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NUR 431 Exam Questions with Complete Solutions
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NUR 431 Exam Questions with Complete Solutions
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NUR 431 Exam Questions with CompleteSolutions
subjective data - Answer--what PATIENT says about himself/herself during history
-Anything the patient says about themselves
Subjective Data Collection - Answer--provides full history of past and present health
-Patients health state
objective data - Answer--what YOU observe by inspecting, percussing, palpating, and
auscultating during physical examination
-Anything you can measure (numbers, vital signs)
The nursing process - Answer-Assessment- collect the date
Diagnosis
Outcome- after assessing and diagnosis. Ask if they are realistic
Plan- make a plan long and short term goals
Implementation
Evaluation
First-level priority (high priority) - Answer--Are those that are emergent, life-threatening,
and immediate.
-Problems: airway, breathing, circulation.
-Can't breathe/do something or they die
Second-level priority (next to urgency) - Answer--those requiring your prompt
intervention to forestall further deterioration
-Mental status change abnormal lab values
-Problems: (mental status ex. stroke) change, acute pain, acute urinary elimination
problems prostate, untreated medical problems, abnormal lab values, risks of infection,
or risk of safety/security.
Third- level priority - Answer--problems are those that are important to the patient's
health but can be attended to after more urgent health problems are addressed.
Interventions to treat these problems are long-term and the response to treatment is
expected to take more time. These problems may require a collaborative effort between
the patient and the healthcare professionals
-Problems: lack of knowledge mobility problems and family coping diabetes
hypertension
Collecting 4 types of patient data - Answer-Complete (total health) database- Complete
health history and full physical
Focused or problem-centered database- Concerns one problem/part of the body
, Follow-up database- status of the problem. The problem should be evaluated at regular
and appropriate intervals
Is the prob getting worse or better?
Emergency database-Urgent rapid collection of crucial information
Diagnostic reasoning - Answer-the process of analyzing health data and drawing a
conclusion to identify a diagnosis.
environment - Answer-Privacy (private room, closed curtain)
Know when to talk to adolescents vs to their parents
Do assessments with nudity last
Only give the patient a gown right before the physical examination
Sit at equal length with no distraction
Room at a comfortable temperature
Sufficient lighting
Quiet
4-5 feet between client
Blockers for Communication - Answer--not being attentive
-no fiddling
-look professional
-be impartial
-a nod to express interest/ understanding
-limit reaction to patients answers
-sit facing patient at eye level
-patient should be able to trust the provider
-be judgement/bias-free
Functional Assessment - Answer-measures a person's self-care ability in the areas of
general physical health
Assessment Techniques: Inspection - Answer--Concentrated watching, close scrutiny of
each person and each body system.
-Always comes first, right when you meet the person.
-Requires good lighting, adequate exposure, occasional use of certain instruments to
enlarge your view (otoscope, ophthalmoscope, penlight, nasal or vaginal specula)
-Compare left and right sides of body
Assessment Techniques: Palpation - Answer--Sense of touch to feel texture,
temperature, moisture, organ location and size, and swelling
-Fingertips: best for texture, swelling, pulsation, presence of lumps
-Grasping of fingers/thumbs: for position, shape, consistency
-Backs/Dorsa of hands: best for temperature
-The base of fingers: best for vibration
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