NUR 2000 Final Exam with Accurate
Solutions
What is a health assessment? - ANS-a systematic method of collecting data about a
client in order to develop a nursing diagnosis.
what is the nursing responsibility? - ANS-to maintain health status changes
the nursing process - ANS-Assessment
Diagnosis
Planning
Implementation
Evaluation
subjective vs. objective data - ANS-Subjective- What the patient tells you
Objective- what you detect during exam
Priority setting frameworks - ANS--Maslow's Hierarchy
-Airway, Breathing, Circulation (ABC) framework
-Safety/Risk reduction
-Assessment/Data Collection First
-Survival Potential
-Least Restrictive/Least Invasive
-Acute vs. Chronic/Urgent vs. Nonurgent/Stable vs. Unstable
primary data vs secondary data - ANS-primary: something the patient directly tells you
secondary: something that doesn't come from the patient ie. health record, list of
medications
standard precautions - ANS-- hand hygiene
-used on all patients
What are the phases of the interview process? - ANS-Pre-interaction phase
Beginning phase
Working phase
Closing phase
what are the components of a health history? - ANS-biographic data, reason for seeking
care, history of present illness, present health status, past health history, family history,
personal and psychosocial history, review of systems. onset, duration of pain
, physical assessment techniques - ANS-inspection, palpation, auscultation, percussion
the medical record is used for - ANS-communication and legal documentation
normal vital signs - ANS-BP: 90/60 to 120/80
Resp: 12 to 18 breaths
Pulse: 60 to 100
Temp: 97.8°F to 99.1°F (36.5°C to 37.3°C)
98.6°F (37°C) = average
bradycardia - ANS-slow heart rate (less than 60 bpm)
tachycardia - ANS-fast heart rate (greater than 100 bpm)
general survey checks - ANS-general appearance, bed locked and low, call bell within
reach, personal belongings, side rails, bed alarm on etc.
normal pulse strength - ANS-2+
dyspnea - ANS-shortness of breath
apnea - ANS-absence of breathing
tachypnea - ANS-rapid breathing
bradypnea - ANS-slow breathing
acute vs chronic pain - ANS-Acute:
Comes on suddenly (trauma, surgery)
Results from disease, inflammation or injury to tissues
Accompanied by anxiety and emotional distress
Self-limiting
Physiologic responses (HR, RR, BP all rise)
If untreated, acute pain can become chronic
Chronic:
Exists over longer period of time (>6 mos.)
Pain persists despite the fact the injury has healed
Resistant to most medical therapies
Made worse by environmental/psychologic factors
Physical and Psychologic effects (sleep disorders, anxiety, depression)
Loss of autonomic signs
pain scales - ANS-numeric pain scale, FACES
Solutions
What is a health assessment? - ANS-a systematic method of collecting data about a
client in order to develop a nursing diagnosis.
what is the nursing responsibility? - ANS-to maintain health status changes
the nursing process - ANS-Assessment
Diagnosis
Planning
Implementation
Evaluation
subjective vs. objective data - ANS-Subjective- What the patient tells you
Objective- what you detect during exam
Priority setting frameworks - ANS--Maslow's Hierarchy
-Airway, Breathing, Circulation (ABC) framework
-Safety/Risk reduction
-Assessment/Data Collection First
-Survival Potential
-Least Restrictive/Least Invasive
-Acute vs. Chronic/Urgent vs. Nonurgent/Stable vs. Unstable
primary data vs secondary data - ANS-primary: something the patient directly tells you
secondary: something that doesn't come from the patient ie. health record, list of
medications
standard precautions - ANS-- hand hygiene
-used on all patients
What are the phases of the interview process? - ANS-Pre-interaction phase
Beginning phase
Working phase
Closing phase
what are the components of a health history? - ANS-biographic data, reason for seeking
care, history of present illness, present health status, past health history, family history,
personal and psychosocial history, review of systems. onset, duration of pain
, physical assessment techniques - ANS-inspection, palpation, auscultation, percussion
the medical record is used for - ANS-communication and legal documentation
normal vital signs - ANS-BP: 90/60 to 120/80
Resp: 12 to 18 breaths
Pulse: 60 to 100
Temp: 97.8°F to 99.1°F (36.5°C to 37.3°C)
98.6°F (37°C) = average
bradycardia - ANS-slow heart rate (less than 60 bpm)
tachycardia - ANS-fast heart rate (greater than 100 bpm)
general survey checks - ANS-general appearance, bed locked and low, call bell within
reach, personal belongings, side rails, bed alarm on etc.
normal pulse strength - ANS-2+
dyspnea - ANS-shortness of breath
apnea - ANS-absence of breathing
tachypnea - ANS-rapid breathing
bradypnea - ANS-slow breathing
acute vs chronic pain - ANS-Acute:
Comes on suddenly (trauma, surgery)
Results from disease, inflammation or injury to tissues
Accompanied by anxiety and emotional distress
Self-limiting
Physiologic responses (HR, RR, BP all rise)
If untreated, acute pain can become chronic
Chronic:
Exists over longer period of time (>6 mos.)
Pain persists despite the fact the injury has healed
Resistant to most medical therapies
Made worse by environmental/psychologic factors
Physical and Psychologic effects (sleep disorders, anxiety, depression)
Loss of autonomic signs
pain scales - ANS-numeric pain scale, FACES
