NUR 205 EVALUATION 2027 SETS ANSWERS AND
QUESTIONS SET A+
✔✔Domestic violence screening - ✔✔-Determines if patient experiences any form of
abuse
-conducted during 1v1 interview with patient
✔✔Mental status exam - ✔✔-appearance
-behavior
-cognitive level of functioning
✔✔General survey - ✔✔Assess's patient general appearance and behavior while
preparing for assessment
✔✔General survey exemplars - ✔✔-Gender
-race
-signs of distress
-body type
-posture
-gait
-body movement
-vital signs
-hygiene and grooming
-dress
- body odor
-affects and mood
-speech
-signs of abuse
-substance abuse
-height and weight
✔✔Integumentary assessment subjective - ✔✔-self care behaviors
-history of skin disease
-medications
-environmental hazards
,-changes in skin color
-changes in mole or scar
✔✔Integumentary assessment objective - ✔✔-Color
-temperature
-dryness
-skin turgor
-texture
-itching
-rash
-edema
✔✔cyanosis - ✔✔Mottled, bluish coloration of skin
-check lips and tongue for gray color
-check nail beds, palms and soles for bluish color
✔✔Erythema - ✔✔redness of skin
✔✔Pallor - ✔✔pale, whiteish color
✔✔Jaundice - ✔✔yellowing color of the skin
-check oral for yellow color
-check eyes for yellow color
✔✔bleeding of integumentary system - ✔✔-look for swelling/darkening of the skin
-compare affected area with unaffected area
✔✔Inflammation of integumentary system - ✔✔-check for warmth or pitting area
-compare affected side with unaffected side
✔✔Edema - ✔✔swelling
1+ bare pit
2+ rebounds for a few seconds
3+ rebounds 10-20 seconds
4+ rebounds more than 30 seconds
✔✔assessing capillary refill - ✔✔1. depress nail bed to produce blanching
2. release and observe for return of color
3. color will return within 3 seconds if arterial capillary perfusion is normal
✔✔HEENT; Head - ✔✔inspection of head
-inspect/palpate
-tenderness
-symmetry
-hair distribution
, -lesions/scars
✔✔HEENT; temporomandibular joint - ✔✔ask patient to open mouth. note tenderness,
or limited range of movement
✔✔HEENT; face - ✔✔inspect facial features
-symmetry
-swelling
✔✔Assessment of eyes subjective - ✔✔-difficulty with vision
-pain
-redness
-use of glasses/contacts
-medications
-history of eye problems
✔✔Assessment of eyes objective - ✔✔-inspect external eye structures
✔✔Vision testing - ✔✔snellen test- measures distance vision
near vision test
confrontation test-measures peripheral vision
✔✔Assessment of sclera and cornea - ✔✔Normal- white color
-in dark skinned patients sclera may appear yellow
cornea should be transparent
-cloudy areas or dots can be result of injury
✔✔PEERLA - ✔✔pupils equal, round, reactive to light and accommodation
✔✔Assessing extraocular muscle function of eyes - ✔✔-Assess 6 cardinal positions
-note any involuntary rhythmic, rapid, twitching of eye balls
✔✔assessment of ears (subjective data) - ✔✔-difficulty hearing
-earaches
-drainage
-dizziness
-ringing in the ears
-hearing aid
-medications
✔✔Assessment of ears (objective data) - ✔✔-inspect and palpate external ear
-size, shape, symmetry
-inspect external auditory
✔✔Assessment of nose subjective - ✔✔-discharge, facial or sinus pain
QUESTIONS SET A+
✔✔Domestic violence screening - ✔✔-Determines if patient experiences any form of
abuse
-conducted during 1v1 interview with patient
✔✔Mental status exam - ✔✔-appearance
-behavior
-cognitive level of functioning
✔✔General survey - ✔✔Assess's patient general appearance and behavior while
preparing for assessment
✔✔General survey exemplars - ✔✔-Gender
-race
-signs of distress
-body type
-posture
-gait
-body movement
-vital signs
-hygiene and grooming
-dress
- body odor
-affects and mood
-speech
-signs of abuse
-substance abuse
-height and weight
✔✔Integumentary assessment subjective - ✔✔-self care behaviors
-history of skin disease
-medications
-environmental hazards
,-changes in skin color
-changes in mole or scar
✔✔Integumentary assessment objective - ✔✔-Color
-temperature
-dryness
-skin turgor
-texture
-itching
-rash
-edema
✔✔cyanosis - ✔✔Mottled, bluish coloration of skin
-check lips and tongue for gray color
-check nail beds, palms and soles for bluish color
✔✔Erythema - ✔✔redness of skin
✔✔Pallor - ✔✔pale, whiteish color
✔✔Jaundice - ✔✔yellowing color of the skin
-check oral for yellow color
-check eyes for yellow color
✔✔bleeding of integumentary system - ✔✔-look for swelling/darkening of the skin
-compare affected area with unaffected area
✔✔Inflammation of integumentary system - ✔✔-check for warmth or pitting area
-compare affected side with unaffected side
✔✔Edema - ✔✔swelling
1+ bare pit
2+ rebounds for a few seconds
3+ rebounds 10-20 seconds
4+ rebounds more than 30 seconds
✔✔assessing capillary refill - ✔✔1. depress nail bed to produce blanching
2. release and observe for return of color
3. color will return within 3 seconds if arterial capillary perfusion is normal
✔✔HEENT; Head - ✔✔inspection of head
-inspect/palpate
-tenderness
-symmetry
-hair distribution
, -lesions/scars
✔✔HEENT; temporomandibular joint - ✔✔ask patient to open mouth. note tenderness,
or limited range of movement
✔✔HEENT; face - ✔✔inspect facial features
-symmetry
-swelling
✔✔Assessment of eyes subjective - ✔✔-difficulty with vision
-pain
-redness
-use of glasses/contacts
-medications
-history of eye problems
✔✔Assessment of eyes objective - ✔✔-inspect external eye structures
✔✔Vision testing - ✔✔snellen test- measures distance vision
near vision test
confrontation test-measures peripheral vision
✔✔Assessment of sclera and cornea - ✔✔Normal- white color
-in dark skinned patients sclera may appear yellow
cornea should be transparent
-cloudy areas or dots can be result of injury
✔✔PEERLA - ✔✔pupils equal, round, reactive to light and accommodation
✔✔Assessing extraocular muscle function of eyes - ✔✔-Assess 6 cardinal positions
-note any involuntary rhythmic, rapid, twitching of eye balls
✔✔assessment of ears (subjective data) - ✔✔-difficulty hearing
-earaches
-drainage
-dizziness
-ringing in the ears
-hearing aid
-medications
✔✔Assessment of ears (objective data) - ✔✔-inspect and palpate external ear
-size, shape, symmetry
-inspect external auditory
✔✔Assessment of nose subjective - ✔✔-discharge, facial or sinus pain
