NURS 328 - Final Exam Study Guide UPDATED ACTUAL
Questions and CORRECT Answers
order of total body assessment by systems - general health state
- nutrition and hydration
- skin, hair, nails
- head and neck
- eyes, ears, nose, mouth, and throat
- thorax and lungs
- heart, neck vessels, peripheral vascular
- breasts
- abdominal → gastrointestinal
- abdominal → urinary
- musculoskeletal
- neurological
- genitalia
- anus, rectum, and prostate
- endocrine and hematologic systems
considerations for the interview environment - limit distractions
- avoid using technical language
- avoid interrupting the patient
,phases of the interview process 1. pre-interaction phase
- compiling existing data
- preparing for patient interview from existing medical records
- looking at the patient's chart
2. beginning phase
- introduction
- state the purpose of the interview
3. working phase
- closed ended or direct questions for specific info
- open ended questions, broad answers in patient's words
- avoid "why" questions
4. closing phase
- summarizing
- stating the most important 2-3 problems or patterns
emergency/life-threatening assessment - based on the mnemonic ABCDE
- A → airway
- B → breathing
- C → circulation
- D → disability
- E → exposure
comprehensive assessment - complete health history and physical assessment performed
- annually for outpatients
- upon hospital/long-term care admission
focused assessment - occurs in all settings
- smaller in scope but increased depth for specific issues
first-level priority patient - emergency, life-threatening, and immediate
- example → ABCs, bleeding out
second-level priority patient - requiring attention to avoid further deterioration
- example → sepsis, hypoglycemia
third-level priority patient - important to the patient's health but can be addressed after more urgent
problems are addressed
- example → UTIs, fracture
allergy questions - verify allergies with patients and compare them to the allergies in their chart
- note the type of response to the allergy → rash, throat swelling, difficulty
breathing, anaphylactic shock
- differentiate between an adverse reaction (nauseousness) and an allergic
reaction (throat swelling, difficulty breathing)
documentation of allergies - patient should have a name band applied noting the allergy
- allergies should be documented appropriately in the patient's chart
, acute pain - from tissue damage
- examples → trauma, surgery, injury
chronic pain - pain that lasts beyond the normal healing period of 3-6 months
- may be no identifiable cause → lower back pain, sickle cell anemia
neuropathic pain - pain that results from damage to nerves in the peripheral or central nervous
system
- example → neuropathy
nociplastic pain - pain that arises from altered nociception despite no clear evidence of actual or
threatened tissue damage cause activation of peripheral nociceptors or evidence
of lesion or disease of the somatosensory system causing pain
- example → fibromyalgia, restless leg syndrome
numeric pain scale - one-dimensional pain scale
- the higher the number, the more severe the pain
FLACC pain assessment - face, legs, activity, cry, consolability
- used for infants and children (2 months-7 years)
FACES pain assessment - uses pictures of facial expressions for patient to rate their pain
- used for nonverbal children/adults, cognitively impaired adults
pain in older adults - may be reluctant to report pain because they want to be considered "good"
patients
- may fear dependence on others
- may fear complaints of pain will lead to expensive tests or medications they
cannot afford
subjective data - based on patient experiences and perceptions
- individual describes the feelings, sensations, or expectations
- patient is the primary source
- example → "I am having 8/10 pain"
objective data - physical assessment
- measurable
- general appearance, vital signs, head-to-toe
- example → "Patient with soft, non-tender abdomen, BSx4"
order of assessment - inspect
- palpate
- percuss
- auscultate
order of abdominal assessment - inspect
- auscultate
- percuss
- palpate
Questions and CORRECT Answers
order of total body assessment by systems - general health state
- nutrition and hydration
- skin, hair, nails
- head and neck
- eyes, ears, nose, mouth, and throat
- thorax and lungs
- heart, neck vessels, peripheral vascular
- breasts
- abdominal → gastrointestinal
- abdominal → urinary
- musculoskeletal
- neurological
- genitalia
- anus, rectum, and prostate
- endocrine and hematologic systems
considerations for the interview environment - limit distractions
- avoid using technical language
- avoid interrupting the patient
,phases of the interview process 1. pre-interaction phase
- compiling existing data
- preparing for patient interview from existing medical records
- looking at the patient's chart
2. beginning phase
- introduction
- state the purpose of the interview
3. working phase
- closed ended or direct questions for specific info
- open ended questions, broad answers in patient's words
- avoid "why" questions
4. closing phase
- summarizing
- stating the most important 2-3 problems or patterns
emergency/life-threatening assessment - based on the mnemonic ABCDE
- A → airway
- B → breathing
- C → circulation
- D → disability
- E → exposure
comprehensive assessment - complete health history and physical assessment performed
- annually for outpatients
- upon hospital/long-term care admission
focused assessment - occurs in all settings
- smaller in scope but increased depth for specific issues
first-level priority patient - emergency, life-threatening, and immediate
- example → ABCs, bleeding out
second-level priority patient - requiring attention to avoid further deterioration
- example → sepsis, hypoglycemia
third-level priority patient - important to the patient's health but can be addressed after more urgent
problems are addressed
- example → UTIs, fracture
allergy questions - verify allergies with patients and compare them to the allergies in their chart
- note the type of response to the allergy → rash, throat swelling, difficulty
breathing, anaphylactic shock
- differentiate between an adverse reaction (nauseousness) and an allergic
reaction (throat swelling, difficulty breathing)
documentation of allergies - patient should have a name band applied noting the allergy
- allergies should be documented appropriately in the patient's chart
, acute pain - from tissue damage
- examples → trauma, surgery, injury
chronic pain - pain that lasts beyond the normal healing period of 3-6 months
- may be no identifiable cause → lower back pain, sickle cell anemia
neuropathic pain - pain that results from damage to nerves in the peripheral or central nervous
system
- example → neuropathy
nociplastic pain - pain that arises from altered nociception despite no clear evidence of actual or
threatened tissue damage cause activation of peripheral nociceptors or evidence
of lesion or disease of the somatosensory system causing pain
- example → fibromyalgia, restless leg syndrome
numeric pain scale - one-dimensional pain scale
- the higher the number, the more severe the pain
FLACC pain assessment - face, legs, activity, cry, consolability
- used for infants and children (2 months-7 years)
FACES pain assessment - uses pictures of facial expressions for patient to rate their pain
- used for nonverbal children/adults, cognitively impaired adults
pain in older adults - may be reluctant to report pain because they want to be considered "good"
patients
- may fear dependence on others
- may fear complaints of pain will lead to expensive tests or medications they
cannot afford
subjective data - based on patient experiences and perceptions
- individual describes the feelings, sensations, or expectations
- patient is the primary source
- example → "I am having 8/10 pain"
objective data - physical assessment
- measurable
- general appearance, vital signs, head-to-toe
- example → "Patient with soft, non-tender abdomen, BSx4"
order of assessment - inspect
- palpate
- percuss
- auscultate
order of abdominal assessment - inspect
- auscultate
- percuss
- palpate
