NUR 216 FINAL EXAM STUDY GUIDE 2024
UPDATED.
HomePC
, NUR 216 FINAL EXAM STUDY GUIDE 2024
UPDATED.
Module 1- Introduction to Health Assessment
1. What are the steps in the nursing process? Be able to identify examples of each step.
• Assessment: Obtaining subjective and objective data
• Diagnosis: Nursing diagnosis analyzes the data collected, identifying actual and
potential problems.
• Planning: Using SMART to create a plan based off data and diagnosis
• Implementation: Use skills to implement appropriate therapeutic interventions.
• Evaluation: Monitor the effectiveness and achievability of goals and the need
for intervention or adjustment
2. What are the components of the general survey?
Physical Appearance
Body structure
Mobility/Gait
Behavior
• Speech
• Dress, hygiene, grooming, and odors (body, breath)
• Vital signs with asking about Pain
3. What types of questions may be asked in the review of systems?
• Start with the head all the way down to toes and ask relevant questions that are
age-appropriate for each system
o Integumentary
o Head, neck, cognitive
o Eyes, ears, nose, mouth
o Respiratory
o Cardiovascular
o GI
o GU
o MSK
o Neuro
o Endocrine
o Mental
4. What are the four techniques used in physical assessment?
• Inspection
• Palpation
• Auscultation
• Percussion
5. What are the techniques used when assessing the abdomen?
Inspection
Auscultation
Palpation
6. How do you properly palpate for temperature?
• With the dorsal side of the hand
7. What is each side of the stethoscope called and used for?
, NUR 216 FINAL EXAM STUDY GUIDE 2024
UPDATED.
• Diaphragm: used for high pitched
• Bell: Low pitched (heart murmur)
Module 2- General Survey
1. What are the vital signs you typically need to collect from every patient?
• Temperature 96.8-100.4F
• Pulse 60-100 bpm
• Respiration rate 12-20 bpm
• Pulse Ox 95-100%
• Blood pressure <120 / <80
o Hypotension <90 / <60
o Hypertension >130--90
2. Be able to identify the most common pulse points.
• Radial (or thumb side of the wrist)
•
3. What are the different ways to take a temperature? What is the technique for each one?
• Oral
• Rectal -- sims position with upper leg flexed. 2.5-3.5 cm (1-1.5 inches) for adult.
• Axillary
• Tympanic -- Pull the ear up and back (for adults) or down and back (for a child)
• Temporal
4. Which sources are considered core and surface temperatures?
CORE = Oral and Rectal
SURFACE = Axillary, Tympanic, and Temporal
5. What are some causes of out-of-range vital signs?
• Exercise, Medication, smoking, lifestyle habits, drinking a cold drink, food,
diseases, conditions, hormonal changes, stress, ect.
6. How do you perform a two-step blood pressure?
Palpate brachial pulse, wait 30 secs, place diaphragm and up 20 above, let out
pressure
7. What are the stages of hypertension?
• Hypotension: <90 systolic, <60 diastolic
• HTN 1: 130 - 139 sys, 80-90 diastolic
• HTN 2: >140 sys, > 90 diastolic
8. How do you describe the behavior and effect of a patient?
• AOX4
• Questions you ask --> Name, DOB, Location, Situation
o Orientation needs to know where they are, who they are and time
9. Be able to differentiate between mobility, posture and body structure.
, NUR 216 FINAL EXAM STUDY GUIDE 2024
UPDATED.
• Mobility: ability to move
• Posture: the position in which someone holds their body when they are sitting or
standing
• Body structure: a particular complex anatomical part of a living thing
10. What does each BMI range
represent?
• Less than 18.5 is underweight
• 18.5-24.9 Normal BMI
• 25-29.9 overweight
• Obese 30 or greater
11. When is a focused assessment appropriate? A full physical examination?
• Focused assessment: focuses on a particular topic, body part, or functional ability
rather than an overall health status
• Physical exam: uses techniques of inspection, palpation, percussion, auscultation
(head to toe assessment)
Module 3- Health History
1. What questions would you ask to obtain a complete health history from a patient?
• Childhood illnesses, chronic illness, hospitalizations, surgeries,
immunizations, examinations, screenings, allergies
2. What is the difference between subjective and objective data? How do you collect each?
• Subjective = symptoms (only what the pt an tell you how they feel)
o Pain scale, Feelings, Symptoms
• Objective = what you can see (5 senses) and observe
o Vital signs, Bruises/cuts, Assessment
3. What is an open-ended question? When is it most appropriate to use them?
• Open-ended questions are not yes or no questions
o Tell me more about...
• Useful when you need to probe but respectfully for more information
4. What question types would you want to avoid?
• Close ended questions/Yes or no
5. What is a functional assessment?
Determines the pt’s ability to care for themselves
o Are they able to do things for themselves (physically, mentally)
o ADL’s
6. How does culture influence a patient’s health?
FICA
o F = Faith
o I = Influence
o C = Community
o A = Address preferences
7. What is the history of present illness (HPI) assessment?
Description of the development of the pt’s present illness --> S/S
o OLD CART
O = Onset
L = Location
D = Duration
UPDATED.
