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Exam (elaborations)

NURN 155 - FINAL EXAM 2025 WITH 100% ACCURATE SOLUTIONS

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NURN 155 - FINAL EXAM 2025 WITH 100% ACCURATE SOLUTIONS

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NURN 155
Course
NURN 155











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Institution
NURN 155
Course
NURN 155

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Uploaded on
May 8, 2025
Number of pages
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Written in
2024/2025
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NURN 155 - FINAL EXAM 2025 WITH 100% ACCURATE SOLUTIONS




1. Interview and Health Assessment - CORRECT -🅰️
🅰️☑️
☑️



a. Assessment- Interview, Health History, and Physical Assessment - CORRECT -🅰️
🅰️☑️
☑️



Interview - CORRECT -🅰️
🅰️☑️
☑§️Obtained on first patient encounter.

§ Completed by RN, cannot be delegated.

§ Consider age-specific prevention guidelines.

§ Gives a picture of the patient's current health history and health risk status.



Health History - CORRECT -🅰️
🅰️☑️
☑️- Bio Data



- Historian - Usually the source of history is the patient (primary source), but can be a family
member or friend, a letter of referral, or the medical record (secondary source).



- Reason for Seeking Care - chief complaint.

- Present Health/Illness.



- PQRSTU: The mnemonic ''PQRSTU'' is used to illicit information about the HPI.

Provoking Factors.

Quality/ quantity.

,Region and Radiation.

Severity scale.

Timing.

Understanding.



- PMH: All of the patient's past medical history.



- Family History - The health history of family members.



ROS - The nurse evaluates each body system's past and present state of health.

- Medication Reconciliation.

- ADL - The patient's ability to provide self care-bathing, toileting, walking, etc.



Physical Assessment - CORRECT -🅰️
🅰️☑️
☑️objective data: Observations or measurements of
the patient's health status.

Example- Checking Vital signs, nurse observing patient's behavior.



c. Health History-sources - CORRECT -🅰️
🅰️☑️
☑️Primary or Secondary Source:

•Patient.

•Family member.

•Observer.

•Caretaker.

•Health care team

•Electronic Medical Record (EMR).

•Other records- Immunization, educational, military, employment.

•Nurses Experience

,d. Interview- Technique, sources, - CORRECT -🅰️
🅰️☑️
☑️Interview techniques:

§ Observation.

§ Open-ended Questions.

§ Closed-ended Questions.

§ Non-verbal skills - body language. I.e., posture, gesture, facial expression, eye contact, foot
tapping, touch etc.



d. Communication technique - CORRECT -🅰️
🅰️☑️
☑•️Sending - verbal and non-verbal
communication.

• Receiving - the receiver uses his or her own interpretations of your own words.

• Internal Factors- Respect, Empathy, Listening, Self-awareness

• External Factors- Privacy, No Interruptions, Environment

• Dress - the client must remain in street clothes when conducting the interview. The
interviewer's appearance should be appropriate to the setting.

• Note-taking - keep note-taking to a minimum.



e. Data collection- Subjective and Objective data, Open ended, closed ended - CORRECT -
🅰️ 🅰️ ☑️ ☑️ • Subjective data - what the person says about himself or herself.

• Objective data - what the interviewer obtains through physical examination.

• Open-ended - allow clients to discuss their concerns freely.

• Closed-ended - can be answered with "Yes" or "No," or they have a limited set of possible
answers.



2. General and Environmental survey, PA technique, documentation - CORRECT -🅰️
🅰️☑️
☑️



a. SWIPE - CORRECT -🅰️ 🅰️ ☑️ ☑️
Safety/Survey, Wash your hands, Identify yourself & client,
Provide for privacy, and Explain.

, b. General survey- Physical Appearance, Body structure, Mobility, and Behavior - CORRECT -
🅰️ 🅰️ ☑️ ☑️



Physical Appearance - CORRECT -🅰️
🅰️☑️
☑️1. Age- appears stated age.

2. Sex - sexual development is appropriate for sex and age.

3. Level of consciousness.

4. Skin Color - color tone is even, pigmentation varying with genetic background.

5. Facial Features - are symmetric with movement.

6. Overall appearance - no signs of acute distress are present.



Body Structure - CORRECT -🅰️ 🅰️
☑️☑1
️ . Stature - the height appears within the normal range
for age and genetic heritage.

2. Nutritional Status - the weight appears within the normal range for height and body build.

3. Symmetry - body parts are equal bilaterally and are in relative proportion.

4. Posture - the client stands comfortably erect as appropriate for their age.

5. Position/Deformities - posture and how the patient holds him/or herself is surveyed.



Mobility - CORRECT -🅰️ 🅰️ ☑️☑️ 1. Gait - Descriptors of normal gait include: smooth, well-
balanced with symmetrical arm swings. The base of the gait should be as wide as the shoulder
width.

2. Range of Motion - note full mobility for each joint and that movement is deliberate, accurate,
smooth, and coordinated .



Behavior - CORRECT -🅰️
🅰️☑️
☑1
️ . Facial expression - the client maintains eye contact.

2. Mood and Affect - the client is comfortable and cooperative with the nurse and interacts
pleasantly.

3. Speech- Articulation clear.

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