NR 304: Final Exam Concepts
Chapter 1:
Identify steps of Nursing Process: Evaluation
o Progress toward outcomes, conduct systematic, ongoing, criterion-based evaluation.
o Include patient and significant others.
o Use ongoing assessment to revise diagnoses, outcomes, plan.
o Disseminate results to patient and family.
Identify tasks in Nursing Process: Diagnosis
o Compare clinical findings with normal & abnormal variation & developmental events.
o Interpret data, validate diagnoses, document diagnoses.
Types of Databases: Problem Centered
o Complete: complete health and full physical examination.
Current & past health state
Forms baseline.
Yields firsts diagnosis.
o Focused: limited or short-term problem.
Mini database
Smaller scope/more targeted.
Concerns mainly one problem.
i.e.: broken leg
o Follow up: problem evaluated at regular intervals.
Getting better or worse?
Short term problems
Long term/chronic problems.
i.e.: diabetes, HBP
o Emergency: urgent, rapid collection.
Lifesaving measures.
Swift & sure.
Chapter 9:
Identify Components of the General Survey
o Physical appearance- age, sex, LOC, skin color, facial features, overall appearance,
o Body structure- stature, nutrition, symmetry, posture, position, body build, contour,
physical deformities.
o Mobility- gait, ROM, involuntary movement.
o Behavior- facial expression, mood/affect, speech, dress, personal hygiene.
o Measurement- weight, height, BMI, waist circumference.
Chapter 10:
Differentiate the grading of Pulse Force
o 3+- full bounding
o 2+- normal
, o 1+- weak, thready
o 0- absent
Identify Hypotension Occurrences and Rationales
o Acute Mi, Shock- decreased CO.
o Hemorrhage- decrease in total blood volume.
o Vasodilation- decrease in peripheral vascular resistance.
o Addison Disease- decrease in circulating aldosterone.
o Symptoms- increased pulse, dizziness, diaphoresis, confusion, blurred vision,
cool/clammy skin.
Recognize how to Count Respirations
o After pulse taken, keep fingers on radial pulse, count respirations without pt knowing.
o Range 10-20 breaths per minute
o Steady, even, deep, shallow, labored.
o Regular- count 30 sec, Irregular- 60 sec.
Recognize the Effects of Smoking on Blood Pressure
o Elevates BP.
Chapter 11:
Identify Physiologic Changes: Acute Pain Responses
o usually sudden, severe, short term.
o Indicated tissue damage, localized/generalized.
o Increase BP/HR, cool, pale, moist skin, increased RR, increased muscle tension, vomiting,
strong emotional response.
Chapter 13:
Recognize the ABCDEF of Skin Lesions
o A: asymmetry,
o B: border irregularity.
o C: color.
o D: diameter greater than 6 mm.
o E: elevation or evolution.
o F: funny looking.
Identify how to Assess for Clubbing and its indications
o Early clubbing- 180 degrees. Late- greater than 180 degrees.
o Congenital cyanotic heart disease, lung cancer, pulmonary disease.
Recognize how to Detect Color Changes in Light and Dark Skin
o Pallor: decreased hematocrit, decreased perfusion, vasoconstriction, anemia, shock
Light: generalized pallor.
Dark: ashen gray, dull, loss of glow, cool to palpation, check conjunctivae.
o Cyanosis: increase in unoxygenated hemoglobin, exposure to cold.
Light: dusky blue.
Dark: dullness, check conjunctivae, oral cavity, nails.
o Jaundice: increased bilirubin, liver inflammation, some infections/viruses.
Chapter 1:
Identify steps of Nursing Process: Evaluation
o Progress toward outcomes, conduct systematic, ongoing, criterion-based evaluation.
o Include patient and significant others.
o Use ongoing assessment to revise diagnoses, outcomes, plan.
o Disseminate results to patient and family.
Identify tasks in Nursing Process: Diagnosis
o Compare clinical findings with normal & abnormal variation & developmental events.
o Interpret data, validate diagnoses, document diagnoses.
Types of Databases: Problem Centered
o Complete: complete health and full physical examination.
Current & past health state
Forms baseline.
Yields firsts diagnosis.
o Focused: limited or short-term problem.
Mini database
Smaller scope/more targeted.
Concerns mainly one problem.
i.e.: broken leg
o Follow up: problem evaluated at regular intervals.
Getting better or worse?
Short term problems
Long term/chronic problems.
i.e.: diabetes, HBP
o Emergency: urgent, rapid collection.
Lifesaving measures.
Swift & sure.
Chapter 9:
Identify Components of the General Survey
o Physical appearance- age, sex, LOC, skin color, facial features, overall appearance,
o Body structure- stature, nutrition, symmetry, posture, position, body build, contour,
physical deformities.
o Mobility- gait, ROM, involuntary movement.
o Behavior- facial expression, mood/affect, speech, dress, personal hygiene.
o Measurement- weight, height, BMI, waist circumference.
Chapter 10:
Differentiate the grading of Pulse Force
o 3+- full bounding
o 2+- normal
, o 1+- weak, thready
o 0- absent
Identify Hypotension Occurrences and Rationales
o Acute Mi, Shock- decreased CO.
o Hemorrhage- decrease in total blood volume.
o Vasodilation- decrease in peripheral vascular resistance.
o Addison Disease- decrease in circulating aldosterone.
o Symptoms- increased pulse, dizziness, diaphoresis, confusion, blurred vision,
cool/clammy skin.
Recognize how to Count Respirations
o After pulse taken, keep fingers on radial pulse, count respirations without pt knowing.
o Range 10-20 breaths per minute
o Steady, even, deep, shallow, labored.
o Regular- count 30 sec, Irregular- 60 sec.
Recognize the Effects of Smoking on Blood Pressure
o Elevates BP.
Chapter 11:
Identify Physiologic Changes: Acute Pain Responses
o usually sudden, severe, short term.
o Indicated tissue damage, localized/generalized.
o Increase BP/HR, cool, pale, moist skin, increased RR, increased muscle tension, vomiting,
strong emotional response.
Chapter 13:
Recognize the ABCDEF of Skin Lesions
o A: asymmetry,
o B: border irregularity.
o C: color.
o D: diameter greater than 6 mm.
o E: elevation or evolution.
o F: funny looking.
Identify how to Assess for Clubbing and its indications
o Early clubbing- 180 degrees. Late- greater than 180 degrees.
o Congenital cyanotic heart disease, lung cancer, pulmonary disease.
Recognize how to Detect Color Changes in Light and Dark Skin
o Pallor: decreased hematocrit, decreased perfusion, vasoconstriction, anemia, shock
Light: generalized pallor.
Dark: ashen gray, dull, loss of glow, cool to palpation, check conjunctivae.
o Cyanosis: increase in unoxygenated hemoglobin, exposure to cold.
Light: dusky blue.
Dark: dullness, check conjunctivae, oral cavity, nails.
o Jaundice: increased bilirubin, liver inflammation, some infections/viruses.
