hair loss
What is clubbing? - Answers - When there is a decrease in oxygen in the blood.
clubbing: nail base angle 180 degrees or greater
Normal nail base angle: 160 degrees
, What is the technique that we use to assess nail clubbing? - Answers - Schamroth
technique
What is macrocephaly?
What is microcephaly? - Answers - Macrocephaly: large head
Microcephaly: small head
What are the lymph nodes that we palpate when assessing the neck in the HEENT
assessment? - Answers - Preauricular
Postauricular
Occipital
Submandibular
Submental
Tonsilar
Superficial cervical
Deep cervical chain
Supraclavicular
Subclavicular
Describe a cancerous lymph node - Answers - Large
Irregular
Non-tender
Cool
Fixed
Describe an inflamed lymph node: - Answers - - Small
- Round
- Tender
- Warm
- Moveable
How do we assess distance vision acuity? - Answers - Snellen chart
- Usually start at line 8
- 20/20 -- patient/normal vision
How do we assess near vision acuity? - Answers - Rosenbaum Screening
- Hold card 14 inches from face
- 14/14 is a normal measurement
Peripheral vision tests which cranial nerves? - Answers - III, IV, VI
(3, 4, 6)
What is nystagmus? - Answers - Shaking of the eye
How do we document a normal finding of peripheral fields: - Answers - Peripheral fields
are full by confrontation
What 3 parts make up the systematic method of collecting data: - Answers - 1.
Determine the client's current health status
2. Predict health risks
3. Identify health promotion
What is subjective data?
What is objective data? - Answers - Subjective: symptoms that the patient or family tells
you.
Objective: signs that the nurse observe, information that has been gathered from the
physical exam
What are the phases of interviewing: - Answers - Pre-interview: background data
Introduction: small talk, confidential unless harmful
Working phase: obtain information
Termination: summarize important points and discuss a plan
What are the component of the interview: - Answers - Environment
Interviewer
Client
Communication
What three things make up the integumentary system? - Answers - Hair
Skin (16% of body weight/largest organ of the body)
Nails
What are normal integumentary changes with age (changes that we should not look
further into) - Answers - - Skin thinning
- Skin elasticity decreases
- Sebum production decreases
- Perspiration decreases
- Decreases melanin production
- Increase sensitivity to sunlight
- Nail growth slows
What are common skin findings with elderly clients: - Answers - Solar lentigines = liver
spots (flat)
Skin tags
Seborrheic keratosis (raised)
What are common findings of a patient that has been abused: - Answers - Ecchymosis
= bruise
,Hematoma = bruise with a bump
Bites
Burns
Wounds/ulcers
Poor care/hygiene
What are general color changes?
What are local color changes? - Answers - General color change: pallor (pale),
erythema (redness), cyanosis (blueish), jaundice (yellow, suggests liver failure)
Local color change: freckles, nevi (moles), mongolian spots (mostly found on the
buttocks
How do we palpate the skin when assessing temperature? - Answers - We use the
dorsal part of the hand
What is an abnormal finding for skin turgor, and where do we assess skin turgor? -
Answers - We assess skin turgor on the abdomen of patients (especially elderly, you
should not be assessing skin turgor on their hands)
An ABNORMAL finding: takes over 30 seconds for skin to flatten. This may suggest
dehydration.
How do we grade pitting edema? - Answers - 1+ 2+ 3+ 4+
2mm,4mm,6mm,8mm
What is a macule? - Answers - Flat
< 1 cm
What is a patch? - Answers - Flat
> 1 cm
What is a papule? - Answers - Raised
< 1 cm
What is a plaque? - Answers - Raised
> 1 cm
What is a vesicle? - Answers - Fluid filled
< 1 cm
Blister
What is a bulla? - Answers - Fluid filled
> 1 cm
,What is a pustule? - Answers - Fluid filled, filled with puss, infection
What is a cyst? - Answers - Fluid filled (below the skin)
What are the different lesion configurations? - Answers - Annular: round
Linear: straight
Discrete: separate
Confluent: lesions rush together
What are the different vascular lesions? - Answers - Cherry angioma = dot
Spider angioma = dot with legs coming out
What are the purpuric lesions? (2) - Answers - Petechiae: small purple spot
Purpura: rash of purple spots
What are the three cancerous lesions? - Answers - Basal cell carcinoma
Squamous cell carcinoma
Malignant melanoma
Describe the four stages of pressure ulcers: - Answers - Stage 1: red and intact skin -
does not blanch
Stage 2: skin broken or blistered, but no superficial loss
Stage 3: skin broken and deeper loss - deep crater (loss of epidermis, dermis, and
subcutaneous tissue)
Stage 4: skin is broken and deep tissue is lost, massive crater (muscle/bone visible)
Unstageable: full tissue thickness loss, base of ulcer is covered my slough or an eschar
When observing the scalp and hair, what do we inspect? - Answers - Color
Condition
Distribution
Infestations
Lesions
What is alopecia? - Answers - Hair loss
What is clubbing? - Answers - When there is a decrease in oxygen in the blood.
clubbing: nail base angle 180 degrees or greater
Normal nail base angle: 160 degrees
, What is the technique that we use to assess nail clubbing? - Answers - Schamroth
technique
What is macrocephaly?
What is microcephaly? - Answers - Macrocephaly: large head
Microcephaly: small head
What are the lymph nodes that we palpate when assessing the neck in the HEENT
assessment? - Answers - Preauricular
Postauricular
Occipital
Submandibular
Submental
Tonsilar
Superficial cervical
Deep cervical chain
Supraclavicular
Subclavicular
Describe a cancerous lymph node - Answers - Large
Irregular
Non-tender
Cool
Fixed
Describe an inflamed lymph node: - Answers - - Small
- Round
- Tender
- Warm
- Moveable
How do we assess distance vision acuity? - Answers - Snellen chart
- Usually start at line 8
- 20/20 -- patient/normal vision
How do we assess near vision acuity? - Answers - Rosenbaum Screening
- Hold card 14 inches from face
- 14/14 is a normal measurement
Peripheral vision tests which cranial nerves? - Answers - III, IV, VI
(3, 4, 6)
What is nystagmus? - Answers - Shaking of the eye
How do we document a normal finding of peripheral fields: - Answers - Peripheral fields
are full by confrontation
