NSG2317 Midterm Exam
the patient trajectory ANS: describes the dynamic (changing) course of health and illness
What is the nursing process? ANS: ADPIE:
Assessment
Diagnosis
Planning
Intervention/Implementation
Evaluation
communicating assessment findings ANS: SBAR and SOAP
SBAR ANS: Situation
Background
Assessment
Recommendation
SOAP ANS: subjective, objective, assessment, plan
history of present illness ANS: PQRSTU
provocation/palliative
quality/quantity
region/radiation
severity
timing
,understanding
Review of Systems (ROS) ANS: physical examination of all body systems in a systematic manner as part
of the nursing assessment (head to toe assessment)
Past Medical History (PMH) ANS: information gathered regarding the patient's health problems in the
past and asking questions about allergies, medications, previous/current illnesses, injuries, surgeries,
last examination date, vaccination status, etc.
Family History (FH) ANS: Facts about the health of the patient's parents, siblings, and other blood
relatives that might be significant to the patient's condition; looking for risk factor.
- may need to construct a genogram
Social History (SH) ANS: information about the patient's tobacco use, alcohol and drug use, sexual
history, relationship status, and other significant social facts that may contribute to the care of the
patient
care continuum ANS: skills are useless if patients do not/cannot present for/follow through with care
General Survey ANS: physical appearance, body structure, mobility, behaviour of patient when they
first walk in
Gestalt ANS: an organized whole that is perceived as more than the sum of its parts
mental status exam ANS: analyzing appearance, behaviour and cognition
Glasgow Coma Scale (GCS) ANS: a scale used to assess the consciousness of a patient upon physical
examination, typically in patients with neurological concerns or complaints
scale is divided into 3 parts:
,eye opening
verbal response
motor response
MOCA ANS: Montreal Cognitive Assessment
used for stoke and cardiac arrest patients to determine appropriate type of rehab
- patient is asked to draw a clock that has to have a certain number of requirements
BMI formula ANS: weight (kg) / height (m^2)
What BMI is considered overweight? ANS: 25-29.9
What BMI is considered obese? ANS: over 30
temperature normal range and critical value ANS: 37.2 (internal setpoint)
greater than 38 or less than 36
Hypothermia ANS: abnormally low body temperature (less than 36)
Pyrexia (fever) high and low grade ANS: low grade: 37.5-38.2
high grade: greater than 38
Hyperthermia ANS: Abnormally high body temperature (greater than 40)
Heart Rate normal range and critical findings ANS: 60-100bpm
, anything less than 60 or greater than 100
Bradycardia ANS: slow heart rate (less than 60 bpm)
Tachycardia ANS: Fast heart rate (HR greater than 100bpm)
respirations normal and critical range ANS: 10 -20 in adult (increased in older adults)
anything less than 10 or greater than 24
- Respiratory rates decrease with age, neonates and children have higher breathing rates (neonates 30-
40 breaths per min is average)
bradypnea ANS: an abnormally slow rate of respiration usually of less than 10 breaths per minute
Tachypnea ANS: Increased breathing rate (greater than 24 breaths per minute)
blood pressure normal and critical ranges ANS: 120/80
systolic pressure less than 90mmHG or greater than 160mmHG
hypotension ANS: abnormally low blood pressure 90/60; 90 is a concern because you are not really
profusing body
Hypertension ANS: high blood pressure 140/90 or higher
oxygen saturation normal and critical ranges ANS: 97-98%
anything less than 92%
the patient trajectory ANS: describes the dynamic (changing) course of health and illness
What is the nursing process? ANS: ADPIE:
Assessment
Diagnosis
Planning
Intervention/Implementation
Evaluation
communicating assessment findings ANS: SBAR and SOAP
SBAR ANS: Situation
Background
Assessment
Recommendation
SOAP ANS: subjective, objective, assessment, plan
history of present illness ANS: PQRSTU
provocation/palliative
quality/quantity
region/radiation
severity
timing
,understanding
Review of Systems (ROS) ANS: physical examination of all body systems in a systematic manner as part
of the nursing assessment (head to toe assessment)
Past Medical History (PMH) ANS: information gathered regarding the patient's health problems in the
past and asking questions about allergies, medications, previous/current illnesses, injuries, surgeries,
last examination date, vaccination status, etc.
Family History (FH) ANS: Facts about the health of the patient's parents, siblings, and other blood
relatives that might be significant to the patient's condition; looking for risk factor.
- may need to construct a genogram
Social History (SH) ANS: information about the patient's tobacco use, alcohol and drug use, sexual
history, relationship status, and other significant social facts that may contribute to the care of the
patient
care continuum ANS: skills are useless if patients do not/cannot present for/follow through with care
General Survey ANS: physical appearance, body structure, mobility, behaviour of patient when they
first walk in
Gestalt ANS: an organized whole that is perceived as more than the sum of its parts
mental status exam ANS: analyzing appearance, behaviour and cognition
Glasgow Coma Scale (GCS) ANS: a scale used to assess the consciousness of a patient upon physical
examination, typically in patients with neurological concerns or complaints
scale is divided into 3 parts:
,eye opening
verbal response
motor response
MOCA ANS: Montreal Cognitive Assessment
used for stoke and cardiac arrest patients to determine appropriate type of rehab
- patient is asked to draw a clock that has to have a certain number of requirements
BMI formula ANS: weight (kg) / height (m^2)
What BMI is considered overweight? ANS: 25-29.9
What BMI is considered obese? ANS: over 30
temperature normal range and critical value ANS: 37.2 (internal setpoint)
greater than 38 or less than 36
Hypothermia ANS: abnormally low body temperature (less than 36)
Pyrexia (fever) high and low grade ANS: low grade: 37.5-38.2
high grade: greater than 38
Hyperthermia ANS: Abnormally high body temperature (greater than 40)
Heart Rate normal range and critical findings ANS: 60-100bpm
, anything less than 60 or greater than 100
Bradycardia ANS: slow heart rate (less than 60 bpm)
Tachycardia ANS: Fast heart rate (HR greater than 100bpm)
respirations normal and critical range ANS: 10 -20 in adult (increased in older adults)
anything less than 10 or greater than 24
- Respiratory rates decrease with age, neonates and children have higher breathing rates (neonates 30-
40 breaths per min is average)
bradypnea ANS: an abnormally slow rate of respiration usually of less than 10 breaths per minute
Tachypnea ANS: Increased breathing rate (greater than 24 breaths per minute)
blood pressure normal and critical ranges ANS: 120/80
systolic pressure less than 90mmHG or greater than 160mmHG
hypotension ANS: abnormally low blood pressure 90/60; 90 is a concern because you are not really
profusing body
Hypertension ANS: high blood pressure 140/90 or higher
oxygen saturation normal and critical ranges ANS: 97-98%
anything less than 92%
