NUR 305 FINAL EXAM STUDY GUIDE
Focused vs. Comprehensive Exams - Answer --Focused: focuses on one system or the
systems affecting an area. Focused cardiac with respiratory
-Comprehensive: head to toe assessment. Someone is admitted to hospital, physical,
and new patient in a clinic.
Subjective data vs. Objective Data - Answer --subjective: what the patient tells you.
Only get by asking the patient questions
+History of present illness
+risk factors
+past medical history
+Review of systems (what else category)
+Signs and symptoms
-Objective: what you gather based on your assessment.
+VS
+Lab data
+Physical assessment
+lung sounds
+facial expressions: grimacing
+nursing diagnosis
How do you state a chief complaint? - Answer --In quotation. In the patient's own word
-Reason for seeking care
What is a review of systems? - Answer -head to toe and if the patient is having any
other symptoms. Going to system by system
Opening and closing interview - Answer --closed: yes or no questions
-open: the patient is able to elaborate on the question: Describe your pain.
+Start interview with open ended questions
Use of interpreter - Answer --US law mandates interpreter availability
-Avoid using children or other relatives
-Interpreters should remain neutral
-Look at the patient, not the interviewer
Therapeutic communication techniques - Answer --Verbal: Restatement, Reflection,
Elaboration, Silence, Focusing, Clarification, Summarizing
-Non-Verbal: Physical Appearance, Facial Expression, Posture, Positioning towards the
patient, Gestures, Eye Contact, Tone of Voice, and Use of touch
,Skin alterations for different ethnicities - Answer --African Americans: Keloid formation;
traction alopecia; pseudofolliculitis; folliculitis barbae; perineal follicularis, Increased
melasma in pregnancy; Mongolin spots; skin is commonly dry; ashy dermatitis
-Asians: Southeast Asian men: less body, facial hair common tattoos, body piercings,
other skin adornments Rarely found outside Asian populations are Hori nevus; nevus of
Ota
-Henna tattoos: Arabic, Indian females
-Newborns: Common Arabic lesions: Mongolian spots; café au lait spots; congenital
nevi
-Arabic: Cupping, coining, 'therapeutic burning
Skin changes with perfusion issues: - Answer -+Cyanosis(look at the tongue, lips, nail
beds, buccal mucosa)
+clubbing of the fingers
-With dark skin look for cyanosis in the oral cavity, nail beds; patients with darker skin
may normally have hypopigmented skin on the palms and soles
-Pallor and jaundice in the conjunctivae**
Common Nursing Diagnoses Skin, Hair, and Nails - Answer -1. Diagnosis: Impaired
skin integrity
+Point of differentiation: Alternations in or damage to one or more layers of the skin
+Assessment Characteristics: Wound, surgical incision, break in skin integrity
+Nursing Interventions: Classify wound as partial or full thickness. Document wound
assessment. Assess for risk of skin breakdown. Apply appropriate dressing. Evaluate
for use of specialty mattress. Avoid positioning over bony prominence
2. Diagnosis: Impaired Tissue Integrity
+Point of differentiation: Damage to tissues of the subcutaneous layer of the skin,
mucous membrane, cornea, or all of these
+Assessment Characteristics: Damaged or destroyed subcutaneous, muscles, bone,
mucous membranes, or corneal tissue
+Nursing Interventions: Determine size and depth of wound, skin around wound,
continence status, tube/incision placement. Apply appropriate dressing. Collaborate with
physician on necessary debridement and or surgical intervention
3. Diagnosis: Pain
+Point of differentiation: Unpleasant experience with actual or potential tissue damage
lasting for > 3 months
+Assessment Characteristics: Self- report on pain scale, altered activities of daily living,
loss in quality of life, fatigue, sleep disturbance, isolation
+Nursing Interventions: Assess pain, provide adjunctive treatments, consider alternative
to opiates, evaluate functional ability
, 4. Diagnosis: Risk for infection
+Point of differentiation: At risks for pathogenic organisms from break in the skin or
tissue, the body' primary defense
+Assessment Characteristics: Break in skin integrity, tubes and procedures, exposure to
pathogens, malnutrition, inadequate immunity, chronic disease
+Nursing Interventions: Practice frequent hand washing and universal precautions.
Protect wound with dressing. Monitor for fever, elevated white blood cells, count, wound
d
Symptoms of dehydration and nursing interventions - Answer -+decreased skin turgor
+dry mucous membranes
+furrows in tongue
+decreased urine output
+Increased thirst
+dark urine
+Tachycardia
+Low BP
+high HR
-Nursing Intervention
+IV fluids
Review pressure sores - Answer --Stage I - Defined area of persistent redness or
blueness , still intact
-Stage II - Partial skin loss involving the epidermis and / or dermis,abrasion.
-Stage III - Full thickness loss of subcutaneous tissue, deep crater.
-Stage IV- Full thickness skin loss with tissue necrosis, damage to muscle , bone , and
supporting structures.
-Stage V - unstageable
Common Symptoms Skin - Answer --Pruritus(itching) - It frequently precedes atopic
lesions but follows inflammatory lesions; recent pruritus may indicate toxic exposure,
insect bite, parasite infections, or viral exanthems, such as varicella; generalized
pruritus is common in medication or food allergies. Severe pruritus interfering with sleep
is frequently from scabies.
-Rash - Single lesions could be cancer; multiple lesions indicate infection. Molluscum
contagiosum virus is a pox virus that produces waxy, umbilicated keratinized lesions.
-Single lesions or wound
Common Nursing Diagnosis for Thorax and Lungs - Answer -1. Diagnosis:Impaired gas
exchange
+Point of differentiation: Describes changes at the capillary level and film/fluid impairing
movement across the alveolar wall.
