Nurs 252 Final Review Questions and
Complete Solutions
Priority levels ✅1. Immediate (emergency, life threatening)
2. Second level (urgent, must be addressed to prevent further deterioration)
3. Third level (important to patient health)
4. Collaborative problems ( interprofessional team, ex. substance abuse)
Arranging the physical setting ✅- Minimize interruptions and establish rapport
-Leave enough distance, and allow for personal space
-Equal seating
Patient introduction ✅1. wash hands
2. NOD (name, occupation, duty)
3. Purpose of assessment
Motivational Interviewing principles ✅-Open ended questions
-Make affirmations
-use reflections
-Summarize
Empathy ✅-Recognition and acceptance of patient's feelings
Barriers to professional therapeutic communication ✅-Failing to listen
-Giving personal opinions, approving or disapproving statements
-Changing the subject
-False reassurance
-Interrupting
-Overusing professional jargon
-Talking too much
-"why" questions
General Survey ✅-Age
-Level of alertness
-Body size and shape
-Non-verbal communication
-Symmetrical comparison
Palpation ✅Touch to assess
-Temperature
-Moisture
-Texture
,-Vibration
-Pulsation
-Rigidity
-Crepitus
-Presence of lumps or masses
-Presence of tenderness or pain
Finger pads- palpation regions ✅-Used to assess texture, moisture, and contour
Fingertips/pads (palpation) ✅-Used to assess pulsatility, fluid content of tissues,
elasticity and turgor, and vascularity
Dorsum of hand (palpation) ✅-Used to assess temperature
Ulnar surface of hand (palpation) ✅-Used to assess temperature and vibration
Light palpation ✅- Communicate for patient comfort, use warm hands and go from non
tender areas to tender areas
-Use Intermittent circular motions with Dominant hand
-Finger pads sense movement of patient's skin and tissue
Deep palpation ✅-Risk of injuring patient, up to discretion of nurse within their scope of
practice
-3-4 cm below skin surface
-Extended fingers of non dominant hand over dominant hand for extra pressure
Percussion ✅-Tapping on body surfaces to create sound
-Helps determine location, size and density of organs
-Detects abnormal mass
-Elicits pain on inflamed area
-Deep tendon reflex
Direct percussion ✅-Tap directly on skin
-Maxillary sinuses
Indirect percussion ✅-Tap middle finger of dominant hand over middle finger of non-
dominant hand placed on a body surface
-Tap twice only, using a quick and forceful wrist action
Percussion sounds ✅1) Flatness
2) Dullness
3) Resonance
4) Tympanic
Auscultation ✅-Ear pieces facing nose
,-Use the diaphragm and bell
-Warm the stethoscope and sanitize
-Hair and friction can produce artifact sounds
-Do not auscultate through clothes
Diaphragm of stethoscope ✅-Flat endpiece of the stethoscope used for hearing
relatively high-pitched heart sounds
-Lung and Heart sounds
Bell of stethoscope ✅-Cup-shaped endpiece used for soft, low-pitched heart sounds
-Heart murmurs
Infants developmental considerations for assessment ✅-Trust the parent
-Prefer warmth
-Perform least distressing assessments first
-Lung, heart and abdominal sounds first if sleeping
Toddlers developmental considerations for assessment ✅-Can have parental
assistance with positioning
-Least distressing assessments first
-Use games/toys
-Praise cooperative children
Preschool developmental considerations for assessment ✅-They have initiative
-Prefer a parental presence
-Can be cooperative, have increasing communication skills
-Still need games/toys
-Least distressing assessments first
School age children developmental considerations of assessment ✅-Industry
-Seek approval, feelings of accomplishment
-Can have small talk about interests
-Perform a head to toe assessment
Adolescents developmental considerations for assessment ✅- Struggle with self-
identity
-Strong awareness of body image
-Educate for self-care
-head to toe assessment
Older adult developmental considerations for assessment ✅-Seated or supine
-Slower pace of examination
-Discriminate between sensory loss and confusion
-Head to toe examination
, Skin function ✅-Protection
-Barrier for penetration
-Perception
-Thermoregulation
-Identification (self-image
-Communication (blushing, blanching)
-Wound repair
-Absorption and secretion
-Vitamin D production
Skin layers ✅1. Epidermis
2. Dermis
3. Hypodermis/subcutaneous layer-has adipose tissue, energy stores, cushioning,
insulation for temp control
Skin colour and tone ✅1. Melanin-brown pigmentation
2. Carotene-yellow/orange
3. Vascular bed- red/purple
-Varies with genetics and health state (edema, fever)
Glands in the skin ✅-Sebaceous glands (open into hair follicles)
-Sweat glands (thermoregulation)
-Eccrine and apocrine glands
Hair ✅-Made of keratin
-Cyclical growth, active and resting phases
-Vellus hair (fine, covers most of the body)
-Terminal hair (dark, thick)
Nail plate, folds and cuticle ✅-Made of keratin
-Pink colour indicates highly vascular epithelial cells
-Lunula is the white semilunar area at proximal end of nail
-Nail fold overlaps posterior and lateral borders
-The cuticle protects nail matrix
Puritis ✅-Intense itching
Things to look for in a skin assessment ✅-Previous history of skin disease
-Changes in pigmentation
-Changes in mole (ABCDE)
-Excessive dryness or moisture
-Puritis
-Excessive bruising
Things to look for in a hair and nails assessment ✅-Hair loss
