NURN 155 - FINAL EXAM QUESTIONS
& ANSWERS (RATED A+)
1. Interview and Health Assessment - ANSWER
a. Assessment- Interview, Health History, and Physical Assessment - ANSWER
Interview - ANSWER§ Obtained on first patient encounter.
§ Completed by RN, cannot be delegated.
§ Consider age-specific prevention guidelines.
§ Gives a picture of the patient's current health history and health risk status.
Health History - ANSWER- Bio Data
- PMH: All of the patient's past medical history.
- Family History - The health history of family members.
ROS - The nurse evaluates each body system's past and present state of health.
- Medication Reconciliation.
- ADL - The patient's ability to provide self care-bathing, toileting, walking, etc.
e. Sensory - ANSWER- Pain - pinprick test.
- Touch - light touch, is used with a stretched cotton ball on the patient's arms,
forearms, legs, hands, thighs, etc.
- Vibration - the nurse uses a tuning fork on the patient.
- Tactile Discrimination - fine touch.
- Stereognosis - the ability to perceive and recognize the form of an object in the
absence of visual and auditory information.
- Graphesthesia - is the ability to "read" a number by having it traced on the skin.
f. Motor - ANSWER• Size- Atrophy, Hypertrophy.
• Strength- Paresis, Paralysis.
• Tone- limited ROM, Flaccid, Spastic.
• Involuntary Movements.
g. Fall Risk Assessment - ANSWERis used to find out if you have a low, moderate,
or high risk of falling.
Physical Assessment - ANSWERobjective data: Observations or measurements of
the patient's health status.
Example- Checking Vital signs, nurse observing patient's behavior.
c. Health History-sources - ANSWERPrimary or Secondary Source:
,•Patient.
•Family member.
•Observer.
•Caretaker.
•Health care team
•Electronic Medical Record (EMR).
•Other records- Immunization, educational, military, employment.
•Nurses Experience
d. Interview- Technique, sources, - ANSWERInterview techniques:
§ Observation.
§ Open-ended Questions.
§ Closed-ended Questions.
§ Non-verbal skills - body language. I.e., posture, gesture, facial expression, eye
contact, foot tapping, touch etc.
d. Communication technique - ANSWER• Sending - verbal and non-verbal
communication.
• Receiving - the receiver uses his or her own interpretations of your own words.
• Internal Factors- Respect, Empathy, Listening, Self-awareness
• External Factors- Privacy, No Interruptions, Environment
• Dress - the client must remain in street clothes when conducting the interview. The
interviewer's appearance should be appropriate to the setting.
• Note-taking - keep note-taking to a minimum.
e. Data collection- Subjective and Objective data, Open ended, closed ended -
ANSWER• Subjective data - what the person says about himself or herself.
• Objective data - what the interviewer obtains through physical examination.
• Open-ended - allow clients to discuss their concerns freely.
• Closed-ended - can be answered with "Yes" or "No," or they have a limited set of
possible answers.
2. General and Environmental survey, PA technique, documentation - ANSWER
a. SWIPE - ANSWERSafety/Survey, Wash your hands, Identify yourself & client,
Provide for privacy, and Explain.
b. General survey- Physical Appearance, Body structure, Mobility, and Behavior -
ANSWER
Physical Appearance - ANSWER1. Age- appears stated age.
2. Sex - sexual development is appropriate for sex and age.
3. Level of consciousness.
4. Skin Color - color tone is even, pigmentation varying with genetic background.
5. Facial Features - are symmetric with movement.
6. Overall appearance - no signs of acute distress are present.
Body Structure - ANSWER1. Stature - the height appears within the normal range for
age and genetic heritage.
, 2. Nutritional Status - the weight appears within the normal range for height and body
build.
3. Symmetry - body parts are equal bilaterally and are in relative proportion.
4. Posture - the client stands comfortably erect as appropriate for their age.
5. Position/Deformities - posture and how the patient holds him/or herself is
surveyed.
Mobility - ANSWER1. Gait - Descriptors of normal gait include: smooth, well-
balanced with symmetrical arm swings. The base of the gait should be as wide as
the shoulder width.
