GCU NSG-316 Exam 1 – Nursing Practice &
Clinical Assessment Study Guide
what information is important for the nurse to know when providing care for
people from diverse backgrounds - -- answer --cultural competence
which interventions will the nurse do to obtain objective data - -- answer --
conduct physical exam, review lab reports, summon previous med records
when would a nurse establish a complete database of a patient - -- answer --
during initial home visit, in primary health setting, community health care setting
ACE unit - -- answer --focuses on preventing functional decline in older adults
during hospitalization
TUG test - -- answer --timed up and go test; quantifies functional mobility; going
outside alone safely, walking 10 ft, turn, walk back to chair and sit down,
ADL - -- answer --activities of daily living; walking, dressing, using stairs, eating,
feeding, grooming, toileting
,IADLs - -- answer --instrumental activities of daily living; shopping, meal cooking,
cleaning, laundry, managing finances, counting, housekeeping, taking meds, using
transportation
Mini Mental State Exam - -- answer --Concentrates only on cognitive functioning,
not on mood or thought processes
Montreal Cognitive Assessment (MoCA) - -- answer --Mild cognitive dysfunction;
Attention and concentration, executive functions, memory, language,
visuoconstructional skills, conceptual thinking calculations and orientation
AADLs - -- answer --Advanced Activities of Daily Living; activities performed in the
community- social or recreational, activities performed within the family
Katz Index of ADL - -- answer ---Assessment for evaluation of activities of daily
living
-Focus: assessment of level of independence functioning and type of assistance
required in six areas of ADL: 1) bathing 2) dressing 3) toileting 4) transferring 5)
continence 6) feeding
syncope - -- answer --loss of consciousness or fainting due to weakness
complete skin assessment - -- answer --- scrutinize outer surface of skin
-concentrate on underlying structures and inspect thoroughly
-inspect feet, toenails, and between toes
-check for color, temperature, moisture, texture, thickness, edema, mobility and
turgor, vascularity or bruising, and lesions
, what causes true pallor (skin) - -- answer --could be due to blood loss or anemic;
slowed circulation (immobility/inactivity, prolonged elevation)
jaundice (skin) - -- answer --Yellowing - decreased liver function
Where is jaundice first seen? - -- answer --In the sclera of the eye, and then the
skin
cyanotic (skin) - -- answer --blue- Not enough oxygen getting to red blood cells
erythema (skin) - -- answer --red- indicates trauma, fever or infection;
vasodilation
what might multiple bruises at different stages of healing indicate - -- answer --
physical abuse
edema can indicate - -- answer --heart failure
Scale to Grade Pitting Edema - -- answer --1+ mild pitting, slight indentation, no
perceptible swelling in the leg
2+ moderate pitting, indentation subsides
rapidly
3+ deep pitting, indention remains for a
short time, leg looks swollen
4+ very deep pitting, indentation lasts a
Clinical Assessment Study Guide
what information is important for the nurse to know when providing care for
people from diverse backgrounds - -- answer --cultural competence
which interventions will the nurse do to obtain objective data - -- answer --
conduct physical exam, review lab reports, summon previous med records
when would a nurse establish a complete database of a patient - -- answer --
during initial home visit, in primary health setting, community health care setting
ACE unit - -- answer --focuses on preventing functional decline in older adults
during hospitalization
TUG test - -- answer --timed up and go test; quantifies functional mobility; going
outside alone safely, walking 10 ft, turn, walk back to chair and sit down,
ADL - -- answer --activities of daily living; walking, dressing, using stairs, eating,
feeding, grooming, toileting
,IADLs - -- answer --instrumental activities of daily living; shopping, meal cooking,
cleaning, laundry, managing finances, counting, housekeeping, taking meds, using
transportation
Mini Mental State Exam - -- answer --Concentrates only on cognitive functioning,
not on mood or thought processes
Montreal Cognitive Assessment (MoCA) - -- answer --Mild cognitive dysfunction;
Attention and concentration, executive functions, memory, language,
visuoconstructional skills, conceptual thinking calculations and orientation
AADLs - -- answer --Advanced Activities of Daily Living; activities performed in the
community- social or recreational, activities performed within the family
Katz Index of ADL - -- answer ---Assessment for evaluation of activities of daily
living
-Focus: assessment of level of independence functioning and type of assistance
required in six areas of ADL: 1) bathing 2) dressing 3) toileting 4) transferring 5)
continence 6) feeding
syncope - -- answer --loss of consciousness or fainting due to weakness
complete skin assessment - -- answer --- scrutinize outer surface of skin
-concentrate on underlying structures and inspect thoroughly
-inspect feet, toenails, and between toes
-check for color, temperature, moisture, texture, thickness, edema, mobility and
turgor, vascularity or bruising, and lesions
, what causes true pallor (skin) - -- answer --could be due to blood loss or anemic;
slowed circulation (immobility/inactivity, prolonged elevation)
jaundice (skin) - -- answer --Yellowing - decreased liver function
Where is jaundice first seen? - -- answer --In the sclera of the eye, and then the
skin
cyanotic (skin) - -- answer --blue- Not enough oxygen getting to red blood cells
erythema (skin) - -- answer --red- indicates trauma, fever or infection;
vasodilation
what might multiple bruises at different stages of healing indicate - -- answer --
physical abuse
edema can indicate - -- answer --heart failure
Scale to Grade Pitting Edema - -- answer --1+ mild pitting, slight indentation, no
perceptible swelling in the leg
2+ moderate pitting, indentation subsides
rapidly
3+ deep pitting, indention remains for a
short time, leg looks swollen
4+ very deep pitting, indentation lasts a
