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Exam (elaborations)

NSG 316 Exam Questions with correct Answers 2025/2026 A+ Graded 100% Verified

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NSG 316 Exam Questions with correct Answers 2025/2026 A+ Graded 100% Verified

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NSG 316 Exam Questions with correct
Answers 2025/2026 A+ Graded 100%
Verified
HIPAA - ANS-Health Insurance Portability and Accountability Act

what does HIPAA cover - ANS-any written verbal or electronic communication

never discuss or review any info regarding a patient of a clinical site (unless part of assignment)

obligate to know and adhere to privacy policies at each clinical site

confidentiality under law and this agreement (medical records, accounting info, patient info,
between health care professionals about patients)

HIPAA rules for clinical - ANS-may not remove any record from the clinical site without written

may not disclose any info about patient during clinical

must attempt to exclude as much of the following info as possible

HIPAA includes what info - ANS-names
vehicle identifiers
date of birth
email address
social security numbers

any info to be linked to the patient

HIPAA rules - ANS-information may be disclosed for health care training and educational
purposes

promptly report any violation of the clinical site privacy policies and procedures

subject to disciplinary action of violation of rules

General survey - ANS-study of the whole person

,general health state and any obvious physical characteristics

General survey encounter - ANS-first impression

-stand promptly when name called
-look sick, rise slow
-converse without difficultly
-introduce and shake hands (palms sweaty, dry, firm handshake?)

-throughout health history, measurements and vital signs, make notes about everything

4 areas to consider - ANS-physical appearance

body structure

mobility

behavior

objective data: physical appearance - ANS-Age: person appears his or her stated age

Sex: sexual development appropriate for gender and age

Level of consciousness: person alert and oriented, attends to your questions and responds
appropriately

Skin color: color tone even, pigmentation varying with genetic background, skin intact with no
obvious lesion

Facial features: symmetric with movement

No signs of acute distress present

objective data: body structure - ANS-Stature: height appears within normal range for age,
genetic heritage

Nutrition: weight appears within normal range for height and body build; body fat distribution
even

Symmetry: body parts look equal bilaterally and are in relative proportion

Posture: person stands comfortably erect as appropriate for age

,Exceptions
Standing toddler who has a normally protuberant abdomen (toddler lordosis)
Aging person who may be stooped with kyphosis

Position: person sits comfortably in chair or on bed or examining table, arms relaxed at sides,
head turned to examiner

Body build, contour: proportions are correct
Arm span (fingertip to fingertip) equals height
Body length from crown to pubis roughly equal to length from pubis to sole

Obvious physical deformities: note any congenital or acquired defects

objective data: mobility - ANS-Gait: normally, base is as wide as shoulder width

Foot placement: accurate; walk smooth, even, and well-balanced; and associated movements,
such as symmetric arm swing, are present

Range of motion: note full mobility for each joint, and that movement is deliberate, accurate,
smooth, and coordinated

No involuntary movement

objective data: behavior - ANS-facial expression: maintain eye contact, expression appropriate
to situation, at rest & talking

mood & affect: person comfortable and cooperative with examiner and interact nicely

speech: articulation clear and understandable, stream of talking is fluent, conveys ideas clearly,
word choice is appropriate, personal communicates in prevailing language easy

Objective data: behavior continue - ANS-dress: appropriate for climate, looks clean & fits,
appropriate for age and culture

ex: indian women may wear saries, amish women wear clothing from 19th century

personal hygiene: appears to be clean and groomed

subjective data - ANS-what patient says about himself or herself during history taking

objective data - ANS-observed when inspecting, percussing, palpating and auscultating patient
during physical examination

database - ANS-formed from these elements, plus patients record and laboratory studies

, complete total health database - ANS-Includes complete health history and full physical
examination

Describes current and past health state and forms baseline to measure all future changes

Yields first diagnoses

episodic or problem centered database - ANS-For limited or short-term problems

Collect "mini" database, smaller scope and more focused than complete database

Concerns mainly one problem, one cue complex, or one body system

History and examination follow direction of presenting concern

follow up database - ANS-status of all identified problems should be evaluated at regular and
appropriate intervals

note changes that have occurred

evaluate whether problem is getting better or worse

identifying coping strategies being used

Emergency database - ANS-rapid collection of data, often compiled concurrently with lifesaving

diagnosis must be rapid and comprehensive in nature

Steps of ADOPIE - ANS-Assessment
Diagnosis
Outcome Identification
Planning
Implementation
Evaluation

Assessment - ANS-collect data (review clinical record, health history, physical examination,
functional assessment)

use evidence base assessment

document relevant data

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