2. Range of Motion - note full mobility for each joint and that movement is deliberate,
accurate, smooth, and coordinated .
Behavior - ANSWER1. Facial expression - the client maintains eye contact.
2. Mood and Affect - the client is comfortable and cooperative with the nurse and
interacts pleasantly.
3. Speech- Articulation clear.
4. Speech pattern - the stream of talking is fluent with an even pace.
5. Dress - clothing is appropriate to the climate, looks clean, fits the body, and is
appropriate to the client's culture and age group.
6. Personal hygiene - the client appears clean and groomed appropriately for his or
her age, occupation, and socioeconomic group.
c. Environmental survey-what to look for? - ANSWERSafety.
d. Physical Assessment-Types, purpose, Preparation - ANSWER
Types of Physical Assessment - ANSWER1. Initial Assessment - comprehensive
nursing assessment resulting in baseline data that enable the nurse to make a
judgment about a patient's health status, ability to manage one's own health care,
and need for nursing, and to plan individualized, holistic health care for the patient.
2. Focused Assessment - assessment is conducted to assess a specific problem;
focuses on pertinent history and body regions but may also be used to address the
immediate and highest priority concerns for an individual patient.
3. Emergency Assessment - type of rapid focused assessment conducted when
addressing a life-threatening or unstable situation.
4. Time-Lapsed Assessment - an assessment that is scheduled to compare a
patient's current status to baseline data obtained earlier.
5. Patient-Centered Assessment method - tool for assessing patient complexity
using the social determinants of health that often explain why patients with the same
or similar health conditions differ in their ability to manage their health and in their
outcomes.
Purpose of physical assessment - ANSWER1. Collection of baseline data.
2. Compare data with norms.
3. Analyze findings- support or refute subjective data obtained in the nursing history.
4. Identify or confirm the nursing diagnoses.
5. Prioritize nursing diagnosis'.
6. Make clinical decisions about the patient's health care and management.
7. Evaluate outcomes of care.
& ANSWERS (RATED A+)
1. Interview and Health Assessment - ANSWER
a. Assessment- Interview, Health History, and Physical Assessment - ANSWER
Interview - ANSWER§ Obtained on first patient encounter.
§ Completed by RN, cannot be delegated.
§ Consider age-specific prevention guidelines.
§ Gives a picture of the patient's current health history and health risk status.
Health History - ANSWER- Bio Data
- PMH: All of the patient's past medical history.
- Family History - The health history of family members.
ROS - The nurse evaluates each body system's past and present state of health.
- Medication Reconciliation.
- ADL - The patient's ability to provide self care-bathing, toileting, walking, etc.
e. Sensory - ANSWER- Pain - pinprick test.
- Touch - light touch, is used with a stretched cotton ball on the patient's arms,
forearms, legs, hands, thighs, etc.
- Vibration - the nurse uses a tuning fork on the patient.
- Tactile Discrimination - fine touch.
- Stereognosis - the ability to perceive and recognize the form of an object in the
absence of visual and auditory information.
- Graphesthesia - is the ability to "read" a number by having it traced on the skin.
f. Motor - ANSWER• Size- Atrophy, Hypertrophy.
• Strength- Paresis, Paralysis.
• Tone- limited ROM, Flaccid, Spastic.
• Involuntary Movements.
g. Fall Risk Assessment - ANSWERis used to find out if you have a low, moderate,
or high risk of falling.
Physical Assessment - ANSWERobjective data: Observations or measurements of
the patient's health status.
Example- Checking Vital signs, nurse observing patient's behavior.
c. Health History-sources - ANSWERPrimary or Secondary Source:
,•Patient.
•Family member.
•Observer.
•Caretaker.
•Health care team
•Electronic Medical Record (EMR).
•Other records- Immunization, educational, military, employment.
•Nurses Experience
d. Interview- Technique, sources, - ANSWERInterview techniques:
§ Observation.
§ Open-ended Questions.
§ Closed-ended Questions.
