NURS 130 Final Exam Study Guide
Questions and Answers 2024
nursing process - Correct Ans-ADPIE = Assessment, Diagnosis, Planning,
Implementation, Evaluation
subjective data - Correct Ans-symptoms - what the client says about himself or herself
objective data - Correct Ans-signs - what the health professional observes during the
exam
cultural competency - Correct Ans-caregivers understand and attend to the total context
of the individuals situation
- immigration status
- stress and social factor
- cultural similarities and differences
exam technique on older adults - Correct Ans-- do everything slower
- don't overwhelm with questions
- assist them as needed
- don't talk in elder voice
interviewing interventions for diverse cultures - Correct Ans-- use interpreters if
necessary
- don't make assumptions
- make sure you understand their beliefs and restrictions regarding healthcare
purpose of health history - Correct Ans-- collect subjective data
- provides picture of person's past and present health
- describes person as a whole and how the person interacts with their environment
- records health strengths and coping skills
- recognize and affirm what patient is doing right and point out improvements needed
collecting data on allergies - Correct Ans-note the allergen and the reaction
mental status - Correct Ans-level of consciousness - alert and oriented to person, time,
and place
A&O X3, lethargic, stuporous, comatose
older adult expected findings (related to mental status) - Correct Ans-*delirium* - acute
confusional change or loss of consciousness and perceptual disturbance, may
accompany acute illness (pneumonia, alcohol or drug intoxication), usually resolved
when underlying cause is treated
, *dementia* - gradual progressive process causing decreased cognitive function even
though person is fully conscious and awake, not reversible, 2/3 is alzheimer's, not part
of normal aging, non-caucasions, older adults, women, singles living alone, lower
education and income are more at risk
*depression* - sad gloomy and dejected, symptoms may occur with rainy weather, after
a holiday, or with illness; if situation is temporary, symptoms fade quickly
abstract reasoning - Correct Ans-math problems, picking what word doesn't fit, anything
that involves deeper thinking
assessing techniques and sequence - Correct Ans-inspect, percuss, palpate, auscultate
normal changes with the older adult (general overview) - Correct Ans-*physical
appearance* - sharper body contour, angular features, redistributed body proportions
*posture* - general flexion
*gait* - wider base to compensate for diminished balance, arms out, steps shorter or
uneven
*weight* - body weight decreases, subcutaneous fat lost from face and periphery, more
fat accumulates at hips and abdomen
*height* - vertebral discs thinning, vertebrae shortening, kyphosis posture, flexion in
knees and hips
vital signs and normal ranges - Correct Ans-*temperature* - normal is 98.6 F or 37 C
(oral, rectal, tympanic, temporal, axillary)
*pulse* - normal is 60-100 bpm, graded 0-3+
*respirations* - normal is 12-20 bpm
*blood pressure* - normal is <120/80 mmHg
*oxygen saturation* - normal is 95-100%
age related changes to vital signs - Correct Ans-*temperature* - sweat gland activity
diminished, increased risk of hypothermia, decreased risk for fever
*pulse* - radial artery may feel stiff, rigid, or tortuos, more rigid vessels (easier to
palpate)
*respirations* - decreased vital capacity and inspiratory reserve volume, shallower and
faster breathing
*blood pressure* - systolic pressure increases due to rigid aorta and arteries, increased
overall bp
pain - Correct Ans-- can be acute or chronic
- use PQRSTU method to asses pain
*P*: provocation/palliation - what triggers and relieves it
*Q*: quality/quantity - what does it feel like
*R*: region/radiation - where is it, where does it radiate
*S*: severity scale - rate on scale of 1-10
*T*: timing - when did it start, how long does it last, how often, sudden or gradual
*U*: how does the pain affect YOU, what is your understanding of it
