EXAM 1 NURS 3325 QUESTIONS WITH CORRECT ANSWERS

EXAM 1 NURS 3325 QUESTIONS WITH r r r r r




CORRECT ANSWERS r r



Components of health assessment - CORRECT ANSWERV-Health History (subjective data) r r r r r r r r r


Physical Examination (objective data)
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Documentation of Data (complete, concise, factual) r r r r r




Why we Learn about health assessments - CORRECT ANSWERV-
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Systematic way of collecting and analyzing
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Used to start patient plan of care
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First step in the health assessment
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The types of health assessments depends on - CORRECT ANSWERV-Context of Care Patient
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Need
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Nurse Expertise r




Type of health assessments - CORRECT ANSWER -Comprehensive Assessment
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Focused Assessment
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Follow-up Assessment r


Shift Assessment
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Screening Assessment
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Clinical reasoning and judgment - CORRECT ANSWER -Collect, organize, analyze, and
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interpret data
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Create plan of care using clinical judgment
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CLINICAL JUDGMENT - CORRECT ANSWER - r r r r r


"interpretation or conclusion about a patient's needs, concerns, or health programs and/or the decision
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t o take action (or not), use or modify standard approaches, or improvise new ones as deemed by the pat
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ient response."
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health promotion - CORRECT ANSWERV-increase well-being and actualize human health potential
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primary health promotion - CORRECT ANSWER -
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prevent disease development through healthy lifestyle choices
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secondary health promotion - CORRECT ANSWERV- r r r r r


screening efforts to promote early detection of disease
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tertiary health promotion - CORRECT ANSWER -minimizing disability from acute or chronic disease
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health protection - CORRECT ANSWER -
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actively avoid illness, early detection, maintain function with illness
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Healthy people 2030 - CORRECT ANSWERV- r r r r r


goal of reducing most significant preventable health threats and reducing preventable health threats
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Skin assessment- when documenting a skin assessment, the nurse should: - CORRECT ANSWER -
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Use standardized terminology to report findings
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, • Use standardized terminology to record findings
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• Perform assessment when risk factors identified r r r r r


• Allow information from the history to help direct the assessment
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• Document both normal and abnormal skin strategies from the assessment r r r r r r r r r




OLD CARTS - CORRECT ANSWER -
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Onset, Location, Duration, Characteristics, Aggravating Factors, Related Symptoms, Treatment, and Se
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verity
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• Example:
• When did the rash start (onset) r r r r r


• What makes the rash worse (aggravating factors)
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• What do you do to make the rash better (treatment)
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• Describe the sensation from the burn, does it burn or itch (related symptoms)
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• Describe what the rash looked like initially (duration/characteristics)
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stage 1 pressure injury - CORRECT ANSWER -intact skin, non- blanchable
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redness over coccyx, tender, warm
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stage 2 pressure injury - CORRECT ANSWER -
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partial thickness loss of dermis, pink wound bed, no slough or bruising
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stage 3 pressure injury - CORRECT ANSWER -
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full thickness skin loss, subcutaneous fat visible, no visible bone
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stage 4 pressure injury - CORRECT ANSWER -
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full thickness tissue loss, tendon exposed, tunneling, slough present
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Nail Assessment - CORRECT ANSWERV-
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Nail surface should be smooth and flat in the center and slightly curved downward at the edges. The
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s kin adjacent to the nail should be intact, the same color as adjacent skin and without edema. The expec
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rted angle of the nail base is 160 degrees. The nail should have uniform thickness and the base should f
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eel firm and adhere to the nail bed.
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jaundice - CORRECT ANSWERV-which is a yellowish-green color in light and dark skinned patients
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Jaundice can best be assessed in - CORRECT ANSWER -Sclera of the eye
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Palms of the hands r r r


Soles of the feet r r r




The appearance of the normal tympanic membrane is - CORRECT ANSWERV-
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Translucent and pearly gray r r r




tympanic membrane - CORRECT ANSWER - r r r r r


Redness of the tympanic membrane may indicate infection
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A brown sticky discharge is cerumen which is a normal finding, but may cause the tympanic
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membran e to be obscured
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Pink may indicate possible otitis externa or impending infection
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