Final Exam Study Guide

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Questions and Answers

What type of data is primarily based on the patient's perception and cannot be measured directly?

Objective data

Quantitative data

Qualitative data

Subjective data (correct)

Which physical assessment technique is utilized for assessing high-pitched sounds?

Percussion

The diaphragm of the stethoscope (correct)

Palpation

The bell of the stethoscope

What is the primary reason for organizing a physical assessment in a 'head-to-toe' approach?

To enhance the patient's comfort

To speed up the assessment process

To ensure a systematic and thorough assessment (correct)

To allow for more patient interaction

Which statement correctly reflects the OLDCARTS assessment method?

It explores the characteristics of a patient's pain. Signup and view all the answers

Which vital sign is considered abnormal when it falls below 60 bpm?

Bradycardic heart rate Signup and view all the answers

What assessment technique is primarily used to evaluate body odor during a general survey?

Inspection Signup and view all the answers

What condition is assessed when a patient exhibits signs of being hunched over?

Postural assessment Signup and view all the answers

What is the 'gold standard' method for assessing pain in patients?

Patient self-reporting of pain Signup and view all the answers

What is the total cholesterol level that should ideally be below?

200 mg/dL Signup and view all the answers

Which heart chambers are separated by the mitral valve?

Left atrium and left ventricle Signup and view all the answers

What does a pulse amplitude of +3 or +4 indicate?

Bounding pulse Signup and view all the answers

What should you do if you are unable to palpate a peripheral pulse?

Use a Doppler ultrasound Signup and view all the answers

What does the mnemonic F.A.S.T. represent in neurological assessments?

Face, Arm, Speech, Time Signup and view all the answers

What is assessed when using the PERRLA acronym?

Pupil reaction to light and accommodation Signup and view all the answers

Which chart is typically used to assess visual acuity?

Snellen chart Signup and view all the answers

At what level of consciousness is a person considered to be at their lowest while still alive?

Coma Signup and view all the answers

What is low blood pressure commonly referred to as?

Hypotension Signup and view all the answers

What is a normal range for oxygen saturation in a healthy individual?

93% to 100% Signup and view all the answers

What is a common name for fluid-filled lesions that are less than 1 cm?

Vesicles Signup and view all the answers

Which BMI range is classified as obese?

35 and above Signup and view all the answers

What is the term for a low respiratory rate?

Bradypnea Signup and view all the answers

Which of the following indicates signs of acute respiratory distress?

Use of accessory muscles for breathing Signup and view all the answers

What is the common term for skin lesions caused by a pressure injury?

Ulcers Signup and view all the answers

What visual acuity representation denotes perfect vision?

20/20 Signup and view all the answers

What response is expected when assessing the Achilles reflex?

Dorsiflexion of the foot Signup and view all the answers

How long should you listen to confirm the absence of bowel sounds?

5 minutes Signup and view all the answers

What is the correct definition of adduction?

Movement towards the midline of the body Signup and view all the answers

What does lordosis describe?

Exaggerated curvature of the lumbar spine Signup and view all the answers

What should be considered when performing a self-breast exam?

The patient should stand with hands on hips Signup and view all the answers

What describes jaundice?

Yellowing of the skin and eyes Signup and view all the answers

What should you assess in addition to breast tissue during a self-breast exam?

Lymph nodes in the armpit area Signup and view all the answers

What is a common characteristic of kyphosis?

Excessive backward curvature of the spine Signup and view all the answers

What is the purpose of percussion of the costovertebral angle (CVA)?

To assess for renal inflammation Signup and view all the answers

In prioritizing patient care, which concern should be addressed first?

Increased respiratory rate of 26 Signup and view all the answers

When recalling the cranial nerves, why is it important to know both the name and the number?

Exam questions may provide either name or number only Signup and view all the answers

What aspect should a nurse remember when conducting an assessment based on the nursing process?

Always begin with assessment Signup and view all the answers

What is an important consideration when reading assessment questions?

Determine if it's an objective or subjective question Signup and view all the answers

Which of the following concerns should still be evaluated after addressing an acute respiratory issue?

Circulation concerns Signup and view all the answers

Study Notes

General/Miscellaneous/Assessment Techniques

Subjective data: Patient-reported information like pain level, feelings, or experiences.
Objective data: Measurable facts, e.g., vitals and laboratory results.
Physical assessment techniques include inspection, palpation, percussion, and auscultation.
Bell of the stethoscope detects low-pitched sounds; diaphragm captures high-pitched sounds like heart and lung sounds (S1/S2).
Equipment for head-to-toe assessment includes a stethoscope, sphygmomanometer, thermometer, and penlight.
Organizing physical assessments "head-to-toe" ensures systematic evaluation and prevents missed findings.
Recommended order: General survey, neurological, cardiovascular, respiratory, gastrointestinal, musculoskeletal, skin assessments.
Start with general survey before specific body system assessments.
Therapeutic communication techniques enhance patient comfort and trust.

