NUR 235 Exam 1 UPDATED ACTUAL
Questions and CORRECT Answers
General Survey - CORRECT ANSWER - study of the whole person, covering the general
health state and any obvious physical characteristics. Should begin at first contact with patient.
Deviations Led to Focused Assessments - CORRECT ANSWER - Appearance/Behavior,
Grooming/Hygiene, Body Type/Posture, Mental State, Speech, Vital Signs, Weight/Height
Components of General Survey - CORRECT ANSWER - Physical Appearance, Mental
Status, Mobility, Behavior and Life Span Considerations
Physical Appearance - CORRECT ANSWER - -Body shape
-Build: Height and weight when compared to age
-Assessment of function and symmetry
Mental Status - CORRECT ANSWER - - Orientation
- Affect
- Anxiety
If patient appears confused, ask: - CORRECT ANSWER - -"Tell me your name."
-"Where are you now?"
-"What is today's date?"
-"What time is it?"
Mobility - CORRECT ANSWER - -Posture: how we hold our bodies while standing,
sitting and lying down.
-Gait: being able to walk
-Range of Motion: extent of movement of a joint
,Patient Behaviors - CORRECT ANSWER - -Grooming
-Body Odors
-Hygiene
-Facial Expression
-Mood
-Level of Anxiety
-Speech
Life Span Considerations: Pediatric Patients - CORRECT ANSWER - Compare
developmental stage to expected findings based on the age of patient
Life Span Considerations: Older Adults - CORRECT ANSWER - -Grooming and hygiene
becomes affected by mobility
-Gait becomes slower with shorter steps
-Behavior may be affected by various disorders.
Height - CORRECT ANSWER - The measurement of someone or something from head to
foot or from base to top.
How should someones height be taken? - CORRECT ANSWER - -Patient should looks
taught ahead while standing straight.
-Heels together & Shoulders Back
- Place level on crown of patient's head at right angle
How is weight taken? - CORRECT ANSWER - -On standard platform or digital scale.
-Best to use same scale, clothing and weigh around same time.
, What is a Nursing Physical Examination? - CORRECT ANSWER - -Part of a general
health assessment
-Used to gather data about the client
-Focuses on functional abilities and responses to illness and stressors
Purpose of Nursing Physical Examination - CORRECT ANSWER - -Establishes baseline
data for patients
-Identifies nursing diagnoses, collaborative problems and wellness diagnoses
Types of Nursing Examinations - CORRECT ANSWER - -Comprehensive
-Focused
-Ongoing
Comprehensive Examination - CORRECT ANSWER - Includes interview plus a complete
head-to-toe examination
Focused Examination - CORRECT ANSWER - Focused on the presenting problem or
chief complaint
Ongoing Examination - CORRECT ANSWER - Performed as needed to assess status,
evaluates client outcomes
Physical Assessment Skills - CORRECT ANSWER - 1. Inspection
2. Palpation
3. Percussion
4. Auscultation
Inspection - CORRECT ANSWER - general observation of the patient as a whole,
progressing to specific body areas.
Questions and CORRECT Answers
General Survey - CORRECT ANSWER - study of the whole person, covering the general
health state and any obvious physical characteristics. Should begin at first contact with patient.
Deviations Led to Focused Assessments - CORRECT ANSWER - Appearance/Behavior,
Grooming/Hygiene, Body Type/Posture, Mental State, Speech, Vital Signs, Weight/Height
Components of General Survey - CORRECT ANSWER - Physical Appearance, Mental
Status, Mobility, Behavior and Life Span Considerations
Physical Appearance - CORRECT ANSWER - -Body shape
-Build: Height and weight when compared to age
-Assessment of function and symmetry
Mental Status - CORRECT ANSWER - - Orientation
- Affect
- Anxiety
If patient appears confused, ask: - CORRECT ANSWER - -"Tell me your name."
-"Where are you now?"
-"What is today's date?"
-"What time is it?"
Mobility - CORRECT ANSWER - -Posture: how we hold our bodies while standing,
sitting and lying down.
-Gait: being able to walk
-Range of Motion: extent of movement of a joint
,Patient Behaviors - CORRECT ANSWER - -Grooming
-Body Odors
-Hygiene
-Facial Expression
-Mood
-Level of Anxiety
-Speech
Life Span Considerations: Pediatric Patients - CORRECT ANSWER - Compare
developmental stage to expected findings based on the age of patient
Life Span Considerations: Older Adults - CORRECT ANSWER - -Grooming and hygiene
becomes affected by mobility
-Gait becomes slower with shorter steps
-Behavior may be affected by various disorders.
Height - CORRECT ANSWER - The measurement of someone or something from head to
foot or from base to top.
How should someones height be taken? - CORRECT ANSWER - -Patient should looks
taught ahead while standing straight.
-Heels together & Shoulders Back
- Place level on crown of patient's head at right angle
How is weight taken? - CORRECT ANSWER - -On standard platform or digital scale.
-Best to use same scale, clothing and weigh around same time.
, What is a Nursing Physical Examination? - CORRECT ANSWER - -Part of a general
health assessment
-Used to gather data about the client
-Focuses on functional abilities and responses to illness and stressors
Purpose of Nursing Physical Examination - CORRECT ANSWER - -Establishes baseline
data for patients
-Identifies nursing diagnoses, collaborative problems and wellness diagnoses
Types of Nursing Examinations - CORRECT ANSWER - -Comprehensive
-Focused
-Ongoing
Comprehensive Examination - CORRECT ANSWER - Includes interview plus a complete
head-to-toe examination
Focused Examination - CORRECT ANSWER - Focused on the presenting problem or
chief complaint
Ongoing Examination - CORRECT ANSWER - Performed as needed to assess status,
evaluates client outcomes
Physical Assessment Skills - CORRECT ANSWER - 1. Inspection
2. Palpation
3. Percussion
4. Auscultation
Inspection - CORRECT ANSWER - general observation of the patient as a whole,
progressing to specific body areas.
