NUR 265 Final
Exam
1. subjective data: Things a person tells you about that you cannot observe through your senses;
symptoms
2. objective data: information that is seen, heard, felt, or smelled by an observer; signs
3. Primary data source: patient
4. Secondary Data Sources: family members, health records, significant others
5. General Survey: physical appearance, body structure, mobility, behavior
6. Complete database: full physical exam
7. Focused database: focuses on 1 or 2 systems
8. Follow-up database: follow-up after implementation
9. inspection: use of sight to
gather data used throughout PE
tools used to enhance inspection (penlight)
10. palpation: start
light to deep palpate tender
areas last
dorsum for temp
palms for pulsations
tips of fingers for texture, moisture, mass, edema
11. percussion: tapping on a surface to determine the ditterence in the density of the
underlying structure (flatness, dullness, resonance, hyperresonance, tympany)
12. Auscultation: Diaphragm- BP,
lungs, BS, heart Bell- vascular sounds,
murmur
Auscultation
13. gender role: a set of expected behaviors for males or for females
14. gender: in psychology, the biologically and socially influenced characteristics by which
people define male and female
15. gender identity: one's sense of being male or female
16. pressure injuries: injuries or wounds that result from skin deterioration and shearing
17. Stage 1 Pressure Injury: non-blanchable erythema of intact skin
, NUR 265 Final
Exam
18. Stage 2 Pressure Injury: partial-thickness skin loss with exposed dermis
, NUR 265 Final
Exam
19. Stage 3 Pressure Injury: full-thickness skin loss; not involving underlying fascia
20. Stage 4 Pressure Injury: full-thickness skin and tissue loss
21. Unstageable Pressure Injury: obscured full-thickness skin and tissue loss
22. Deep Tissue Pressure Injury: persistent non-blanchable deep red, maroon,
rple or pu
discoloration
23. prevention of pressure injuries: -good nursing care:
-assessment of skin/pressure points (done on daily basis)
-assist bedfast patient's pressure point every 2 hours
-multiple risk factor for skin break down (check every 2-3 hours)
24. ABCDE: asymmetry, border, color, diameter, evolution
25. primary lesions: lesions arising from previously normal skin
26. secondary lesions: lesions that result in changes in primary lesions
27. skin assessment: color: - general pigmentation, freckles, moles, birthmarks
- widespread color change such as pallor, erythema, cyanosis, or jaundice
28. annular, discrete:
Exam
1. subjective data: Things a person tells you about that you cannot observe through your senses;
symptoms
2. objective data: information that is seen, heard, felt, or smelled by an observer; signs
3. Primary data source: patient
4. Secondary Data Sources: family members, health records, significant others
5. General Survey: physical appearance, body structure, mobility, behavior
6. Complete database: full physical exam
7. Focused database: focuses on 1 or 2 systems
8. Follow-up database: follow-up after implementation
9. inspection: use of sight to
gather data used throughout PE
tools used to enhance inspection (penlight)
10. palpation: start
light to deep palpate tender
areas last
dorsum for temp
palms for pulsations
tips of fingers for texture, moisture, mass, edema
11. percussion: tapping on a surface to determine the ditterence in the density of the
underlying structure (flatness, dullness, resonance, hyperresonance, tympany)
12. Auscultation: Diaphragm- BP,
lungs, BS, heart Bell- vascular sounds,
murmur
Auscultation
13. gender role: a set of expected behaviors for males or for females
14. gender: in psychology, the biologically and socially influenced characteristics by which
people define male and female
15. gender identity: one's sense of being male or female
16. pressure injuries: injuries or wounds that result from skin deterioration and shearing
17. Stage 1 Pressure Injury: non-blanchable erythema of intact skin
, NUR 265 Final
Exam
18. Stage 2 Pressure Injury: partial-thickness skin loss with exposed dermis
, NUR 265 Final
Exam
19. Stage 3 Pressure Injury: full-thickness skin loss; not involving underlying fascia
20. Stage 4 Pressure Injury: full-thickness skin and tissue loss
21. Unstageable Pressure Injury: obscured full-thickness skin and tissue loss
22. Deep Tissue Pressure Injury: persistent non-blanchable deep red, maroon,
rple or pu
discoloration
23. prevention of pressure injuries: -good nursing care:
-assessment of skin/pressure points (done on daily basis)
-assist bedfast patient's pressure point every 2 hours
-multiple risk factor for skin break down (check every 2-3 hours)
24. ABCDE: asymmetry, border, color, diameter, evolution
25. primary lesions: lesions arising from previously normal skin
26. secondary lesions: lesions that result in changes in primary lesions
27. skin assessment: color: - general pigmentation, freckles, moles, birthmarks
- widespread color change such as pallor, erythema, cyanosis, or jaundice
28. annular, discrete:
