GNUR 238 FINAL EXAM STUDY GUIDE
Skin Assessment: Palpation - Answers - color, moisture, temperature, texture, turgor,
vascularity, edema, lesions
primary data - Answers - one on one interviews with patient
Secondary data - Answers - Subjective data, objective data
Subjective Data Health History Questions - Answers - Past history of skin disease,
allergies, hives, psoriasis, or eczema?
Change in pigmentation or color, size, shape, tenderness?
Excessive dryness or moisture?
Pruritus or skin itching?
Excessive bruising?
Rash or lesions?
Medications: prescription and over-the-counter?
Hair loss?
Change in nails' shape, color, or brittleness?
Environmental or occupational hazards?
Self-care behaviors?
objective data (signs) - Answers - Hard data from your senses and physical examination
clinical reasoning - Answers - a specific term usually referring to ways of thinking about
patient care issues (determining, preventing, and managing patient problems); for
reasoning about other clinical issues (e.g., teamwork, collaboration, and streamlining
work flow); nurses usually use critical thinking
Types of Health Assessment - Answers - 1. Comprehensive Assessment.
2. Problem-Based/Focused Assessment.
3. Episodic/Follow-up Assessment.
4. Shift Assessment.
5. Screening Assessment.
comprehensive assessment - Answers - health history and complete physical
examination, usually conducted when a patient first enters a health care setting;
provides a baseline for comparing later assessment
Problem-based/focused health assessment - Answers - history and examination that
are limited to a specific problem or complaint; most commonly used in a walk-in clinic or
emergency department
Shift Assessment - Answers - when individuals are hospitalized, nurses conduct
assessments each shift
, episodic assessment - Answers - follow up
Screening Assessment - Answers - short examination focused on disease detection
Documentation of Data - Answers - > improves plan of care
> legal document of patient's health status
> baseline for evaluation, changes and decisions related to care
> must be accurate, concise, and without bias or opinion
Levels of Prevention: Primary - Answers - altering susceptibility; reducing exposure for
susceptible persons (vaccines, exercise, and nutrition)
Levels of Prevention: Secondary - Answers - early detection, screening, and
management of disease
Levels of Prevention: Tertiary - Answers - rehabilitation, supportive care, reducing
disability, and restoring effective functioning following disease
Nursing Process - Answers - Assessment
Diagnosis
Planning
Implementation
Evaluation
Nursing Process: Assessment - Answers - Systematic and continuous collection,
analysis, validation, and communication of patient data.
Data reflect how health functioning is enhanced by health promotion or compromised by
illness/injury.
A database includes all the pertinent patient information collected by the nurse and
other health care professionals.
The database enables the nurse to partner with patients to develop a comprehensive
and effective plan of care.
Nursing Process: Diagnosis - Answers - Identify problem and etiology
Construct NANDA
Prioritize diagnosis
Nursing Process: Implementation - Answers - Determine patient readiness and involve
patient(s) in health care process
Review planned interventions with interdisciplinary health care team members to
facilitate collaborative effort
Utilize principles of delegation, being mindful of supervision and evaluation
Counsel person and significant others
Skin Assessment: Palpation - Answers - color, moisture, temperature, texture, turgor,
vascularity, edema, lesions
primary data - Answers - one on one interviews with patient
Secondary data - Answers - Subjective data, objective data
Subjective Data Health History Questions - Answers - Past history of skin disease,
allergies, hives, psoriasis, or eczema?
Change in pigmentation or color, size, shape, tenderness?
Excessive dryness or moisture?
Pruritus or skin itching?
Excessive bruising?
Rash or lesions?
Medications: prescription and over-the-counter?
Hair loss?
Change in nails' shape, color, or brittleness?
Environmental or occupational hazards?
Self-care behaviors?
objective data (signs) - Answers - Hard data from your senses and physical examination
clinical reasoning - Answers - a specific term usually referring to ways of thinking about
patient care issues (determining, preventing, and managing patient problems); for
reasoning about other clinical issues (e.g., teamwork, collaboration, and streamlining
work flow); nurses usually use critical thinking
Types of Health Assessment - Answers - 1. Comprehensive Assessment.
2. Problem-Based/Focused Assessment.
3. Episodic/Follow-up Assessment.
4. Shift Assessment.
5. Screening Assessment.
comprehensive assessment - Answers - health history and complete physical
examination, usually conducted when a patient first enters a health care setting;
provides a baseline for comparing later assessment
Problem-based/focused health assessment - Answers - history and examination that
are limited to a specific problem or complaint; most commonly used in a walk-in clinic or
emergency department
Shift Assessment - Answers - when individuals are hospitalized, nurses conduct
assessments each shift
, episodic assessment - Answers - follow up
Screening Assessment - Answers - short examination focused on disease detection
Documentation of Data - Answers - > improves plan of care
> legal document of patient's health status
> baseline for evaluation, changes and decisions related to care
> must be accurate, concise, and without bias or opinion
Levels of Prevention: Primary - Answers - altering susceptibility; reducing exposure for
susceptible persons (vaccines, exercise, and nutrition)
Levels of Prevention: Secondary - Answers - early detection, screening, and
management of disease
Levels of Prevention: Tertiary - Answers - rehabilitation, supportive care, reducing
disability, and restoring effective functioning following disease
Nursing Process - Answers - Assessment
Diagnosis
Planning
Implementation
Evaluation
Nursing Process: Assessment - Answers - Systematic and continuous collection,
analysis, validation, and communication of patient data.
Data reflect how health functioning is enhanced by health promotion or compromised by
illness/injury.
A database includes all the pertinent patient information collected by the nurse and
other health care professionals.
The database enables the nurse to partner with patients to develop a comprehensive
and effective plan of care.
Nursing Process: Diagnosis - Answers - Identify problem and etiology
Construct NANDA
Prioritize diagnosis
Nursing Process: Implementation - Answers - Determine patient readiness and involve
patient(s) in health care process
Review planned interventions with interdisciplinary health care team members to
facilitate collaborative effort
Utilize principles of delegation, being mindful of supervision and evaluation
Counsel person and significant others
