NUR 216 Study Guide Health Assessment Exam 2025

Rash - -Skin condition requiring assessment for pain or itching. OLDCARTS - -A mnemonic for assessing symptoms: Onset, Location, Duration, Characteristics, Aggravating factors, Relieving factors, Treatment, Severity. Gloves - -Protective wear for healthcare providers during assessments. Cold therapy - -Use of cold packs to relieve injury pain. Assessment frequency - -Assess site every 5-10 minutes for changes. Documentation - -Record intervention details including duration and skin condition. Sunscreen use - -Daily application recommended for skin health. ABCDE mnemonic - -Guideline for assessing abnormal moles: Asymmetry, Border, Color, Diameter, Evolving. Nail clubbing - -Nail bed angle greater than 180 degrees. Chronic hypoxia - -Long-term oxygen deficiency affecting nail shape. Onychomycosis - -Fungal infection of the nails, common in older adults. Dehydration - -Priority nursing diagnosis related to circulation issues. GI losses - -Fluid loss from vomiting and diarrhea. Inadequate intake - -Poor oral fluid intake leading to dehydration. Fluid requirements - -Increased needs during infection, fever, or bleeding. Intervention reporting - -Notify provider of suspicious mole findings. Debriding - -Surgical procedure outside nursing scope of practice. Hair thinning - -Common change in older adults affecting scalp. Skin assessment - -Evaluation of skin for lesions and abnormalities. NUR216 NUR216 Patient education - -Instruct patients on reporting new symptoms. Skin Tenting - -Decreased skin turgor assessed by pinching skin. Dryness of Skin - -Lack of moisture, may indicate dehydration. Vesicles - -Small fluid-filled blisters, seen in herpes. Bullae - -Large fluid-filled blisters, often painful. Macules - -Flat hypo/hyper pigmented skin areas. Papules - -Small raised solid lesions on skin. Pustules - -Pus-filled lesions, often inflamed and painful. Patches - -Large macules, usually erythematous like eczema. Eczema - -Itchy, erythematous patches, often in antecubital space. Wheals - -Raised, swollen lesions, often seen in hives. Braden Scale - -Tool assessing pressure injury risk, scores 6-23. Stage 1 Pressure Injury - -Non-blanchable erythema without open wound. Stage 2 Pressure Injury - -Superficial ulcer, no deeper tissue involvement. Stage 3 Pressure Injury - -Involves subcutaneous tissue, may have tunneling. Stage 4 Pressure Injury - -Involves muscle or bone, very deep. Hydration Status - -Adequate fluid levels necessary for skin health. Migraine Headaches - -Severe unilateral throbbing, sensitivity to light. Cranial Nerve I - -Olfactory nerve, responsible for sense of smell. Cranial Nerve II - -Optic nerve, responsible for vision. Cranial Nerve V - -Trigeminal nerve, assesses facial sensation. Cranial Nerve VII - -Facial nerve, controls facial expressions. Cranial Nerve VIII - -Vestibulocochlear nerve, responsible for hearing. NUR216 NUR216 PERRLA - -Pupils equal, round, reactive to light and accommodation. Snellen Eye Chart - -Tests visual acuity, normal is 20/20. Ishihara Chart - -Assesses for color blindness. Rosenbaum Chart - -Assesses near vision, held 14 inches away. Nystagmus - -Rapid, jerky eye movements. Diplopia - -Double vision, may indicate serious complications. Conductive Hearing Loss - -Caused by excessive cerumen buildup. Sensorineural Hearing Loss - -Dysfunction of cranial nerve VIII. Epistaxis - -Nosebleed, assess for potential head injury. Dyspnea - -Subjective respiratory distress experienced by the patient. Tachypnea - -Abnormally rapid breathing rate, often accompanying dyspnea. Tripod position - -Patient leans forward to ease breathing. Kussmaul respirations - -Deep, rapid breathing without pauses, correcting acidosis. Cheyne-Stokes respirations - -Pattern of increasing depth and rate, followed by apnea. Crackles - -Breath sounds from air passing through secretions. Fine crackles - -Soft, high-pitched sounds resembling crunching. Coarse crackles - -Loud, low-pitched sounds like ripping Velcro. Wheezing - -High-pitched sound from air through narrowed airways. Rhonchi - -Louder, deeper sounds best heard during exhalation. Broncho vesicular sounds - -Heard over sternum and between scapulae. COPD - -Chronic obstructive pulmonary disease, includes emphysema and bronchitis. Over-oxygenation in COPD - -Avoid giving oxygen unless spO2 is low. Barrel chest appearance - -Normal finding in patients with COPD. NUR216 NUR216 Clubbing - -Nail deformity indicating chronic respiratory issues. Pursed lip breathing - -Technique to improve ventilation, mouth mostly closed. Exercise-induced bronchospasm - -Wheezing and dyspnea during exercise, mimics asthma. Incentive spirometer - -Device to encourage deep breathing and prevent atelectasis. Priority findings - -Critical signs indicating need for immediate assessment. RRT - -Rapid response team for respiratory distress or hypoxia. SpO2 - -Oxygen saturation level; indicates respiratory efficiency. Supplemental oxygen - -Administered if hypoxia is present. HOB - -Head of Bed; raises for dyspnea relief. Priority intervention - -Action taken first based on patient needs. UAP - -Unlicensed Assistive Personnel; can assist with ADLs. ADLs - -Activities of Daily Living; basic self-care tasks. NCLEX - -National Council Licensure Examination for nurses. Hypoxia - -Low oxygen levels in the body. Portable O2 tank - -Used for ambulation in patients ne