NUR1020C Term 1 Exam 2 Study Guide
Study online at https://quizlet.com/_i0oh8s
1. List the cranial nerves in order: I Olfactory (Smell)
II Optic (Vision)
III Oculomotor (Moves eyelid and eyeball and adjusts the pupil and lens of the eye)
IV Trochlear (Moves eyeballs)
V Trigeminal (Facial muscles incl. chewing; Facial sensations)
VI Abducens (Moves eyeballs)
VII Facial (Taste, tears, saliva, facial expressions)
VIII Vestibulocochlear (Auditory/balance)
IX Glossopharyngeal (Swallowing, speech)
X Vagus (swalling/coughing/voice production)
XI Accessory (Moving head & shoulders)
XII Hypoglossal (Tongue muscles - speech & swallowing)
2. Cranial Nerve I: Olfactory (Smell) - SENSORY
3. Cranial Nerve II: Optic (Vision) - SENSORY
4. Cranial Nerve III: Oculomotor (Moves eyelid and eyeball and adjusts the pupil and lens of the eye) - MOTOR
5. Cranial Nerve IV: Trochlear (Moves eyeballs) - MOTOR
6. Cranial Nerve V: Trigeminal (Facial muscles incl. chewing; Facial sensations) - SENSORY/MOTOR
7. Cranial Nerve VI: Abducens (Moves eyeballs) - MOTOR
8. Cranial Nerve VII: Facial (Taste, tears, saliva, facial expressions) - SENSORY/MOTOR
9. Cranial Nerve VIII: Vestibulocochlear (Auditory/balance) - SENSORY
10. Cranial Nerve IX: Glossopharyngeal (Swallowing, speech) -SENSORY/MOTOR
11. Cranial Nerve X: Vagus (swalling/coughing/voice production) - SENSORY/MOTOR
12. Cranial Nerve XI: Accessory (Moving head & shoulders) - MOTOR
13. Cranial Nerve XII: Hypoglossal (Tongue muscles - speech & swallowing) - MOTOR
14. How to test cranial nerve III, IV, VI: Have pt follow penlight without moving head
15. How to test cranial nerve V: Cotton on face/ testing TMJ (Temporomandibular joint disorder) - trying
to pull jaw down
16. How to test cranial nerve VII: Raise eyebrows, closing eyes tight, show teeth, smile, frown, puff cheeks
and let air out - look for symmetry
17. How to test cranial nerve XI: ROM - head forward, back, side to side. Shrug shoulders. Then with
resistance.
18. What is PERRLA: Pupils equal, Round, React to light, and Accommodation
, NUR1020C Term 1 Exam 2 Study Guide
Study online at https://quizlet.com/_i0oh8s
19. Examine PERRLA by: Asking the patient to stare off and focus on something and bring pen light from side
and watch pupils react.
20. Nursing Process: critical thinking five-step process
Involves looking at the whole patient at all times
Personalizes the patient
It provides a "road map" that ensures good nursing care & improves patient outcomes
21. ADPIE: Assessment - Gather information about the patient's condition
Diagnosis - Identify the patient's problem
Planning - Set goals of care and desired outcomes and identify appropriate nursing action
Implementation - Preform the nursing actions identified in planning
Evaluation - Determine if goals and expected outcomes are achieved
22. Types of assessments: - the patient-centered interview during a nursing health history.
- a physical examination.
- the periodic assessments you make during rounding or administering care.
- Cue (information that you obtain through use of the senses)
- Inference (your judgment or interpretation of these cues)
23. subjective data: patient's verbal descriptions of their health problems
ex: Mr. Lawson's self-report of pain at the area where his incision slightly separated
24. objective data: observations or measurements of a patient's health status
ex: vital signs; describing an observed behavior; condition of a surgical wound
25. The second step in the nursing process can be started after...: interpreting and
validating assessment data, which ensures collection of complete database.
26. Data documentation should be ________ and ______ and will be used for _______
?: clear and concise (appropriate terminology)
baseline for care
27. Formulating a nursing diagnosis statement consists of...: Identifying the correct
diagnostic label with associated defining characteristics or risk factors and a related factor.
