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NUR 120 - Exam 4 Questions with Complete Answers
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NUR 120 - Exam 4 Questions with Complete Answers
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NUR 120 - Exam 4 Questions withComplete Answers
full physical exam - Answer-Typically done by an MD, NP, or PA. a full evaluation on
every system in the body
head to toe assessment - Answer-done by the nurse at the bedside, an assessment that
looks at the basic information of a patients body
focused assessment - Answer-assessment conducted to assess a specific problem;
focuses on pertinent history and body regions
concepts of a head to toe assessment that are addressed simultaneously - Answer-1.
general survey
2. safety
3. psychosocial
4. tissue integrity
what are the components of a general survey? - Answer-IV access
tubing
use of O2
activity
appearance
orientation
level of consciousness
what are the components of safety? - Answer-restraints
mobility
sensory deficits
wristbands
environment
tubing
anything out of the ordinary?
what are the components of psychosocial? - Answer-mood and affect
stress/coping
pain
support system
religious beliefs
what are the components of tissue integrity? - Answer-intactness of skin
sores
braden scale
incisions
, bruises
dressings
what do we focus on when assessing the head? - Answer-cognition - level of
consciousness
A+O
speech
what do we focus on when assessing intracranial regulation? - Answer-neuro status
changes in sensation
PERRLA
what do we focus on when assessing tissue perfusion? - Answer-assess carotid pulse
vital signs
color of mucous membranes
color
apical pulse
is S1-S2 present?
edema (pitting?)
pedal pulse
push/pull on feet: is it equal on both sides?
what do we focus on when assessing fluids and electrolyte balance? - Answer-are
mouth/eyes moist?
what do we focus on when assessing nutrition? - Answer-state of dentition - dentures?
pain/discomfort when eating?
N/V?
what percentage of meal was eaten?
what is their appetite like?
BMI?
nutritional deficits?
Lab data:
albumin
NA
K
Mg
H+H
what do we focus on when assessing sensory perception and sensation? - Answer-any
hearing or visual deficits?
what do we focus on when assessing upper extremities? - Answer-capillary refill (<3
sec)
BP
Pulses (whether you can feel them or not)
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