Complete Solutions
Priority levels ✅1. Immediate (emergency, life threatening)
2. Second level (urgent, must be addressed to prevent further deterioration)
3. Third level (important to patient health)
4. Collaborative problems ( interprofessional team, ex. substance abuse)
Arranging the physical setting ✅- Minimize interruptions and establish rapport
-Leave enough distance, and allow for personal space
-Equal seating
Patient introduction ✅1. wash hands
2. NOD (name, occupation, duty)
3. Purpose of assessment
Motivational Interviewing principles ✅-Open ended questions
-Make affirmations
-use reflections
-Summarize
Empathy ✅-Recognition and acceptance of patient's feelings
Barriers to professional therapeutic communication ✅-Failing to listen
-Giving personal opinions, approving or disapproving statements
-Changing the subject
-False reassurance
-Interrupting
-Overusing professional jargon
-Talking too much
-"why" questions
General Survey ✅-Age
-Level of alertness
-Body size and shape
-Non-verbal communication
-Symmetrical comparison
Palpation ✅Touch to assess
-Temperature
-Moisture
-Texture
,-Vibration
-Pulsation
-Rigidity
-Crepitus
-Presence of lumps or masses
-Presence of tenderness or pain
Finger pads- palpation regions ✅-Used to assess texture, moisture, and contour
Fingertips/pads (palpation) ✅-Used to assess pulsatility, fluid content of tissues,
elasticity and turgor, and vascularity
Dorsum of hand (palpation) ✅-Used to assess temperature
Ulnar surface of hand (palpation) ✅-Used to assess temperature and vibration
Light palpation ✅- Communicate for patient comfort, use warm hands and go from non
tender areas to tender areas
-Use Intermittent circular motions with Dominant hand
-Finger pads sense movement of patient's skin and tissue
Deep palpation ✅-Risk of injuring patient, up to discretion of nurse within their scope of
practice
-3-4 cm below skin surface
-Extended fingers of non dominant hand over dominant hand for extra pressure
Percussion ✅-Tapping on body surfaces to create sound
-Helps determine location, size and density of organs
-Detects abnormal mass
-Elicits pain on inflamed area
-Deep tendon reflex
Direct percussion ✅-Tap directly on skin
-Maxillary sinuses
Indirect percussion ✅-Tap middle finger of dominant hand over middle finger of non-
dominant hand placed on a body surface
-Tap twice only, using a quick and forceful wrist action
Percussion sounds ✅1) Flatness
2) Dullness
3) Resonance
4) Tympanic
Auscultation ✅-Ear pieces facing nose
,-Use the diaphragm and bell
-Warm the stethoscope and sanitize
-Hair and friction can produce artifact sounds
-Do not auscultate through clothes
Diaphragm of stethoscope ✅-Flat endpiece of the stethoscope used for hearing
relatively high-pitched heart sounds
-Lung and Heart sounds
Bell of stethoscope ✅-Cup-shaped endpiece used for soft, low-pitched heart sounds
-Heart murmurs
Infants developmental considerations for assessment ✅-Trust the parent
-Prefer warmth
-Perform least distressing assessments first
-Lung, heart and abdominal sounds first if sleeping
Toddlers developmental considerations for assessment ✅-Can have parental
assistance with positioning
-Least distressing assessments first
-Use games/toys
-Praise cooperative children
Preschool developmental considerations for assessment ✅-They have initiative
-Prefer a parental presence
-Can be cooperative, have increasing communication skills
-Still need games/toys
-Least distressing assessments first
School age children developmental considerations of assessment ✅-Industry
-Seek approval, feelings of accomplishment
-Can have small talk about interests
-Perform a head to toe assessment
Adolescents developmental considerations for assessment ✅- Struggle with self-
identity
-Strong awareness of body image
-Educate for self-care
-head to toe assessment
Older adult developmental considerations for assessment ✅-Seated or supine
-Slower pace of examination
-Discriminate between sensory loss and confusion
-Head to toe examination
, Skin function ✅-Protection
-Barrier for penetration
-Perception
-Thermoregulation
-Identification (self-image
-Communication (blushing, blanching)
-Wound repair
-Absorption and secretion
-Vitamin D production
Skin layers ✅1. Epidermis
2. Dermis
3. Hypodermis/subcutaneous layer-has adipose tissue, energy stores, cushioning,
insulation for temp control
Skin colour and tone ✅1. Melanin-brown pigmentation
2. Carotene-yellow/orange
3. Vascular bed- red/purple
-Varies with genetics and health state (edema, fever)
Glands in the skin ✅-Sebaceous glands (open into hair follicles)
-Sweat glands (thermoregulation)
-Eccrine and apocrine glands
Hair ✅-Made of keratin
-Cyclical growth, active and resting phases
-Vellus hair (fine, covers most of the body)
-Terminal hair (dark, thick)
Nail plate, folds and cuticle ✅-Made of keratin
-Pink colour indicates highly vascular epithelial cells
-Lunula is the white semilunar area at proximal end of nail
-Nail fold overlaps posterior and lateral borders
-The cuticle protects nail matrix
Puritis ✅-Intense itching
Things to look for in a skin assessment ✅-Previous history of skin disease
-Changes in pigmentation
-Changes in mole (ABCDE)
-Excessive dryness or moisture
-Puritis
-Excessive bruising
Things to look for in a hair and nails assessment ✅-Hair loss
