NUR 120 - Exam 4 Questions With
Correct Answers
full physical exam - CORRECT ANSWER✔✔-Typically done by an MD, NP,
| | | | | | | | | | |
or PA. a full evaluation on every system in the body
| | | | | | | | | |
head to toe assessment - CORRECT ANSWER✔✔-done by the nurse at
| | | | | | | | | | |
the bedside, an assessment that looks at the basic information of a
| | | | | | | | | | | |
patients body |
focused assessment - CORRECT ANSWER✔✔-assessment conducted to
| | | | | | |
assess a specific problem; focuses on pertinent history and body regions
| | | | | | | | | |
concepts of a head to toe assessment that are addressed
| | | | | | | | | |
simultaneously - CORRECT ANSWER✔✔-1. general survey | | | | |
2. safety
| |
3. psychosocial
| |
4. tissue integrity
| |
what are the components of a general survey? - CORRECT ANSWER✔✔-
| | | | | | | | | |
IV access
|
,tubing
use of O2
| |
activity
appearance |
orientation
level of consciousness
| |
what are the components of safety? - CORRECT ANSWER✔✔-restraints
| | | | | | | |
mobility
sensory deficits |
wristbands
environment |
tubing
anything out of the ordinary?
| | | |
what are the components of psychosocial? - CORRECT ANSWER✔✔-
| | | | | | | |
mood and affect | |
stress/coping
pain
support system |
religious beliefs |
,what are the components of tissue integrity? - CORRECT ANSWER✔✔-
| | | | | | | | |
intactness of skin | |
sores
braden scale |
incisions |
bruises
dressings
what do we focus on when assessing the head? - CORRECT
| | | | | | | | | | |
ANSWER✔✔-cognition - level of consciousness | | | | |
A+O
speech
what do we focus on when assessing intracranial regulation? - CORRECT
| | | | | | | | | | |
ANSWER✔✔-neuro status |
changes in sensation
| |
PERRLA
what do we focus on when assessing tissue perfusion? - CORRECT
| | | | | | | | | | |
ANSWER✔✔-assess carotid pulse | |
vital signs
|
, color of mucous membranes
| | |
color
apical pulse |
is S1-S2 present?
| |
edema (pitting?) |
pedal pulse | |
push/pull on feet: is it equal on both sides?
| | | | | | | |
what do we focus on when assessing fluids and electrolyte balance? -
| | | | | | | | | | | |
CORRECT ANSWER✔✔-are mouth/eyes moist?
| | |
what do we focus on when assessing nutrition? - CORRECT
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ANSWER✔✔-state of dentition - dentures? | | | |
pain/discomfort when eating? | |
N/V?
what percentage of meal was eaten?
| | | | |
what is their appetite like?
| | | |
BMI?
nutritional deficits? |
Lab data:
|
albumin
NA
Correct Answers
full physical exam - CORRECT ANSWER✔✔-Typically done by an MD, NP,
| | | | | | | | | | |
or PA. a full evaluation on every system in the body
| | | | | | | | | |
head to toe assessment - CORRECT ANSWER✔✔-done by the nurse at
| | | | | | | | | | |
the bedside, an assessment that looks at the basic information of a
| | | | | | | | | | | |
patients body |
focused assessment - CORRECT ANSWER✔✔-assessment conducted to
| | | | | | |
assess a specific problem; focuses on pertinent history and body regions
| | | | | | | | | |
concepts of a head to toe assessment that are addressed
| | | | | | | | | |
simultaneously - CORRECT ANSWER✔✔-1. general survey | | | | |
2. safety
| |
3. psychosocial
| |
4. tissue integrity
| |
what are the components of a general survey? - CORRECT ANSWER✔✔-
| | | | | | | | | |
IV access
|
,tubing
use of O2
| |
activity
appearance |
orientation
level of consciousness
| |
what are the components of safety? - CORRECT ANSWER✔✔-restraints
| | | | | | | |
mobility
sensory deficits |
wristbands
environment |
tubing
anything out of the ordinary?
| | | |
what are the components of psychosocial? - CORRECT ANSWER✔✔-
| | | | | | | |
mood and affect | |
stress/coping
pain
support system |
religious beliefs |
,what are the components of tissue integrity? - CORRECT ANSWER✔✔-
| | | | | | | | |
intactness of skin | |
sores
braden scale |
incisions |
bruises
dressings
what do we focus on when assessing the head? - CORRECT
| | | | | | | | | | |
ANSWER✔✔-cognition - level of consciousness | | | | |
A+O
speech
what do we focus on when assessing intracranial regulation? - CORRECT
| | | | | | | | | | |
ANSWER✔✔-neuro status |
changes in sensation
| |
PERRLA
what do we focus on when assessing tissue perfusion? - CORRECT
| | | | | | | | | | |
ANSWER✔✔-assess carotid pulse | |
vital signs
|
, color of mucous membranes
| | |
color
apical pulse |
is S1-S2 present?
| |
edema (pitting?) |
pedal pulse | |
push/pull on feet: is it equal on both sides?
| | | | | | | |
what do we focus on when assessing fluids and electrolyte balance? -
| | | | | | | | | | | |
CORRECT ANSWER✔✔-are mouth/eyes moist?
| | |
what do we focus on when assessing nutrition? - CORRECT
| | | | | | | | | |
ANSWER✔✔-state of dentition - dentures? | | | |
pain/discomfort when eating? | |
N/V?
what percentage of meal was eaten?
| | | | |
what is their appetite like?
| | | |
BMI?
nutritional deficits? |
Lab data:
|
albumin
NA
