NUR265 FINAL UPDATED ACTUAL Questions and CORRECT Answers
subjective what the client tells you
objective what is observed, things that can be measured
primary data collection that client telling me, right from client, or from my own assessment
family member or another nurse tells you data; data from source that isn't you or
secondary data collection
client
general survery physical appearance, body structure, mobility, behavior
full physical assessment; info about client's full history, past medical history, diseases,
complete assessment meds they're on; provides baseline; annual physical, admission assessment, initial
home visit
focused assessment focusing on primary complaint; focused on one area
follow-up assessment after being diagnosed to manage condition; on a specific disease or post-op
inspection looking, using sight to gather info
feeling, using sense of touch to gather info; light to deep; assess temp w back of
palpation
hand; textures w fingertips; tender areas last
percussion tapping (usu abdomen) to learn about underlying structures using sound
flatness percussion bone or muscle
dullness percussion heart, liver, spleen
resonance percussion air filled lungs (hollow)
hyperresonance percussion emphysematous lung (hyperinflated)
tympany percussion air filled stomach (drum like)
auscultation listening w a stethoscope
, emergent/life-threatening; if you don't do something, client is going to die; ABCs
first level priority
(airway, breathing, circulation)
hollow side of stethoscope (for one I have, just don't press as hard with diaphragm);
bell
picks up murmur and other vascular sounds; to listen to carotids - listen for bruit
diaphragm for BP, apical pulse, press harder with stethoscope I have
urgent, necessitating prompt intervention; acute pain, mental status change, safety
second level priority
risk
need attention, but not priority; problems with lack of knowledge, mobility, rest,
third level priority
coping, chronic pain
gender role how society expected one to dress, think, act based on their sex assigned at birth
social construct of norms, behaviors, and roles that varies between societies and
over time, its how your identity related to societys idea of being a man, woman,
gender
neither, mix; can be different than culture's ideas and expectations for sex one is
assigned at birth
our sense of being male, female, some combination of the two, or neither; can be
gender identity
same or different than assigned sex at birth
pt's practices, perceptions of healthcare/treatments; how religion plays a role in their
cultural and spiritual interventions
care; therapeutic communication
creates nonjudgmental environment and encourages open communication; body
therapeutic communication language, tone of voice, sensory alterations, language barrier, internal and eternal
factors all play a role
layers of the skin epidermis, dermis, subcutaneous
epidermis surface layer of skin; combo of dead cells on outside and live cells on inside
middle layer; composed of connective tissue that contains blood vessels, hair
dermis
follicles, and sebaceous & sweat glands
subcutaneous innermost layer containing adipose (fat) tissue
Protect inner body parts and organs
Body temperature regulation
Sensory perception
functions of skin
Excrete waste and toxins
Produce vitamin D
Wound repair
even and consistent w race and ethnicity
warm, dry, smooth, intact
normal skin findings
areas with increased blood flow may appear more red/pink at times (cheeks, chest,
genitals)
hyperpigmentation melanin increased in that area
causes of hyperpigmentation birthmarks, sun damage, pregnancy
hypopigmentation melanin decreased, not absent
causes of hypopigmentation scars, stretch marks
staging of pressure injuries
stage 1 pressure injury non-blanchable erythema of intact skin; vulnerable to further breakdown
stage 2 pressure injury partial thickness skin loss with exposed dermis
subjective what the client tells you
objective what is observed, things that can be measured
primary data collection that client telling me, right from client, or from my own assessment
family member or another nurse tells you data; data from source that isn't you or
secondary data collection
client
general survery physical appearance, body structure, mobility, behavior
full physical assessment; info about client's full history, past medical history, diseases,
complete assessment meds they're on; provides baseline; annual physical, admission assessment, initial
home visit
focused assessment focusing on primary complaint; focused on one area
follow-up assessment after being diagnosed to manage condition; on a specific disease or post-op
inspection looking, using sight to gather info
feeling, using sense of touch to gather info; light to deep; assess temp w back of
palpation
hand; textures w fingertips; tender areas last
percussion tapping (usu abdomen) to learn about underlying structures using sound
flatness percussion bone or muscle
dullness percussion heart, liver, spleen
resonance percussion air filled lungs (hollow)
hyperresonance percussion emphysematous lung (hyperinflated)
tympany percussion air filled stomach (drum like)
auscultation listening w a stethoscope
, emergent/life-threatening; if you don't do something, client is going to die; ABCs
first level priority
(airway, breathing, circulation)
hollow side of stethoscope (for one I have, just don't press as hard with diaphragm);
bell
picks up murmur and other vascular sounds; to listen to carotids - listen for bruit
diaphragm for BP, apical pulse, press harder with stethoscope I have
urgent, necessitating prompt intervention; acute pain, mental status change, safety
second level priority
risk
need attention, but not priority; problems with lack of knowledge, mobility, rest,
third level priority
coping, chronic pain
gender role how society expected one to dress, think, act based on their sex assigned at birth
social construct of norms, behaviors, and roles that varies between societies and
over time, its how your identity related to societys idea of being a man, woman,
gender
neither, mix; can be different than culture's ideas and expectations for sex one is
assigned at birth
our sense of being male, female, some combination of the two, or neither; can be
gender identity
same or different than assigned sex at birth
pt's practices, perceptions of healthcare/treatments; how religion plays a role in their
cultural and spiritual interventions
care; therapeutic communication
creates nonjudgmental environment and encourages open communication; body
therapeutic communication language, tone of voice, sensory alterations, language barrier, internal and eternal
factors all play a role
layers of the skin epidermis, dermis, subcutaneous
epidermis surface layer of skin; combo of dead cells on outside and live cells on inside
middle layer; composed of connective tissue that contains blood vessels, hair
dermis
follicles, and sebaceous & sweat glands
subcutaneous innermost layer containing adipose (fat) tissue
Protect inner body parts and organs
Body temperature regulation
Sensory perception
functions of skin
Excrete waste and toxins
Produce vitamin D
Wound repair
even and consistent w race and ethnicity
warm, dry, smooth, intact
normal skin findings
areas with increased blood flow may appear more red/pink at times (cheeks, chest,
genitals)
hyperpigmentation melanin increased in that area
causes of hyperpigmentation birthmarks, sun damage, pregnancy
hypopigmentation melanin decreased, not absent
causes of hypopigmentation scars, stretch marks
staging of pressure injuries
stage 1 pressure injury non-blanchable erythema of intact skin; vulnerable to further breakdown
stage 2 pressure injury partial thickness skin loss with exposed dermis
