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NSG 1010 Exam 3 Guide With Complete Solution
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NSG 1010 Exam 3 Guide WithComplete Solution
What is the reason(s) for a nurse to perform a nursing assessment of a client?
- ANSWER to obtain baseline data
to obtain a nursing diagnosis
to monitoring status of identified problems
to screen for health problems
What is *baseline data*? - ANSWER Data about the patient's physical status
and functional abilities to serve as a comparison as their health changes
What is a *nursing diagnosis*? - ANSWER Problem statements form the basis
for the plan of care and help the nurse address the patient's nursing care
needs
Why is it important to monitor the status of a previously identified problem?
- ANSWER Exam can give information that can help in exploring further into
the problem
Why should clients screen for health problems? - ANSWER Regular checkups
can help identify health problems at early ages
What are the different types of physical examinations? - ANSWER
Comprehensive Physical Examination
Focused Physical Assessment
System-Specific Assessment
,Ongoing Assessment
*Comprehensive Physical Examination* - ANSWER AKA: Physical Assessment
includes a health history interview and a complete head-to-toe examination
of all body systems
*Focused Physical Assessment* - ANSWER or examination
pertains to a particular topic, body part, or functional ability rather than
overall health status, and it adds to the database created by the
comprehensive assessment
*System-Specific Assessment* - ANSWER Is a focused assessment limited to
one body system (e.g., the lungs, the peripheral circulation)
*Ongoing Assessment* - ANSWER Is performed as needed after the initial
database is completed and, ideally, at every interaction with the patient
How should a nurse prepare themselves for a physical examination? -
ANSWER >>Requires<<
Theoretical Knowledge
Self-Knowledge
Familiarize yourself with the situation
Review the nursing plan of care
What is a *physical assessment*? - ANSWER a systemic collection of head to
toe objective information
When is a physical assessment used? - ANSWER used in the nursing process
with assessment, diagnosis, interventions and evaluating a client's health
,status
What is *objective data*? - ANSWER observable and measurable data
What is *subjective data*? - ANSWER "symptoms"
information from the *client's point of view*, including feelings, perceptions,
and concerns obtained
What are the basic techniques used when conducting a health assessment? -
ANSWER *inspection, palpation, percussion, ausculation, and olfaction*
>>in that order<<
What is the purpose of inspection? - ANSWER it is deliberate and purposeful
observations that can be done throughout the whole exam
What are some things to assess when inspecting a client? - ANSWER size,
color, shape, position, symmetry, and general physical observations of age
weight, body type, nutritional status is also noted
What is *palpation*? - ANSWER touching the client with hands and fingers or
"the use of touch to gather data" *pg. 503*
What is a nurse assessing when palpating a client? - ANSWER temperature,
turgur, texture, moisture, and shape of the skin
What should the nurse use to assess the temperature of a client's skin? -
ANSWER back of the hand
What are some areas to palpate when assessing a client? - ANSWER the skin,
blood vessels (pulse), lungs, abdomen, muscles
What should be palpated last on the body? - ANSWER areas of tenderness
, What is *percussion*? - ANSWER tapping on body areas to produce sounds
of air space vs. solidity
What are the body areas that the nurse should percuss? - ANSWER lungs and
abdomen
--assessing the location, shape, size, and density of the tissues
What is *auscultation*? - ANSWER listening with a stethoscope to asses the
heart, lungs, and abdomen
What are some areas of the body to physically assess? - ANSWER skin
head/ neck
thorax/ lungs
peripheral vascular/ cardiovascular
abdomen
musculoskeletal
neurological
breast/genitalia/rectum
What should a nurse check for when *assessing the skin*? - ANSWER color,
vascularity, temperature, texture, turgor, moisture, and lesions
What are some significant findings of the skin color? - ANSWER
Pigmentation Changes: loss of color
Cyanosis, Jaundice, Pallor, Erythema
Describe Cyanosis, Jaundice, Pallor, Erythema. - ANSWER *Cyanosis* - blue or
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