Pain Assessment

OLDCARTS and PQRST assess pain characteristics and impact.
They do not evaluate patient's emotional or psychological history.
The gold standard for pain assessment is self-reporting.
Inability to self-report due to cognitive impairment necessitates observational pain assessment, monitoring non-verbal cues.
Symptoms of acute pain include increased heart rate, hypertension, and facial grimacing.

General Survey, Vitals, & Nutritional Assessment

General survey's purpose is to assess overall health status and identify potential areas of concern.
Components include appearance, body structure, posture, and hygiene.
Normal heart rate ranges from 60-100 beats per minute; bradycardia refers to a rate below 60, tachycardia above 100.
Normal blood pressure is usually under 120/80; hypotension refers to values below 90/60.
Avoid placing blood pressure cuffs over areas with lymphedema or injury.
Normal oxygen saturation is above 95%; normal respiratory rate is 12-20 breaths per minute.
BMI classifications: normal (18.5-24.9), underweight (below 18.5), overweight (25-29.9), obese (30 and above).
Nutritional assessment includes dietary history, lifestyle choices, and anthropometric measurements.

Skin/Hair/Nails

Functions of skin: protection, sensation, thermoregulation, and vitamin D synthesis.
Fluid-filled lesions <1 cm are called vesicles; pressure ulcers may cause ulcerative lesions.
The ABCDE mnemonic for suspicious nevi involves Asymmetry, Border irregularity, Color variation, Diameter > 6mm, and Evolving changes.

Head, Eyes, Ears, Neck, & Throat

Assess facial sinuses via palpation and percussion, the latter involving tapping.
External ear assessment includes inspection and otoscopy.
Normal findings: head should be normocephalic, symmetrical; visual acuity should be 20/20.

Respiratory

Signs of acute respiratory distress include use of accessory muscles, cyanosis, and altered mental status.
Chronic pulmonary disease may present with wheezing and clubbing.
Tactile fremitus assessment reveals equal vibrations in healthy lungs.
Crackles sound like popping or bubbling; rhonchi are low-pitched, wheezing is high-pitched and indicates airflow obstruction.
COPD patients should avoid smoking, maintain a healthy weight, and engage in regular exercise to enhance lung function.

Cardiovascular

Assessment sequence: inspection, palpation, percussion, and auscultation.
Ideal total cholesterol level should be below 200 mg/dL.
Apical pulse located at the fifth intercostal space; separated by the mitral valve.
Peripheral pulse amplitude normal between +2 to +3; absent (0), weak (+1), or bounding (+3 or +4) indicate different conditions.
Carotid pulse assessed at the neck; radial at the wrist; femoral, popliteal, posterior tibial, and dorsalis pedis are assessed in lower extremities.
Irregular pulses require further assessment, possibly using an EKG if unable to palpate.

Neurological & Musculoskeletal

F.A.S.T: Face drooping, Arm weakness, Speech difficulties, Time to call emergency services.
Each cranial nerve has specific functions: tested using various assessments including visual acuity, smell, and sensation.
PERRLA: Pupils Equal, Round, Reactive to Light and Accommodation; requires penlight for assessment.
Deep tendon reflexes tested with a reflex hammer; Achilles reflex should show plantar flexion.
Range of motion movements include adduction (moving toward the body), abduction (moving away), flexion (decreasing angle), and extension (increasing angle).
Spinal deformities: lordosis (inward curve), kyphosis (outward curve), scoliosis (lateral curvature).

Abdomen & Rectum/Anus

Client should empty bladder before abdomen assessment.
Sequence: inspection, auscultation, percussion, and palpation.
Jaundice indicates liver dysfunction caused by excessive bilirubin.
Striae are stretch marks; not typically concerning unless associated with other symptoms.
Confirm bowel sounds' absence only after listening for 5 minutes; normal findings: 5-30 bowel sounds per minute.
Costovertebral angle percussion assesses kidney health; tenderness may indicate inflammation.
Assess painful areas last when palpating the abdomen. Hemorrhoids are swollen veins causing rectal symptoms.

Breast & Lymphatic

Self-breast exams recommend monthly during the same time each month, preferably a few days after menstruation.
Position patient comfortably; assess breast tissue, underlying structures, and lymph nodes.
Normal lymph node findings include non-tender, mobile nodes. Abnormal findings may include fixed or enlarged nodes.

Older Adult

Older adults may need additional time and accommodations for assessments due to slower processing and sensory deficits.
Age-related findings may include changes in skin elasticity, decreased peripheral circulation, and altered mobility.

Tips

Always start with assessment per nursing process.
Recall the assessment sequence consistently to streamline care.
Know both names and numbers of cranial nerves for effective recall.
Prioritize issues using ABCs: address airway and breathing concerns first.
Distinguish between objective and subjective data during assessments to enhance accuracy.

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Description

Prepare for the NUR 216 final exam with this comprehensive study guide focusing on assessment techniques and data classification. Understand the difference between subjective and objective data, and familiarize yourself with the various physical assessment tools and techniques critical for nursing professionals.

Final Exam Study Guide - NUR 216

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