NURS 143 Finals Study Guide With
Complete Solution
Describe the components general survey? - ANSWER 1. Physical appearance -
age, sexual development, LOC, skin, facial features.
2. Body structure - stature, nutrition, symmetry, posture, position, body
build, contour
3. Mobility - normal gait, ROM
4. Behaviour - facial expression, mood and affect, speech, dress, personal
hygiene
Describe the components of a priority assessment. - ANSWER 1. General
appearance - facial expression, body position, LOC, colour, eyes (open),
speech, hearing, hygiene
2. Airway - patency, gurgling, coughing, suction
3. Breathing - rate, rhythm, effectiveness, O2
4. Circulation/movement/sensation - radial pulse (regular/irregular), ability
to squeeze fingers, dorsal pedal, tibial, edema, sensation
5. Discomfort/Disability - O-V, pupil reactivity, facial symmetry, GCS
6. Equipment - IV, O2, drainage, catheters, dressings
7. Measurements - vitals
Describe a focused assessment. - ANSWER Assessment which is determining
the status of a specific problem identified in an initial assessment.
,How do you complete a PCRA? - ANSWER 1. Check for signage outside of the
room
2. Scan floor for spills and tripping hazards
3. Assess bed rails and brakes
4. Check necessary equipment
5. ID the patient + complete primary and general survey
6. Pull the curtain for privacy
When does the nurse complete a head-to-toe assessment or a complete
health assessment? - ANSWER A nurse completes a complete health
assessment when the patient is being admitted to a facility, or when they
have little information previously on the patient.
In what order is data taken for a focused assessment? - ANSWER 1.
Inspection
2. Palpation
3. Percussion
4. Auscultation
What is involved in a pain assessment? - ANSWER O-V questions.
1. Onset
2. Provoking/palliating factos
3. Quality
4. Region/radiation
,5. Severity
6. Treatment
7. Understanding
8. Values
What are the components of safe administration of medication? - ANSWER 1.
Familiarity with the medication (generic/trade names, mechanism of action,
classification, effects, side effects, interactions, contraindications)
2. Identifies patient allergies
3. Checks accuracy of the MAR
4. Performs 10 rights 3x
5. Hand hygiene
6. Appropriate administration
What are some developmental considerations concerning the integumentary
system for newborns? - ANSWER Lanugo, vernix caseosa, permeability of the
skin, risk for fluid loss, and ineffective temperature regulation.
Define lanugo. - ANSWER Fine, soft hair of newborns.
Define vernix caseosa. - ANSWER A cheesy coating on newborn skin.
What are some developmental considerations concerning the integumentary
system for children during puberty? - ANSWER - Increased sweat gland
secretions
- More active sebaceous glands
, - Evidence of secondary sex characteristics in the skin
What are some development considerations concerning the integumentary
system for pregnant individuals? - ANSWER - Linea nigra
- Striae gravidarum
- Chloasma
- Increased sweat and sebaceous secretions
- Fat deposits
Define linea nigra. - ANSWER Darkening line down abdomen that can occur
during pregnancy.
Define chloasma. - ANSWER Discoloration changes on the face from
increased estrogen levels that stimulates increased melanin production
(hyper pigmentation). This can occur during pregnancy.
Define striae gravidarum. - ANSWER Stretch marks, which can develop over
the abdomen, breast, and thighs during pregnancy.
What are some developmental considerations concerning the integumentary
system for older adults? - ANSWER - Atrophy of skin structures
- Loss of elasticity, collagen, subcutaneous fat
- Thinning of stratum corneum and dermis
- Decreased sweat and sebaceous glands
- Greater risk for heat stroke
- Senile purpura
Complete Solution
Describe the components general survey? - ANSWER 1. Physical appearance -
age, sexual development, LOC, skin, facial features.
2. Body structure - stature, nutrition, symmetry, posture, position, body
build, contour
3. Mobility - normal gait, ROM
4. Behaviour - facial expression, mood and affect, speech, dress, personal
hygiene
Describe the components of a priority assessment. - ANSWER 1. General
appearance - facial expression, body position, LOC, colour, eyes (open),
speech, hearing, hygiene
2. Airway - patency, gurgling, coughing, suction
3. Breathing - rate, rhythm, effectiveness, O2
4. Circulation/movement/sensation - radial pulse (regular/irregular), ability
to squeeze fingers, dorsal pedal, tibial, edema, sensation
5. Discomfort/Disability - O-V, pupil reactivity, facial symmetry, GCS
6. Equipment - IV, O2, drainage, catheters, dressings
7. Measurements - vitals
Describe a focused assessment. - ANSWER Assessment which is determining
the status of a specific problem identified in an initial assessment.
,How do you complete a PCRA? - ANSWER 1. Check for signage outside of the
room
2. Scan floor for spills and tripping hazards
3. Assess bed rails and brakes
4. Check necessary equipment
5. ID the patient + complete primary and general survey
6. Pull the curtain for privacy
When does the nurse complete a head-to-toe assessment or a complete
health assessment? - ANSWER A nurse completes a complete health
assessment when the patient is being admitted to a facility, or when they
have little information previously on the patient.
In what order is data taken for a focused assessment? - ANSWER 1.
Inspection
2. Palpation
3. Percussion
4. Auscultation
What is involved in a pain assessment? - ANSWER O-V questions.
1. Onset
2. Provoking/palliating factos
3. Quality
4. Region/radiation
,5. Severity
6. Treatment
7. Understanding
8. Values
What are the components of safe administration of medication? - ANSWER 1.
Familiarity with the medication (generic/trade names, mechanism of action,
classification, effects, side effects, interactions, contraindications)
2. Identifies patient allergies
3. Checks accuracy of the MAR
4. Performs 10 rights 3x
5. Hand hygiene
6. Appropriate administration
What are some developmental considerations concerning the integumentary
system for newborns? - ANSWER Lanugo, vernix caseosa, permeability of the
skin, risk for fluid loss, and ineffective temperature regulation.
Define lanugo. - ANSWER Fine, soft hair of newborns.
Define vernix caseosa. - ANSWER A cheesy coating on newborn skin.
What are some developmental considerations concerning the integumentary
system for children during puberty? - ANSWER - Increased sweat gland
secretions
- More active sebaceous glands
, - Evidence of secondary sex characteristics in the skin
What are some development considerations concerning the integumentary
system for pregnant individuals? - ANSWER - Linea nigra
- Striae gravidarum
- Chloasma
- Increased sweat and sebaceous secretions
- Fat deposits
Define linea nigra. - ANSWER Darkening line down abdomen that can occur
during pregnancy.
Define chloasma. - ANSWER Discoloration changes on the face from
increased estrogen levels that stimulates increased melanin production
(hyper pigmentation). This can occur during pregnancy.
Define striae gravidarum. - ANSWER Stretch marks, which can develop over
the abdomen, breast, and thighs during pregnancy.
What are some developmental considerations concerning the integumentary
system for older adults? - ANSWER - Atrophy of skin structures
- Loss of elasticity, collagen, subcutaneous fat
- Thinning of stratum corneum and dermis
- Decreased sweat and sebaceous glands
- Greater risk for heat stroke
- Senile purpura