28. What is the difference between a medical diagnosis and a nursing diagno-
sis?: medical diagnosis: identification of a disease condition based on a specific evaluation of physical signs and
, NUR1020C Term 1 Exam 2 Study Guide
Study online at https://quizlet.com/_i0oh8s
symptoms, a patient's medical history, and the results of diagnostic tests and procedures
nursing diagnosis: a clinical judgment concerning a human response to health condition/life processes, vulnerability
for that response by an individual, family, or community that a nurse is licensed and competent to treat
29. What does NANDA nursing diagnosis include?: problem focused
risk (physiological, environmental, psychosocial)
health promotion
30. What is a data cluster?: a set of cues, the signs or symptoms gathered during assessment
31. Two-part format in focused nursing diagnoses -: Potential:
P - Problem - risk for
E - etiology
NANDA-I diagnostic label followed by a statement of a related factor
32. Three-part format in focused nursing diagnoses -: P - Problem (Example: Impaired
Physical Mobility)
E - Etiology (Example: incisional pain)
S - Symptoms (Example: evidenced by restricted turning and positioning)
problem r/t etiology aeb symptoms
33. What does PES stand for?: Problem, Etiology, signs/symptoms (Actual Nursing Diagnosis)
34. Risk Diagnosis: Used to identify potential problems of individuals vulnerable to developing complications
resulting from their current disease sate or life experience
35. How to compose a Risk Diagnosis: Include a diagnosis label, and risk factors (or related factors)
36. Health Promotion Nursing Diagnosis: Clinical judgements based on the expressed desire of
patients, families, or groups for change
37. How to compose Health Promotion Nursing Diagnosis: Include a diagnosis label, and
defining characteristics.
38. Related Factors and Risk factors: The underlying cause or etiology of a patients problem
39. Prioritize nursing diagnosis using: ABC's - Airway, Breathing, circulating
(Use Maslow's hierarchy also)
40. Planning process: Prioritize --> make goals --> Plan intervention
41. Short term goal: Achievable in one week or less
42. Long term goal: Weeks or months to achieve
Study online at https://quizlet.com/_i0oh8s
1. List the cranial nerves in order: I Olfactory (Smell)
II Optic (Vision)
III Oculomotor (Moves eyelid and eyeball and adjusts the pupil and lens of the eye)
IV Trochlear (Moves eyeballs)
V Trigeminal (Facial muscles incl. chewing; Facial sensations)
VI Abducens (Moves eyeballs)
VII Facial (Taste, tears, saliva, facial expressions)
VIII Vestibulocochlear (Auditory/balance)
IX Glossopharyngeal (Swallowing, speech)
X Vagus (swalling/coughing/voice production)
XI Accessory (Moving head & shoulders)
XII Hypoglossal (Tongue muscles - speech & swallowing)
2. Cranial Nerve I: Olfactory (Smell) - SENSORY
3. Cranial Nerve II: Optic (Vision) - SENSORY
4. Cranial Nerve III: Oculomotor (Moves eyelid and eyeball and adjusts the pupil and lens of the eye) - MOTOR
5. Cranial Nerve IV: Trochlear (Moves eyeballs) - MOTOR
6. Cranial Nerve V: Trigeminal (Facial muscles incl. chewing; Facial sensations) - SENSORY/MOTOR
7. Cranial Nerve VI: Abducens (Moves eyeballs) - MOTOR
8. Cranial Nerve VII: Facial (Taste, tears, saliva, facial expressions) - SENSORY/MOTOR
9. Cranial Nerve VIII: Vestibulocochlear (Auditory/balance) - SENSORY
10. Cranial Nerve IX: Glossopharyngeal (Swallowing, speech) -SENSORY/MOTOR
11. Cranial Nerve X: Vagus (swalling/coughing/voice production) - SENSORY/MOTOR
12. Cranial Nerve XI: Accessory (Moving head & shoulders) - MOTOR
13. Cranial Nerve XII: Hypoglossal (Tongue muscles - speech & swallowing) - MOTOR
14. How to test cranial nerve III, IV, VI: Have pt follow penlight without moving head
15. How to test cranial nerve V: Cotton on face/ testing TMJ (Temporomandibular joint disorder) - trying
to pull jaw down
16. How to test cranial nerve VII: Raise eyebrows, closing eyes tight, show teeth, smile, frown, puff cheeks
and let air out - look for symmetry
17. How to test cranial nerve XI: ROM - head forward, back, side to side. Shrug shoulders. Then with
resistance.
