Nursing 101 Final Exam Study Guide
UPDATED ACTUAL Questions and
CORRECT Answers
What is the purpose of a nurse performing a physical assessment? - CORRECT ANSWER - -
Establish baseline data.
- Identify nursing diagnoses, collaborative problems, or wellness diagnoses.
- Monitor the status of an identified problem.
- Screen for health problems
Types of physical exams a nurse may perform: - CORRECT ANSWER - 1. Comprehensive:
Interview plus complete head-to-toe examination.
2. Focused: "Focused" on presenting problems.
3. System-specific: Limited to one body system.
4. Ongoing: Performed as needed to assess status. Evaluates the client outcomes.
Preparing the client and environment: - CORRECT ANSWER - Environment:
- Privacy is key: Draping, use of curtains.
- Noise control: Tv/radio/computer off
- Enable visualization: Lighting, flashlight if needed.
- Temperature
- Equipment
Client:
, - Client comfort: Develop rapport. Explain procedure. Respect cultural differences.
- Proper positioning
Four assessment techniques: - CORRECT ANSWER - 1. Inspection
2. Palpation
3. Percussion
4. Auscultation
GI is a different sequence
Inspection: - CORRECT ANSWER - Use of sight o gather data. Adequate lighting and proper
positioning aid inspection.
Palpation: - CORRECT ANSWER - - Assesses temperature, skin texture, moisture, anatomical
landmarks, and such abnormalities as edema, masses, or areas of tenderness.
- Always inform the client that you are about to touch them and use a gentle approach.
- Begin with light pressure to detect surface characteristics, then move to deep palpation to assess the
underlying structure. Examine last any areas of discomfort or sensitivity.
Percussion: - CORRECT ANSWER - Tapping your fingers on the skin using short strokes.
Tapping produces vibrations, and the resulting sound allows you to determine location, size, and density
of underlying structures. Percussion is especially useful when assessing the abdomen and lungs.
Auscultation: - CORRECT ANSWER - Use of hearing to gather data. Direct auscultation is
listening without using an instrument. If you have heard wheezing or chest congestion without the use of
a stethoscope, you have already performed direct auscultation. Indirect Auscultation is listening with the
help of a stethoscope.
Development considerations when performing an assessment: - CORRECT ANSWER - - Infants:
Attend to safety.
UPDATED ACTUAL Questions and
CORRECT Answers
What is the purpose of a nurse performing a physical assessment? - CORRECT ANSWER - -
Establish baseline data.
- Identify nursing diagnoses, collaborative problems, or wellness diagnoses.
- Monitor the status of an identified problem.
- Screen for health problems
Types of physical exams a nurse may perform: - CORRECT ANSWER - 1. Comprehensive:
Interview plus complete head-to-toe examination.
2. Focused: "Focused" on presenting problems.
3. System-specific: Limited to one body system.
4. Ongoing: Performed as needed to assess status. Evaluates the client outcomes.
Preparing the client and environment: - CORRECT ANSWER - Environment:
- Privacy is key: Draping, use of curtains.
- Noise control: Tv/radio/computer off
- Enable visualization: Lighting, flashlight if needed.
- Temperature
- Equipment
Client:
, - Client comfort: Develop rapport. Explain procedure. Respect cultural differences.
- Proper positioning
Four assessment techniques: - CORRECT ANSWER - 1. Inspection
2. Palpation
3. Percussion
4. Auscultation
GI is a different sequence
Inspection: - CORRECT ANSWER - Use of sight o gather data. Adequate lighting and proper
positioning aid inspection.
Palpation: - CORRECT ANSWER - - Assesses temperature, skin texture, moisture, anatomical
landmarks, and such abnormalities as edema, masses, or areas of tenderness.
- Always inform the client that you are about to touch them and use a gentle approach.
- Begin with light pressure to detect surface characteristics, then move to deep palpation to assess the
underlying structure. Examine last any areas of discomfort or sensitivity.
Percussion: - CORRECT ANSWER - Tapping your fingers on the skin using short strokes.
Tapping produces vibrations, and the resulting sound allows you to determine location, size, and density
of underlying structures. Percussion is especially useful when assessing the abdomen and lungs.
Auscultation: - CORRECT ANSWER - Use of hearing to gather data. Direct auscultation is
listening without using an instrument. If you have heard wheezing or chest congestion without the use of
a stethoscope, you have already performed direct auscultation. Indirect Auscultation is listening with the
help of a stethoscope.
Development considerations when performing an assessment: - CORRECT ANSWER - - Infants:
Attend to safety.
