Exam date and time: Monday 6/13 exam starts at 09:00, I will post the password at 08:50 in an
announcement
Total questions: 45
Total points: 50
Question formats:
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Time allowed: 60 min
Topics covered:
Multiple choice (majority of questions)
Select all that apply (multiple choice with
more than one answer)
Fill in the blank
Matching
*** There are no questions on Cranial Nerves on
this exam. It will be included in the Neuro
Assessment content.
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Health History
Head-to-toe-assessment
Math
Nursing process - ADPIE
Interviewing
Communications
Nutrition
Documentation
Skin, hair, nails
Eyes/Ears
Head, Face, Neck, Lymphatic
Nose, Mouth, Throat
Nursing Process
1. ADPIE - A decision-making model
a. Assess, Diagnose, Plan, Implementation, Evaluation
2. Asses: gather information about the patient’s condition
a. Nursing assessment
i. Collection and verification of data
ii. Analysis of data
b. Database
i. Consists of client’s perceived needs, health problems and responses to problems
c. Data collection
i. Subjective data
1. what the patient tells you
ii. Objective data
1. what you can see or measure
iii. Sources of data
1. Client
2. Family and significant others
3. Health care team
4. Medical records
d. Methods of data collection
i. Interview
ii. Nursing health history
1. Biographical information
2. Reason for seeking care
3. Client expectations
4. Present illness
5. Health history
6. Family history
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7. Environmental history
8. Psychosocial history
9. Spiritual health
10. Review of systems
11. Depends on the situation; may not collect all information for every visit
iii. Documentation of findings
e. Physical assessment
i. 40% of physical exams can be completed by observing the patient from the
bedside
ii. Observation of client behavior
iii. Diagnostic and laboratory data
iv. Interpreting assessment data and making nursing judgements
f. Documentation
i. The last component of assessment
ii. Legal and professional responsibility
iii. Requires accurate and approved terminology and abbreviations
iv. If you didn’t document it, it didn’t happen
g. Concept mapping
i. A visual representation that allows nurses to graphically illustrate the connections
between a client’s health problems
ii. Allows nurses to obtain a holistic perspective of health care needs
3. Diagnose: identify the patient’s problems
1. Medical diagnosis
The identification of a disease condition based on specific
evaluation of signs and symptoms
2. Nursing diagnosis
A clinical judgement about the client in response to an
actual or potential health problem
3. Collaborative problem
An actual or potential complication that nurses monitor to
detect a change in client status
a. Nurses do not provide medical diagnoses
i. A problem related to an etiology (a cause) as evidenced by a sign or symptoms
1. Don’t use a medical diagnosis as a cause/etiology
ii. “fever r/t infectious process as evidenced by increased temperature”
iii. “impaired comfort r/t itching as evidenced by patient scratching”
iv. “risk for electrolyte imbalance r/t renal dysfunction”
1. When starting with “risk for” no need to add as evidenced by; establishing
a potential problem, may not have evidence yet
v. “disturbed body image r/t lesions on the body as evidenced by patient stating ‘I
can’t look at myself in the mirror’”
vi. “deficient fluid volume r/t active fluid loss as evidenced by (aeb) excessive
diuresis”
vii. You will not have to write these out if your institution uses an EHR
b. Collaborative problem – an elaboration on nursing diagnosis
c. History of Diagnosis
i. First introduced in 1950
1. In 1953 Fry proposed the formulation of nursing diagnosis.
2. Emphasis on nurse’s independent practice, e.g. symptom relief and client
education, versus the dependent practice driven by physicians’ orders.
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ii. In 1982, North American Nursing Diagnosis Association (NANDA) was founded.
