NR 304 Final Exam – Questions With Expert Solutions
Health history Correct Answer - a collection of subjective information
that provides information about the patient's health status
Steps to setting priorities Correct Answer - 1. Assign high priority to
First-level priority problems (immediate priorities): Remember the "ABCs
plus V"
2. Next, attend to Second-level priority problems:
Mental status change (ex. confusion, decreased alertnesS) Untreated medical
problems requiring immediate attention (ex. a diabetic who has not had
insulin)Acute pain, Acute urinary elimination problems, Abnormal laboratory
values
Risks of infection, safety, or security (for hte patient or for others)
3. Address Third-level priority problems (later priorities):
Health problems that do not fit into the above categories (ex. problems with
lack of knowledge, activity, rest, family coping)
Is pain a normal process of aging? Correct Answer - No, although it is a
common experience it is NOT normal
Acute pain responses to the respiratory system Correct Answer -
Hypoventilation
Hypoxia
Decreased cough
Atelectasis
Acute pain behaviors include Correct Answer - Guarding
Grimacing
Vocalizations such as moaning
Agitation
Restlessness
Stillness
Diaphoresis
Change in vital signs
Chronic pain behaviors include Correct Answer - Bracing
,Rubbing
Diminished activity
Sighing
Change in appetite
Objective assessment of the skin Correct Answer - Skin color and general
pigmentation
Temperature
Moisture
Texture
Thickness
Edema
Mobility and Turgor
Vascularity or bruising
Lesions
When performing a skin assessment what clinical manifestations of
dehydration could there be Correct Answer - Mucous membranes are
dry, and lips look parched and cracked.
With extreme dryness the skin is fissured, resembling cracks in a dry lake bed.
Danger signs of pigmented lesions Correct Answer - ABCDEF:
Asymmetry (not regularly round or oval, two halves of lesion do not look the
same)
Border irregularity (notching, scalloping, ragged edges, poorly defined
margins)
Color variation (areas of brown, tan, black, blue, red, white, or combination)
Diameter greater than 6 mm (i.e., the size of a pencil eraser), although early
melanomas may be diagnosed at a smaller size.
Elevation or Evolution
Funny looking (refers to the "ugly duckling" sign, in which the suspicious
lesion stands out as looking different compared with its neighboring nevi)
Pressure Injuries risk factors Correct Answer - Immobilization /
impaired mobility
Thin fragile skin of aging
Decreased sensory perception
Impaired level of consciousness
Moisture from urine or stool incontinence
,Excessive Perspiration or wound drainage
Shearing injury
Poor nutrition
Infection
Interventions for pressure ulcers Correct Answer - Turn frequently
Ambulate
Good skin care
Balanced diet with protein, vitamins, minerals
How do you assess jaundice on dark skinned patients? Correct Answer -
Sclera of eyes
Junction of hard and soft palate
Palms
urge incontinence Correct Answer - involuntary urine loss from
overactive detrusor muscle in bladder
stress incontinence Correct Answer - involuntary urine loss with
physical strain, sneezing, or coughing caused by weakness of pelvic floor
What two things determine how complete a patients health history will be?
Correct Answer - Time and patient priorities
Purpose of health history Correct Answer - To obtain subjective data
from patients to later combine with objective date found during assessment
and make a judgment or diagnosis about the patients health status
Health History Sequence Correct Answer - 1. Biographic data
2. Reason for seeking care
3. Present health or history of present illness
4. Past history
5. Medication reconciliation
6. Family history
7. Review of systems
8. Functional assessment or activities of daily living (ADLs)
, First-level priority problems Correct Answer - emergent, life-
threatening, and immediate, such as establishing an airway or supporting
breathing
Second-level priority problems Correct Answer - those that are next in
urgency requiring your prompt intervention to forestall further deterioration.
(mental status change, acute pain, acute urinary elimination problem,
untreated medical problems, abnormal lab test results
Third-level priority problems Correct Answer - those that are important
to the patient's health but can be addressed after more urgent health
problems are addressed. (Knowledge deficit, altered family processes, and low
self esteem)
What are the four types of of databases an examiner may use? Correct
Answer - Complete
Focused or problem centered
Follow up
Emergency
What screening questionnaire is used to identify excessive or uncontrolled
drinking? Correct Answer - CAGE
Have you ever felt you should Cut down on your drinking?
Have people Annoyed you by criticizing your drinking?
Have you ever felt bad or Guilty about your drinking?
