NSG 3160 MAIN ANSWERS AND QUESTIONS SET A+
✔✔Behavior findings in the survey - ✔✔Speech, mood, dress, hygiene.
✔✔How to measure height and weight - ✔✔Same scale, same time of day, minimal
clothing.
✔✔Cachexia - ✔✔Severe muscle wasting due to chronic illness or malnutrition.
✔✔Common spinal change in aging adults - ✔✔Kyphosis (hunched posture).
✔✔Vital measurement reflecting fluid balance best - ✔✔Daily weight.
✔✔Normal oral temperature range - ✔✔97°F-99°F (36.1°C-37.2°C).
✔✔Rectal temperature comparison with oral - ✔✔About 0.5°C (1°F) higher.
✔✔Normal adult pulse rate - ✔✔60-100 bpm, regular rhythm.
✔✔Pulse amplitude grading scale - ✔✔3+ bounding, 2+ normal, 1+ weak, 0 absent.
✔✔Normal adult respiratory rate - ✔✔12-20 breaths per minute.
✔✔Normal adult blood pressure - ✔✔≤ 120/80 mm Hg.
✔✔Orthostatic hypotension - ✔✔Drop of ≥ 20 mm Hg systolic or ≥ 10 mm Hg diastolic
upon standing.
✔✔Normal oxygen saturation (SpO₂) - ✔✔95-100 %.
✔✔Factors falsely elevating BP - ✔✔Small cuff, crossed legs, recent caffeine/smoking.
✔✔Action after obtaining abnormal vital sign - ✔✔Recheck manually, validate, and
report if confirmed.
, ✔✔ Purpose of a health assessment - ✔✔To collect and analyze subjective + objective
data to form a complete picture of a patient's health and guide nursing judgment.
✔✔Six steps of the nursing process - ✔✔Assessment, Diagnosis, Outcome
Identification, Planning, Implementation, Evaluation.
✔✔Evidence-Based Practice (EBP) - ✔✔Integration of best current research, clinical
expertise, patient preferences, and accurate assessment data.
✔✔Five steps of EBP - ✔✔Ask, Acquire, Appraise, Apply, Assess.
✔✔Complete (Total Health) database - ✔✔Database gathered on admission for
baseline data.
✔✔Emergency database - ✔✔Database used in urgent, life-threatening situations.
✔✔Order of priority according to ABCs - ✔✔Airway → Breathing → Circulation (then
Disability & Exposure).
✔✔Holistic health model - ✔✔Approach recognizing mind, body, spirit, and environment
interact to affect health.
✔✔First-level priority problem example - ✔✔Obstructed airway or absent respirations.
✔✔Outdated interventions - ✔✔They increase risk for harm; EBP ensures safety and
effectiveness.
✔✔Culture - ✔✔A learned, shared set of values, beliefs, and norms guiding a group's
thinking and behavior.
✔✔Acculturation vs. Assimilation - ✔✔Acculturation = adapting while retaining identity;
Assimilation = full adoption of dominant culture.
✔✔Three major illness-causation models - ✔✔Biomedical (disease = germs),
Naturalistic (balance of hot/cold or yin/yang), Magicoreligious (supernatural forces).
✔✔Examples of traditional healers - ✔✔Curandero (Hispanic), Shaman (Native
American), Herbalist (Asian), Braucher (Amish).
✔✔Traditional objects for health protection - ✔✔Amulets or charms (e.g., evil-eye
bracelet, St. Christopher medal, jade pendant).
✔✔Behavior findings in the survey - ✔✔Speech, mood, dress, hygiene.
✔✔How to measure height and weight - ✔✔Same scale, same time of day, minimal
clothing.
✔✔Cachexia - ✔✔Severe muscle wasting due to chronic illness or malnutrition.
✔✔Common spinal change in aging adults - ✔✔Kyphosis (hunched posture).
✔✔Vital measurement reflecting fluid balance best - ✔✔Daily weight.
✔✔Normal oral temperature range - ✔✔97°F-99°F (36.1°C-37.2°C).
✔✔Rectal temperature comparison with oral - ✔✔About 0.5°C (1°F) higher.
✔✔Normal adult pulse rate - ✔✔60-100 bpm, regular rhythm.
✔✔Pulse amplitude grading scale - ✔✔3+ bounding, 2+ normal, 1+ weak, 0 absent.
✔✔Normal adult respiratory rate - ✔✔12-20 breaths per minute.
✔✔Normal adult blood pressure - ✔✔≤ 120/80 mm Hg.
✔✔Orthostatic hypotension - ✔✔Drop of ≥ 20 mm Hg systolic or ≥ 10 mm Hg diastolic
upon standing.
✔✔Normal oxygen saturation (SpO₂) - ✔✔95-100 %.
✔✔Factors falsely elevating BP - ✔✔Small cuff, crossed legs, recent caffeine/smoking.
✔✔Action after obtaining abnormal vital sign - ✔✔Recheck manually, validate, and
report if confirmed.
, ✔✔ Purpose of a health assessment - ✔✔To collect and analyze subjective + objective
data to form a complete picture of a patient's health and guide nursing judgment.
✔✔Six steps of the nursing process - ✔✔Assessment, Diagnosis, Outcome
Identification, Planning, Implementation, Evaluation.
✔✔Evidence-Based Practice (EBP) - ✔✔Integration of best current research, clinical
expertise, patient preferences, and accurate assessment data.
✔✔Five steps of EBP - ✔✔Ask, Acquire, Appraise, Apply, Assess.
✔✔Complete (Total Health) database - ✔✔Database gathered on admission for
baseline data.
✔✔Emergency database - ✔✔Database used in urgent, life-threatening situations.
✔✔Order of priority according to ABCs - ✔✔Airway → Breathing → Circulation (then
Disability & Exposure).
✔✔Holistic health model - ✔✔Approach recognizing mind, body, spirit, and environment
interact to affect health.
✔✔First-level priority problem example - ✔✔Obstructed airway or absent respirations.
✔✔Outdated interventions - ✔✔They increase risk for harm; EBP ensures safety and
effectiveness.
✔✔Culture - ✔✔A learned, shared set of values, beliefs, and norms guiding a group's
thinking and behavior.
✔✔Acculturation vs. Assimilation - ✔✔Acculturation = adapting while retaining identity;
Assimilation = full adoption of dominant culture.
✔✔Three major illness-causation models - ✔✔Biomedical (disease = germs),
Naturalistic (balance of hot/cold or yin/yang), Magicoreligious (supernatural forces).
✔✔Examples of traditional healers - ✔✔Curandero (Hispanic), Shaman (Native
American), Herbalist (Asian), Braucher (Amish).
✔✔Traditional objects for health protection - ✔✔Amulets or charms (e.g., evil-eye
bracelet, St. Christopher medal, jade pendant).