Focused vs. Comprehensive Exams - Answer --Focused: focuses on one system or the
systems affecting an area. Focused cardiac with respiratory
-Comprehensive: head to toe assessment. Someone is admitted to hospital, physical,
and new patient in a clinic.
Subjective data vs. Objective Data - Answer --subjective: what the patient tells you.
Only get by asking the patient questions
+History of present illness
+risk factors
+past medical history
+Review of systems (what else category)
+Signs and symptoms
-Objective: what you gather based on your assessment.
+VS
+Lab data
+Physical assessment
+lung sounds
+facial expressions: grimacing
+nursing diagnosis
How do you state a chief complaint? - Answer --In quotation. In the patient's own word
-Reason for seeking care
What is a review of systems? - Answer -head to toe and if the patient is having any
other symptoms. Going to system by system
Opening and closing interview - Answer --closed: yes or no questions
-open: the patient is able to elaborate on the question: Describe your pain.
+Start interview with open ended questions
Use of interpreter - Answer --US law mandates interpreter availability
-Avoid using children or other relatives
-Interpreters should remain neutral
-Look at the patient, not the interviewer
Therapeutic communication techniques - Answer --Verbal: Restatement, Reflection,
Elaboration, Silence, Focusing, Clarification, Summarizing
-Non-Verbal: Physical Appearance, Facial Expression, Posture, Positioning towards the
patient, Gestures, Eye Contact, Tone of Voice, and Use of touch
,Skin alterations for different ethnicities - Answer --African Americans: Keloid formation;
traction alopecia; pseudofolliculitis; folliculitis barbae; perineal follicularis, Increased
melasma in pregnancy; Mongolin spots; skin is commonly dry; ashy dermatitis
-Asians: Southeast Asian men: less body, facial hair common tattoos, body piercings,
other skin adornments Rarely found outside Asian populations are Hori nevus; nevus of
Ota
-Henna tattoos: Arabic, Indian females
-Newborns: Common Arabic lesions: Mongolian spots; café au lait spots; congenital
nevi
-Arabic: Cupping, coining, 'therapeutic burning
Skin changes with perfusion issues: - Answer -+Cyanosis(look at the tongue, lips, nail
beds, buccal mucosa)
+clubbing of the fingers
-With dark skin look for cyanosis in the oral cavity, nail beds; patients with darker skin
may normally have hypopigmented skin on the palms and soles
-Pallor and jaundice in the conjunctivae**
Common Nursing Diagnoses Skin, Hair, and Nails - Answer -1. Diagnosis: Impaired
skin integrity
+Point of differentiation: Alternations in or damage to one or more layers of the skin
+Assessment Characteristics: Wound, surgical incision, break in skin integrity
+Nursing Interventions: Classify wound as partial or full thickness. Document wound
assessment. Assess for risk of skin breakdown. Apply appropriate dressing. Evaluate
for use of specialty mattress. Avoid positioning over bony prominence
2. Diagnosis: Impaired Tissue Integrity
+Point of differentiation: Damage to tissues of the subcutaneous layer of the skin,
mucous membrane, cornea, or all of these
+Assessment Characteristics: Damaged or destroyed subcutaneous, muscles, bone,
mucous membranes, or corneal tissue
+Nursing Interventions: Determine size and depth of wound, skin around wound,
continence status, tube/incision placement. Apply appropriate dressing. Collaborate with
physician on necessary debridement and or surgical intervention
3. Diagnosis: Pain
+Point of differentiation: Unpleasant experience with actual or potential tissue damage
lasting for > 3 months
+Assessment Characteristics: Self- report on pain scale, altered activities of daily living,
loss in quality of life, fatigue, sleep disturbance, isolation
+Nursing Interventions: Assess pain, provide adjunctive treatments, consider alternative
to opiates, evaluate functional ability
, 4. Diagnosis: Risk for infection
+Point of differentiation: At risks for pathogenic organisms from break in the skin or
tissue, the body' primary defense
+Assessment Characteristics: Break in skin integrity, tubes and procedures, exposure to
pathogens, malnutrition, inadequate immunity, chronic disease
+Nursing Interventions: Practice frequent hand washing and universal precautions.
Protect wound with dressing. Monitor for fever, elevated white blood cells, count, wound
d
Symptoms of dehydration and nursing interventions - Answer -+decreased skin turgor
+dry mucous membranes
+furrows in tongue
+decreased urine output
+Increased thirst
+dark urine
+Tachycardia
+Low BP
+high HR
-Nursing Intervention
+IV fluids
Review pressure sores - Answer --Stage I - Defined area of persistent redness or
blueness , still intact
-Stage II - Partial skin loss involving the epidermis and / or dermis,abrasion.
-Stage III - Full thickness loss of subcutaneous tissue, deep crater.
-Stage IV- Full thickness skin loss with tissue necrosis, damage to muscle , bone , and
supporting structures.
-Stage V - unstageable
Common Symptoms Skin - Answer --Pruritus(itching) - It frequently precedes atopic
lesions but follows inflammatory lesions; recent pruritus may indicate toxic exposure,
insect bite, parasite infections, or viral exanthems, such as varicella; generalized
pruritus is common in medication or food allergies. Severe pruritus interfering with sleep
is frequently from scabies.
-Rash - Single lesions could be cancer; multiple lesions indicate infection. Molluscum
contagiosum virus is a pox virus that produces waxy, umbilicated keratinized lesions.
-Single lesions or wound
Common Nursing Diagnosis for Thorax and Lungs - Answer -1. Diagnosis:Impaired gas
exchange
+Point of differentiation: Describes changes at the capillary level and film/fluid impairing
movement across the alveolar wall.