Have you ever had a drink first thing in the morning to steady your nerves
(Eye-opener)?
levels of consciousness Correct Answer - 1. Alert
2. Lethargic
3. Obtunded
4. Stupor/Semi-Coma
5. Coma
When asking a patient questions from the CAGE screening you would continue
with a more complete substance abuse assessment if they answer yes to how
many questions? Correct Answer - 2 or more
Health history Correct Answer - a collection of subjective information
that provides information about the patient's health status
Steps to setting priorities Correct Answer - 1. Assign high priority to
First-level priority problems (immediate priorities): Remember the "ABCs
plus V"
2. Next, attend to Second-level priority problems:
Mental status change (ex. confusion, decreased alertnesS) Untreated medical
problems requiring immediate attention (ex. a diabetic who has not had
insulin)Acute pain, Acute urinary elimination problems, Abnormal laboratory
values
Risks of infection, safety, or security (for hte patient or for others)
3. Address Third-level priority problems (later priorities):
Health problems that do not fit into the above categories (ex. problems with
lack of knowledge, activity, rest, family coping)
Is pain a normal process of aging? Correct Answer - No, although it is a
common experience it is NOT normal
Acute pain responses to the respiratory system Correct Answer -
Hypoventilation
Hypoxia
Decreased cough
Atelectasis
Acute pain behaviors include Correct Answer - Guarding
Grimacing
Vocalizations such as moaning
Agitation
Restlessness
Stillness
Diaphoresis
Change in vital signs
Chronic pain behaviors include Correct Answer - Bracing
,Rubbing
Diminished activity
Sighing
Change in appetite
Objective assessment of the skin Correct Answer - Skin color and general
pigmentation
Temperature
Moisture
Texture
Thickness
Edema
Mobility and Turgor
Vascularity or bruising
Lesions
When performing a skin assessment what clinical manifestations of
dehydration could there be Correct Answer - Mucous membranes are
dry, and lips look parched and cracked.
With extreme dryness the skin is fissured, resembling cracks in a dry lake bed.
Danger signs of pigmented lesions Correct Answer - ABCDEF:
Asymmetry (not regularly round or oval, two halves of lesion do not look the
same)
Border irregularity (notching, scalloping, ragged edges, poorly defined
margins)
Color variation (areas of brown, tan, black, blue, red, white, or combination)
Diameter greater than 6 mm (i.e., the size of a pencil eraser), although early
melanomas may be diagnosed at a smaller size.
Elevation or Evolution
Funny looking (refers to the "ugly duckling" sign, in which the suspicious
lesion stands out as looking different compared with its neighboring nevi)
Pressure Injuries risk factors Correct Answer - Immobilization /
impaired mobility
Thin fragile skin of aging
Decreased sensory perception
Impaired level of consciousness
Moisture from urine or stool incontinence
,Excessive Perspiration or wound drainage
Shearing injury
Poor nutrition
Infection
Interventions for pressure ulcers Correct Answer - Turn frequently
Ambulate
Good skin care
Balanced diet with protein, vitamins, minerals
How do you assess jaundice on dark skinned patients? Correct Answer -
Sclera of eyes
Junction of hard and soft palate
Palms
urge incontinence Correct Answer - involuntary urine loss from
overactive detrusor muscle in bladder
stress incontinence Correct Answer - involuntary urine loss with
physical strain, sneezing, or coughing caused by weakness of pelvic floor
What two things determine how complete a patients health history will be?
Correct Answer - Time and patient priorities
Purpose of health history Correct Answer - To obtain subjective data
from patients to later combine with objective date found during assessment
and make a judgment or diagnosis about the patients health status
Health History Sequence Correct Answer - 1. Biographic data
2. Reason for seeking care
3. Present health or history of present illness
4. Past history
5. Medication reconciliation
6. Family history
7. Review of systems
8. Functional assessment or activities of daily living (ADLs)
, First-level priority problems Correct Answer - emergent, life-
threatening, and immediate, such as establishing an airway or supporting
breathing
Second-level priority problems Correct Answer - those that are next in
urgency requiring your prompt intervention to forestall further deterioration.
(mental status change, acute pain, acute urinary elimination problem,
untreated medical problems, abnormal lab test results
Third-level priority problems Correct Answer - those that are important
to the patient's health but can be addressed after more urgent health
problems are addressed. (Knowledge deficit, altered family processes, and low
self esteem)
What are the four types of of databases an examiner may use? Correct
Answer - Complete
Focused or problem centered
Follow up
Emergency
What screening questionnaire is used to identify excessive or uncontrolled
drinking? Correct Answer - CAGE
Have you ever felt you should Cut down on your drinking?
Have people Annoyed you by criticizing your drinking?
Have you ever felt bad or Guilty about your drinking?
Have you ever had a drink first thing in the morning to steady your nerves
(Eye-opener)?
levels of consciousness Correct Answer - 1. Alert
2. Lethargic
3. Obtunded
4. Stupor/Semi-Coma
5. Coma
When asking a patient questions from the CAGE screening you would continue
with a more complete substance abuse assessment if they answer yes to how
many questions? Correct Answer - 2 or more