§ Non-verbal skills - body language. I.e., posture, gesture, facial expression, eye
contact, foot tapping, touch etc.
d. Communication technique - ANSWER• Sending - verbal and non-verbal
communication.
• Receiving - the receiver uses his or her own interpretations of your own words.
• Internal Factors- Respect, Empathy, Listening, Self-awareness
• External Factors- Privacy, No Interruptions, Environment
• Dress - the client must remain in street clothes when conducting the interview. The
interviewer's appearance should be appropriate to the setting.
• Note-taking - keep note-taking to a minimum.
e. Data collection- Subjective and Objective data, Open ended, closed ended -
ANSWER• Subjective data - what the person says about himself or herself.
• Objective data - what the interviewer obtains through physical examination.
• Open-ended - allow clients to discuss their concerns freely.
• Closed-ended - can be answered with "Yes" or "No," or they have a limited set of
possible answers.
2. General and Environmental survey, PA technique, documentation - ANSWER
a. SWIPE - ANSWERSafety/Survey, Wash your hands, Identify yourself & client,
Provide for privacy, and Explain.
b. General survey- Physical Appearance, Body structure, Mobility, and Behavior -
ANSWER
Physical Appearance - ANSWER1. Age- appears stated age.
2. Sex - sexual development is appropriate for sex and age.
3. Level of consciousness.
4. Skin Color - color tone is even, pigmentation varying with genetic background.
5. Facial Features - are symmetric with movement.
6. Overall appearance - no signs of acute distress are present.
Body Structure - ANSWER1. Stature - the height appears within the normal range for
age and genetic heritage.
, 2. Nutritional Status - the weight appears within the normal range for height and body
build.
3. Symmetry - body parts are equal bilaterally and are in relative proportion.
4. Posture - the client stands comfortably erect as appropriate for their age.
5. Position/Deformities - posture and how the patient holds him/or herself is
surveyed.
Mobility - ANSWER1. Gait - Descriptors of normal gait include: smooth, well-
balanced with symmetrical arm swings. The base of the gait should be as wide as
the shoulder width.
2. Range of Motion - note full mobility for each joint and that movement is deliberate,
accurate, smooth, and coordinated .
Behavior - ANSWER1. Facial expression - the client maintains eye contact.
2. Mood and Affect - the client is comfortable and cooperative with the nurse and
interacts pleasantly.
3. Speech- Articulation clear.
4. Speech pattern - the stream of talking is fluent with an even pace.
5. Dress - clothing is appropriate to the climate, looks clean, fits the body, and is
appropriate to the client's culture and age group.
6. Personal hygiene - the client appears clean and groomed appropriately for his or
her age, occupation, and socioeconomic group.
c. Environmental survey-what to look for? - ANSWERSafety.
d. Physical Assessment-Types, purpose, Preparation - ANSWER
Types of Physical Assessment - ANSWER1. Initial Assessment - comprehensive
nursing assessment resulting in baseline data that enable the nurse to make a
judgment about a patient's health status, ability to manage one's own health care,
and need for nursing, and to plan individualized, holistic health care for the patient.
2. Focused Assessment - assessment is conducted to assess a specific problem;
focuses on pertinent history and body regions but may also be used to address the
immediate and highest priority concerns for an individual patient.
3. Emergency Assessment - type of rapid focused assessment conducted when
addressing a life-threatening or unstable situation.
4. Time-Lapsed Assessment - an assessment that is scheduled to compare a
patient's current status to baseline data obtained earlier.
5. Patient-Centered Assessment method - tool for assessing patient complexity
using the social determinants of health that often explain why patients with the same
or similar health conditions differ in their ability to manage their health and in their
outcomes.
Purpose of physical assessment - ANSWER1. Collection of baseline data.
2. Compare data with norms.
3. Analyze findings- support or refute subjective data obtained in the nursing history.
4. Identify or confirm the nursing diagnoses.
5. Prioritize nursing diagnosis'.
6. Make clinical decisions about the patient's health care and management.
7. Evaluate outcomes of care.
