NURS 258 Final Exam With
Complete Solution
Physical assessment - ANSWER phase pf the nursing process during which
data are gathered for the purpose of identifying actual or potential health
problems
Complete (total health) database
Episodic (problem) Centered database
Follow-Up database
Emergency database
Lifespan Considerations - ANSWER What are the 5 types of data collection?
Complete (total health) database - ANSWER Data collection of health history
+ complete exam
- initial assessment on admission
Episodic (problem) centered database - ANSWER Data collection that is a
focused assessment for a specific problem
Follow-up database - ANSWER Data collection that is a time-lapsed
re-assessment or a re-progress check
Emergency database - ANSWER Data collection that is done when there is a
serious or life-threatening situations or an emergency
Position: Instruct parent to comfort hold (hug from back holding arms)
,Preparation: Get everything ready before hand
Sequence: Least invasive procedures to most invasive procedures (No NOT
use head to toe approach) - ANSWER What is the Position, Preparation, and
Sequence when assessing a Infant or Toddler?
Position: Sit on parents lap or on bed
Preparation: Do not offer choices, if there is no choice to be made
Sequence: Body first then head (HEENT) - ANSWER What is the Position,
Preparation, and Sequence when assessing a Preschooler?
Position: Sit on bed
Preparation: Tell then what you are doing
Sequence: Head to toe with good explanations - ANSWER What is the
Position, Preparation, and Sequence when assessing a School-age (6-12)
child?
Position: Sit on bed, chair, or stand
Preparation: Health promotion focus due to new/risky behaviors
Sequence: Head to toe assessment - ANSWER What is the Position,
Preparation, and Sequence when assessing a Adolescent (10-19)?
Position: Sit of bed or chair and monitor comfort
Preparation: Don't assume hearing difficulty, be aware of changes in senses,
and encourage rest periods
Sequence: Head to toe minimizing position changes - ANSWER What is the
Position, Preparation, and Sequence when assessing an aging adult?
,Privacy
Adequate lighting
Warmth
Necessary equipment to prevent interruption
Physical and psychological preparation
Third person if indicated or needed to maintain safety - ANSWER What are
the 6 things needed for the Setting of an Assessment?
Vision, Hearing, Touch, and Smell - ANSWER What are the 4 senses Nursing
use in a Physical exam?
inspection, palpation, percussion, auscultation - ANSWER What are the 4
physical exam techniques?
Inspection - ANSWER What is done the moment you first see the patient?
- First physical exam technique used
Palpation - ANSWER What physical exam technique often confirms
inspection?
Percussion - ANSWER Physical exam technique that involves tapping on skin
Direct percussion - ANSWER Nurse tapping directly against a body surface
indirect percussion - ANSWER Nurse using a finger to tap against another
finger to produce a sound to find out what is underneath the skin
- organs
- size
, - shape
- fluid accumulation
Auscultation - ANSWER Physical exam technique that uses a stethoscope and
directs sound to ears
Bell - ANSWER Used when listening to soft or low pitched sounds
Diaphragm - ANSWER Used when listening to high pitched sounds
Vital signs - ANSWER Indicate some of the bodies basic functions and reflect
many things about health
- several sets form a baseline
After surgery, during a blood transfusion, or changes in patient status -
ANSWER When do we take vital signs more frequently?
96.4-99.1 F (35.8-37.3 C) - ANSWER Normal adult range of Body Temperature
98.6 F (37 C) - ANSWER Average adult temperature
Age
Environment
Time of day
Exercise
Stress
Hormones - ANSWER What factors influence our body temperature?
drops - ANSWER As we age out temperature ___________
1-4 am - ANSWER When is our body temperature at its lowest?
Complete Solution
Physical assessment - ANSWER phase pf the nursing process during which
data are gathered for the purpose of identifying actual or potential health
problems
Complete (total health) database
Episodic (problem) Centered database
Follow-Up database
Emergency database
Lifespan Considerations - ANSWER What are the 5 types of data collection?
Complete (total health) database - ANSWER Data collection of health history
+ complete exam
- initial assessment on admission
Episodic (problem) centered database - ANSWER Data collection that is a
focused assessment for a specific problem
Follow-up database - ANSWER Data collection that is a time-lapsed
re-assessment or a re-progress check
Emergency database - ANSWER Data collection that is done when there is a
serious or life-threatening situations or an emergency
Position: Instruct parent to comfort hold (hug from back holding arms)
,Preparation: Get everything ready before hand
Sequence: Least invasive procedures to most invasive procedures (No NOT
use head to toe approach) - ANSWER What is the Position, Preparation, and
Sequence when assessing a Infant or Toddler?
Position: Sit on parents lap or on bed
Preparation: Do not offer choices, if there is no choice to be made
Sequence: Body first then head (HEENT) - ANSWER What is the Position,
Preparation, and Sequence when assessing a Preschooler?
Position: Sit on bed
Preparation: Tell then what you are doing
Sequence: Head to toe with good explanations - ANSWER What is the
Position, Preparation, and Sequence when assessing a School-age (6-12)
child?
Position: Sit on bed, chair, or stand
Preparation: Health promotion focus due to new/risky behaviors
Sequence: Head to toe assessment - ANSWER What is the Position,
Preparation, and Sequence when assessing a Adolescent (10-19)?
Position: Sit of bed or chair and monitor comfort
Preparation: Don't assume hearing difficulty, be aware of changes in senses,
and encourage rest periods
Sequence: Head to toe minimizing position changes - ANSWER What is the
Position, Preparation, and Sequence when assessing an aging adult?
,Privacy
Adequate lighting
Warmth
Necessary equipment to prevent interruption
Physical and psychological preparation
Third person if indicated or needed to maintain safety - ANSWER What are
the 6 things needed for the Setting of an Assessment?
Vision, Hearing, Touch, and Smell - ANSWER What are the 4 senses Nursing
use in a Physical exam?
inspection, palpation, percussion, auscultation - ANSWER What are the 4
physical exam techniques?
Inspection - ANSWER What is done the moment you first see the patient?
- First physical exam technique used
Palpation - ANSWER What physical exam technique often confirms
inspection?
Percussion - ANSWER Physical exam technique that involves tapping on skin
Direct percussion - ANSWER Nurse tapping directly against a body surface
indirect percussion - ANSWER Nurse using a finger to tap against another
finger to produce a sound to find out what is underneath the skin
- organs
- size
, - shape
- fluid accumulation
Auscultation - ANSWER Physical exam technique that uses a stethoscope and
directs sound to ears
Bell - ANSWER Used when listening to soft or low pitched sounds
Diaphragm - ANSWER Used when listening to high pitched sounds
Vital signs - ANSWER Indicate some of the bodies basic functions and reflect
many things about health
- several sets form a baseline
After surgery, during a blood transfusion, or changes in patient status -
ANSWER When do we take vital signs more frequently?
96.4-99.1 F (35.8-37.3 C) - ANSWER Normal adult range of Body Temperature
98.6 F (37 C) - ANSWER Average adult temperature
Age
Environment
Time of day
Exercise
Stress
Hormones - ANSWER What factors influence our body temperature?
drops - ANSWER As we age out temperature ___________
1-4 am - ANSWER When is our body temperature at its lowest?