d. Diagnosis Formulation
i. Actual nursing diagnosis
1. Describe human responses to levels of wellness that have a readiness for
enhancement
ii. Risk nursing diagnosis
1. Describes human responses to health conditions/ life processes that may
develop
e. Diagnosis components
i. Diagnostic label (NANDA-I)
ii. Related factors (r/t = related to)
iii. Definition (NANDA-I)
iv. Risk factors
4. Plan: set goals of care and desired outcomes and identify appropriate nursing actions
a. Planning
b. Establishing priorities
i. Classification of priorities
1. High, intermediate, low
ii. ABC’s
1. Look at ABC’s, or whatever will kill your patient first
iii. Maslow’s Hierarchy of Needs
1. Look at physiological needs first
c. Establishing goals and outcomes
i. Goal: a broad statement that describes the desired change in a client’s condition
or behavior
1. An aim, intent, or end
ii. Expected outcome
1. Should be measurable, achievable, and have a time frame
2. Measurable criteria to evaluate goal achievement
3. Nursing Outcomes Classification
d. Goals of care
i. Client-centered goal
1. A specific and measurable behavior or response
ii. Short-term goal
1. An objective behavior or response expected within hours to a week
iii. Long-term goal
1. An objective behavior or response expected within days, weeks, or
months
e. Expected outcomes
i. A specific, measurable change in a client’s status
ii. Provide focus or direction
iii. Determine when a specific, client-centered goal has been met
f. Guidelines for writing goals
i. Client-centered
ii. Singular goal or outcome
iii. Observable
iv. Measurable
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v. Time-limited
vi. Mutual factors
vii. Realistic
g. Types of intervention
i. Nurse initiated - Independent
1. Physician initiated - Dependent
2. Collaborative - Interdependent
h. Nursing care
i. Nursing care plan
ii. Institutional care plan
1. there are certain nursing specific goals that are established by the
institution
i. Concept map
5. Implement: perform the nursing actions identified in planning
a. Review the set of all possible nursing interventions
b. Review all possible consequences associated with each possible nursing action
c. Determine the probability of all possible consequences
d. Make a judgement of the value of that consequence to the client
e. Standard nursing interventions
i. Clinical practice guidelines and protocols
ii. Standing orders
iii. Nursing Interventions Classification (NIC)
1. Standardized nursing interventions using a common language
f. Implementation process – Action!
i. Reassessing the client
ii. Reviewing and revising the care plan
1. Making judgement calls –may lead nurses to change the plan
iii. Organizing resources
1. Equipment
2. Personnel
3. Environment
4. Client
iv. Anticipating and preventing complications
v. Ex making a phone call to another department
6. Evaluate: determine if goals and expected outcomes are achieved
a. Evaluation is an ongoing process
i. If outcomes are met, client goals are met
ii. Positive evaluation occurs when nurses meet desired outcomes
iii. Positive evaluations lead nurses to conclude that interventions were successful
b. Evaluation process – five elements
i. Identify evaluative criteria and standards
ii. Collect data
iii. Interpret and summarize findings
iv. Document findings and clinical judgements
v. Terminate, continue, or revise the care plan
7. Nursing Process – ADPIE model
Assessment
Diagnosis
Planning
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Implementation
Evaluating
Subjective
Objective
Actual
Vs
At risk for
(NANDA)
Prioritized goals
and Expected
outcomes (NOC)
Standardized
nursing
interventions
(NIC)
Rigorous followup
Nursing
judgement
Critical thinking
Health History
1. Objective data
a. Opportunity to collect the history of the patient
i. Can be complete or incomplete - depending on the type of visit
b. Incorporates the general appearance of patient (general survey)
c. Elements: interview of patient to gather information, analyze data, and record
i. Tailored to address the patient’s current emergency first
2. Components
a. Reason for seeking care
i. May be obvious ex. broken limb, bleeding, extreme pain
ii. Present health state or present illness
iii. Family history
1. May depend on why the patient is seeking care
2. Collect the pertinent family history
iv. Review of systems
v. Functional patterns of living
1. Patient's level of functionality at home
3. Actions
4. Biographical data:
a. Name, age, gender, marital status, occupation, employer information, race/ethnicity,
address, phone
5. Past history:
a. General health, childhood illness, accidents/injuries, surgeries, hospitalizations,
obstetric history, immunizations, last examination, family history
6. Review of systems
a. Head to Toe assessment
7. Functional assessment:
a. Self-esteem, self-concept:
i. Education/training, financial status, exercise, sleep/rest, self-care behaviors,
nutritional, elimination, mental health, interpersonal relationships, significant
changes in the last year
8. Personal habits
a. Smoking, drugs, alcohol
i. Patients rarely report an honest measurement of the amount of alcohol
9. Environmental hazards
10. Intimate partner violence
11. Occupational health
a. Works around heavy machinery
b. Exposure to chemicals like asbestos
i. Ex tire factory employees are more likely to develop a latex allergy
c. Exposure to microorganisms or biohazards
12. Perception of their own health
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Interview
1. Subjective data
2. Techniques:
a. Interview is a way to establish trust to foster acceptance and allow for data sharing
b. Give the patient a chance to respond
c. Bring their anxiety level down