HomePC
, NUR 216 FINAL EXAM STUDY GUIDE 2024
UPDATED.
Module 1- Introduction to Health Assessment
1. What are the steps in the nursing process? Be able to identify examples of each step.
• Assessment: Obtaining subjective and objective data
• Diagnosis: Nursing diagnosis analyzes the data collected, identifying actual and
potential problems.
• Planning: Using SMART to create a plan based off data and diagnosis
• Implementation: Use skills to implement appropriate therapeutic interventions.
• Evaluation: Monitor the effectiveness and achievability of goals and the need
for intervention or adjustment
2. What are the components of the general survey?
Physical Appearance
Body structure
Mobility/Gait
Behavior
• Speech
• Dress, hygiene, grooming, and odors (body, breath)
• Vital signs with asking about Pain
3. What types of questions may be asked in the review of systems?
• Start with the head all the way down to toes and ask relevant questions that are
age-appropriate for each system
o Integumentary
o Head, neck, cognitive
o Eyes, ears, nose, mouth
o Respiratory
o Cardiovascular
o GI
o GU
o MSK
o Neuro
o Endocrine
o Mental
4. What are the four techniques used in physical assessment?
• Inspection
• Palpation
• Auscultation
• Percussion
5. What are the techniques used when assessing the abdomen?
Inspection
Auscultation
Palpation
6. How do you properly palpate for temperature?
• With the dorsal side of the hand
7. What is each side of the stethoscope called and used for?
, NUR 216 FINAL EXAM STUDY GUIDE 2024
UPDATED.
• Diaphragm: used for high pitched
• Bell: Low pitched (heart murmur)
Module 2- General Survey
1. What are the vital signs you typically need to collect from every patient?
• Temperature 96.8-100.4F
• Pulse 60-100 bpm
• Respiration rate 12-20 bpm
• Pulse Ox 95-100%
• Blood pressure <120 / <80
o Hypotension <90 / <60
o Hypertension >130--90
2. Be able to identify the most common pulse points.
• Radial (or thumb side of the wrist)
•
3. What are the different ways to take a temperature? What is the technique for each one?
• Oral
• Rectal -- sims position with upper leg flexed. 2.5-3.5 cm (1-1.5 inches) for adult.
• Axillary
• Tympanic -- Pull the ear up and back (for adults) or down and back (for a child)
• Temporal
4. Which sources are considered core and surface temperatures?
CORE = Oral and Rectal
SURFACE = Axillary, Tympanic, and Temporal
5. What are some causes of out-of-range vital signs?
• Exercise, Medication, smoking, lifestyle habits, drinking a cold drink, food,
diseases, conditions, hormonal changes, stress, ect.
6. How do you perform a two-step blood pressure?
Palpate brachial pulse, wait 30 secs, place diaphragm and up 20 above, let out
pressure
7. What are the stages of hypertension?
• Hypotension: <90 systolic, <60 diastolic
• HTN 1: 130 - 139 sys, 80-90 diastolic
• HTN 2: >140 sys, > 90 diastolic
8. How do you describe the behavior and effect of a patient?
• AOX4
• Questions you ask --> Name, DOB, Location, Situation
o Orientation needs to know where they are, who they are and time
9. Be able to differentiate between mobility, posture and body structure.
, NUR 216 FINAL EXAM STUDY GUIDE 2024
UPDATED.
• Mobility: ability to move
• Posture: the position in which someone holds their body when they are sitting or
standing
• Body structure: a particular complex anatomical part of a living thing
10. What does each BMI range
represent?
• Less than 18.5 is underweight
• 18.5-24.9 Normal BMI
• 25-29.9 overweight
• Obese 30 or greater
11. When is a focused assessment appropriate? A full physical examination?
• Focused assessment: focuses on a particular topic, body part, or functional ability
rather than an overall health status
• Physical exam: uses techniques of inspection, palpation, percussion, auscultation
(head to toe assessment)
Module 3- Health History
1. What questions would you ask to obtain a complete health history from a patient?
• Childhood illnesses, chronic illness, hospitalizations, surgeries,
immunizations, examinations, screenings, allergies
2. What is the difference between subjective and objective data? How do you collect each?
• Subjective = symptoms (only what the pt an tell you how they feel)
o Pain scale, Feelings, Symptoms
• Objective = what you can see (5 senses) and observe
o Vital signs, Bruises/cuts, Assessment
3. What is an open-ended question? When is it most appropriate to use them?
• Open-ended questions are not yes or no questions
o Tell me more about...
• Useful when you need to probe but respectfully for more information
4. What question types would you want to avoid?
• Close ended questions/Yes or no
5. What is a functional assessment?
Determines the pt’s ability to care for themselves
o Are they able to do things for themselves (physically, mentally)
o ADL’s
6. How does culture influence a patient’s health?
FICA
o F = Faith
o I = Influence
o C = Community
o A = Address preferences
7. What is the history of present illness (HPI) assessment?
Description of the development of the pt’s present illness --> S/S
o OLD CART
O = Onset
L = Location
D = Duration