18. What is PERRLA: Pupils equal, Round, React to light, and Accommodation
, NUR1020C Term 1 Exam 2 Study Guide
Study online at https://quizlet.com/_i0oh8s
19. Examine PERRLA by: Asking the patient to stare off and focus on something and bring pen light from side
and watch pupils react.
20. Nursing Process: critical thinking five-step process
Involves looking at the whole patient at all times
Personalizes the patient
It provides a "road map" that ensures good nursing care & improves patient outcomes
21. ADPIE: Assessment - Gather information about the patient's condition
Diagnosis - Identify the patient's problem
Planning - Set goals of care and desired outcomes and identify appropriate nursing action
Implementation - Preform the nursing actions identified in planning
Evaluation - Determine if goals and expected outcomes are achieved
22. Types of assessments: - the patient-centered interview during a nursing health history.
- a physical examination.
- the periodic assessments you make during rounding or administering care.
- Cue (information that you obtain through use of the senses)
- Inference (your judgment or interpretation of these cues)
23. subjective data: patient's verbal descriptions of their health problems
ex: Mr. Lawson's self-report of pain at the area where his incision slightly separated
24. objective data: observations or measurements of a patient's health status
ex: vital signs; describing an observed behavior; condition of a surgical wound
25. The second step in the nursing process can be started after...: interpreting and
validating assessment data, which ensures collection of complete database.
26. Data documentation should be ________ and ______ and will be used for _______
?: clear and concise (appropriate terminology)
baseline for care
27. Formulating a nursing diagnosis statement consists of...: Identifying the correct
diagnostic label with associated defining characteristics or risk factors and a related factor.
28. What is the difference between a medical diagnosis and a nursing diagno-
sis?: medical diagnosis: identification of a disease condition based on a specific evaluation of physical signs and
, NUR1020C Term 1 Exam 2 Study Guide
Study online at https://quizlet.com/_i0oh8s
symptoms, a patient's medical history, and the results of diagnostic tests and procedures
nursing diagnosis: a clinical judgment concerning a human response to health condition/life processes, vulnerability
for that response by an individual, family, or community that a nurse is licensed and competent to treat
29. What does NANDA nursing diagnosis include?: problem focused
risk (physiological, environmental, psychosocial)
health promotion
30. What is a data cluster?: a set of cues, the signs or symptoms gathered during assessment
31. Two-part format in focused nursing diagnoses -: Potential:
P - Problem - risk for
E - etiology
NANDA-I diagnostic label followed by a statement of a related factor
32. Three-part format in focused nursing diagnoses -: P - Problem (Example: Impaired
Physical Mobility)
E - Etiology (Example: incisional pain)
S - Symptoms (Example: evidenced by restricted turning and positioning)
problem r/t etiology aeb symptoms
33. What does PES stand for?: Problem, Etiology, signs/symptoms (Actual Nursing Diagnosis)
34. Risk Diagnosis: Used to identify potential problems of individuals vulnerable to developing complications
resulting from their current disease sate or life experience
35. How to compose a Risk Diagnosis: Include a diagnosis label, and risk factors (or related factors)
36. Health Promotion Nursing Diagnosis: Clinical judgements based on the expressed desire of
patients, families, or groups for change
37. How to compose Health Promotion Nursing Diagnosis: Include a diagnosis label, and
defining characteristics.
38. Related Factors and Risk factors: The underlying cause or etiology of a patients problem
39. Prioritize nursing diagnosis using: ABC's - Airway, Breathing, circulating
(Use Maslow's hierarchy also)
40. Planning process: Prioritize --> make goals --> Plan intervention
41. Short term goal: Achievable in one week or less
42. Long term goal: Weeks or months to achieve