d. Be genuine: “your health/comfort is my priority”
e. Introduce yourself
f. Build a rapport to continue therapeutic relationship
i. Find something in common, or some connection beyond just the professional
patient-nurse relationship
g. Acts of service – tell the patient
i. Ex “I'm going the close the curtain to ensure your privacy”
h. Discuss health promotion and disease prevention
3. Verbal communication
a. The words you speak – vocalization
b. Tone used in conversation
4. Non verbal communication
a. Body language helps to provide cues which may be correlated with truer feelings
b. Recognize the importance of unconscious messages
i. Ex don’t turn away when the patient is talking to you
ii. Maintain eye contact when appropriate
5. What is needed to maximize communication skills
a. Internal factors
i. Genuine approach
ii. Empathy
iii. Ability to listen
iv. Self awareness
1. Know if/when you have different opinions and beliefs
b. External factors
i. Ensure privacy
ii. Avoid interruptions
iii. Minimal note taking – offer focused attention
iv. Equal status seating
1. Compensate for power imbalance with physical positions changes
2. Try to be at the same height as the patient to minimize the power
imbalance/differential
6. Types of verbal responses:
a. Facilitation – encourage the patient to say more
b. Silence – directed attentiveness
c. Reflection – assists
d. Empathy – names a feeling and allows expression
e. Clarification – asking for confirmation
i. Mirroring
f. Confrontation – clarifies inconsistent information
g. Interpretation – makes associations to identify cause/conclusion
h. Explanation – sharing factual and objective information
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i. Summary – conclusion of verified information
7. Traps:
a. False assurance
i. Be careful when assuring the patient “it will be alright, everything will be fine/get
better” if that is not absolutely guaranteed
b. Giving unwanted advice
c. Using authority
d. Using avoidance language
e. Professional jargon
f. Leading and biased questions
g. Talking too much
h. Interrupting
i. Using “why” questions
8. Nonverbal - 80% of total communication
a. Stance, eye contact, facial expressions, voice
b. Congruency:
i. When verbal and nonverbal messages align => the messages are reinforced
ii. When congruence is absent, nonverbal messages are viewed as more true
9. Special considerations
a. Older adult
i. Address respectfully, keep good verbal pacing (slower), physical limitations,
increase response time, may need nurse to provide more information, use
therapeutic touch
b. Special needs: acutely ill, drug/ETHOH)
i. Use appropriate resources, may use ulterior motives
c. Culture – genetics:
i. Gender: cultural norms for interview and examination
ii. Sexual orientation: maintain neutrality, mindful communication patterns,
awareness ow your own personal bias
d. Interpreter
i. Use services when language/communication barriers exist
Communications
1. Occurs between the nurse and patient; and between the nurse and coworkers
2. Elements of professional communication – AIDET
a. A – Acknowledge
b. I – Introduce
c. D – Duration: give time frame
d. E – Explain
e. T – Thank
3. Standardized communication – SBAR
a. Especially useful when contacting a doctor
b. S – Situation
i. Provide a brief description of pertinent patient variables, demographics, clinical
diagnosis, and location
c. B – Background
i. Provide pertinent history as it directly relates to patient’s current health status
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d. A – Assessment
i. State pertinent assessment findings obtained with interpretation of data
e. R – Recommendation or Request
i. State what you need or want for the patient in terms of medical treatment and/or
assistance
1. May not have a specific request in mind – ask for doctor’s advice or
feedback
f. Ex: Hello Dr., I have a 50 year old female patient who is complaining of 8/10 pain. In the
past four hours, her temperature has increased from 99F to 101.3F. She had a total
right hip replacement two days ago, but has no wound drainage, and is allergic to
shellfish. Can you prescribe medication to help her pain and reduce the fever? Thank
you, CC
Nutrition
1. Considerations:
a. Ageing: under-nutrition or over-nutrition
b. Cultural/religious: eating customs and practices
2. Screening:
a. Quick method to obtain data
b. Includes:
i. Weight
ii. Weight history
iii. Conditions associated with increased nutritional risk
iv. Diet information
v. Route laboratory data
c. Screening tools
d. Best indicator or nutritional status is weight
3. Assessment
a. Eating patterns
b. Types and amount
c. Diets
i. Some patients eat kosher, vegetarian, pescetarian, vegan, etc.
d. Preferences/dislikes
e. Usual weight? - ask patient, look and health history
i. Flag if 20% below or above usual weight
4. Subjective data:
a. Changes in appetite
i. COVID: some patients cannot smell or taste -> reduced appetite
b. Smell, chewing, swallowing
c. Chronic illnesses
d. Nausea, vomiting, diarrhea, constipation
e. Medications/ nutritional supplements
f. ETOH/Drug use
i. Give ETOH patients vitamin B + folic acid + magnesium
ii. ETOH patients may have low albumin level
g. Exercise
h. Family history
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5. Objective data:
a. Obese, cachectic, edematous
b. Laboratory findings – needed for diagnosis
i. Electrolyte levels
ii. Iron
iii. Albumin (½ life of 21 days – for longer term evaluation of malnourishment)
c. Deficiencies – assess skin, hair, nails, lips, eyes, musculoskeletal
i. Malnourished: thinning hair, brittle nails, jaundiced, tinted sclera, pale conjunctiva
Head-to-Assessment / Complete Health History
1.
