NR 302 FINAL EXAM STUDY GUIDE
Chapter 1
Evidence based assessment: Systematic approach to practice that use the best evidence the
clinician’s experience and patients preferences and values to make decisions about care and tx.
Why do we do Evidence Based Assessment: Proper documentation, correct information.
Double check were preforming the right way, things are always changing.
Subjective Data: What the patient tells you, not measureable (nausea, pain, etc) symptoms.
Objective Data: Measureable manifestations of a disease (fever, blood pressure, etc) sings.
Nursing Process: Assessment, Diagnostic, Outcome,
Priority Levels (table 1.1 pg 5): Level 1: Emergency->ABC’s of Nursing, Level 2: Pain, potential to
be a level 1. Level 3: Maintenance
First-level priority problems are emergent, life-threatening, and immediate, such as
establishing an airway or supporting breathing.
Second-level priority problems are next in urgency. They require prompt intervention to
prevent deterioration, and may include a mental status change or acute pain
Third-level priority problems are important to the patient's health, but can be addressed after
more urgent problems. Examples include lack of knowledge or family coping.
Database (4 kinds) pg 6:
AMPLE:
Chapter 2
Culture Competence: Make sure you ask about their culture and incorporate into care
Chapter 3
The interview: make sure you are in a comfortable well-lit environment, limit interruptions,
private, not too cold not too hot. Nonverbal needs to match verbal. Making sure the patient is
fully dressed during the interview. Best to ask open-ended questions.
Closed-Ended: Use if the interview is running on too long and you need direct answers, but
always start with open-ended
Jargon: Use layman’s terms
-Never promise someone something will be fine or okay, you never know.
-Never use “Why”, or interrupt
-Nonverbal skills
Written information: written at a 5th grade reading level or below, preform a teach-back, use
pictures
, Chapter 4
Health History: preform to obtain the complete picture of someone past and current health
history
-Family History-
Review of Systems: not a physical assessment- the past and present condition of the body
system (i.e. asking about “recent” changes)
Perception of Health: how they view their current health situation
Adolescent: HEEDASS (pg. 64) –assess home environment, safety concern, sex, drugs
Chapter 5
Mental Health Status: ABCT- appearance, behavior, cognition, and though process
In an older adult: make sure you do a sensory exam first, making sure they can see and hear
Aphasia: difficult speaking
Expressive: they understand but can’t talk (Brocas)
Receptive: They can hear you but do not understand, they can talk (Wernickes)
Mini-mental status: 5-10 min, check for delirium or dementia.
Chapter 6
Cage Test: Alcoholism
-Cut down:
-Annoyed
-Guilty
-Eye opener: “do you drink in the morning”
Chapter 7
Nurses are mandated reporters for children, handicapped patients, and the elderly
-In someone who is a competent adult it is not our responsibility
Intimate Partner Violence: If they feel safe to go home. Any sexually, emotional, financial,
mental, etc. abuse.
Documentation: all useable in court, is a legal document. Document any subjective data
(verbal) from patient, any injuries
Chapter 8
Assessment Techniques
1. Inspection- first thing we do when patient walks in
2. Palpation- feeling the patient
3. Percussion (table 8.1)-
Chapter 1
Evidence based assessment: Systematic approach to practice that use the best evidence the
clinician’s experience and patients preferences and values to make decisions about care and tx.
Why do we do Evidence Based Assessment: Proper documentation, correct information.
Double check were preforming the right way, things are always changing.
Subjective Data: What the patient tells you, not measureable (nausea, pain, etc) symptoms.
Objective Data: Measureable manifestations of a disease (fever, blood pressure, etc) sings.
Nursing Process: Assessment, Diagnostic, Outcome,
Priority Levels (table 1.1 pg 5): Level 1: Emergency->ABC’s of Nursing, Level 2: Pain, potential to
be a level 1. Level 3: Maintenance
First-level priority problems are emergent, life-threatening, and immediate, such as
establishing an airway or supporting breathing.
Second-level priority problems are next in urgency. They require prompt intervention to
prevent deterioration, and may include a mental status change or acute pain
Third-level priority problems are important to the patient's health, but can be addressed after
more urgent problems. Examples include lack of knowledge or family coping.
Database (4 kinds) pg 6:
AMPLE:
Chapter 2
Culture Competence: Make sure you ask about their culture and incorporate into care
Chapter 3
The interview: make sure you are in a comfortable well-lit environment, limit interruptions,
private, not too cold not too hot. Nonverbal needs to match verbal. Making sure the patient is
fully dressed during the interview. Best to ask open-ended questions.
Closed-Ended: Use if the interview is running on too long and you need direct answers, but
always start with open-ended
Jargon: Use layman’s terms
-Never promise someone something will be fine or okay, you never know.
-Never use “Why”, or interrupt
-Nonverbal skills
Written information: written at a 5th grade reading level or below, preform a teach-back, use
pictures
, Chapter 4
Health History: preform to obtain the complete picture of someone past and current health
history
-Family History-
Review of Systems: not a physical assessment- the past and present condition of the body
system (i.e. asking about “recent” changes)
Perception of Health: how they view their current health situation
Adolescent: HEEDASS (pg. 64) –assess home environment, safety concern, sex, drugs
Chapter 5
Mental Health Status: ABCT- appearance, behavior, cognition, and though process
In an older adult: make sure you do a sensory exam first, making sure they can see and hear
Aphasia: difficult speaking
Expressive: they understand but can’t talk (Brocas)
Receptive: They can hear you but do not understand, they can talk (Wernickes)
Mini-mental status: 5-10 min, check for delirium or dementia.
Chapter 6
Cage Test: Alcoholism
-Cut down:
-Annoyed
-Guilty
-Eye opener: “do you drink in the morning”
Chapter 7
Nurses are mandated reporters for children, handicapped patients, and the elderly
-In someone who is a competent adult it is not our responsibility
Intimate Partner Violence: If they feel safe to go home. Any sexually, emotional, financial,
mental, etc. abuse.
Documentation: all useable in court, is a legal document. Document any subjective data
(verbal) from patient, any injuries
Chapter 8
Assessment Techniques
1. Inspection- first thing we do when patient walks in
2. Palpation- feeling the patient
3. Percussion (table 8.1)-