2.
3.
4.
H2T Handout
Grouped into systems
Complete vs focal assessment
Other assessments to consider
a. Mental status
b. Substance abuse
c. Domestic and family violence
5. Assessment techniques:
a. Inspection – careful scrutiny, whole versus individual body system
b. Palpation – touch to determine texture, temperature, organ location/size, swelling,
vibration, pulsation, rigidity, spasticity, lumps/masses or presence of pain/tenderness
c. Percussion – tapping the person’s skin with short, sharp strokes to test underlying
structures
d. Auscultation – listening to sounds within the body using the stethoscope
i. Diaphragm – high pitch sounds
ii. Bell – low pitch sounds
Skin, Hair and Nails
1. Skin is waterproof, protective, and adaptive
a. Protection from environment
b. Prevents penetration
c. Temperature regulation
d. Wound repair
e. Absorption and excretion
f. Production of vitamin D
2. Layers
a. May be altered by thickness or presence of edema
b. Epidermis
c. Dermis
d. Subcutaneous tissue
3. Assessment
a. Skin turgor - assessment of dehydration
i. Pinching skin on forearm is not a reliable method of testing for patients over 60
1. Can check oral mucous membranes or I/O instead
b. Breakdown of skin
c. Elasticity
d. Hair growth
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4. Equipment needed:
a. Good lighting/penlight
b. Gloves
c. Ruler
d. Magnifying glass
5. Color
a. General pigmentation, freckles, moles, birthmarks
6. Temperature
a. Use the back of the hand to palpate
i. The back of the hand is more sensitive to temperature than the palm
b. Warm and equal bilaterally – normal circulation
c. Signs of infection – warmer to touch and red in nature
7. Moisture
a. Diaphoresis
b. Dehydration
8. Texture
a. Smooth, soft/firm
9. Thickness
a. Thickened areas – callus
10. Edema
a. Fluid accumulation in the interstitial space
b. Pitting factor – to check for edema
i. Use the thumb to press over a bony prominence to see if the finger indentation
will remain
c. Doesn’t always mean fluid overload
i. Could be low osmotic pressure due to albumin deficiency
11. Turgor
12. Vascularity or bruising
13. Other
a. Tattoos, pierces, branding, inserts
14. What to document
a. Lesions
i. Color
ii. Elevation
iii. Pattern/shape
iv. Size
v. Location
vi. Distribution
vii. Exudate – presence/absence of, type of
b. Use the above descriptions to help you/other providers identify the lesion
15. Color changes
a. Be aware of normal variations for the following variables:
i. Pallor – being pale
ii. Cyanosis – blue
iii. Erythema – red
iv. Jaundice – yellow
v. Brown-tan
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b. Check inside the mouth for darker-skinned patients
16. Skin shapes and configurations
a. Annular or circular
i. Begins in center and spreads to periphery
ii. Primary lesions
b. Confluent
i. Lesions run together
ii. Joining of lesions
c. Discrete
i. Distinct and separate
ii. Doesn’t have to be in a circular shape
iii. Can be discrete or annular
d. Linear
i. Scratch, streak, line or stripe
ii. Lesion is shaped in a line
17. Primary skin lesions
a. Primary skin lesion – caused by the skin condition itself
b. Macule and patch
i. Just a color change
ii. Macule: smaller than 1 cm
iii. Patch: larger than 1 cm
c. Papule and plaque
i. Papule – smaller than 1 cm
ii. Plaque – larger than 1 cm
d. Nodule and tumor
i. Tumor does not imply that it is malignant or cancerous
e. Cyst
i. Filled with fluid
ii. Not solid in the middle
f. Pustule
i. A cyst filled with pus
ii. Has infectious material inside
18. Secondary skin lesions
a. Crust
i. Ex. Scab
ii. Broken skin released exudate that hardened and formed a crust
b. Scale
i. The top layer of skin is hard and flaky
ii. Psoriasis is a common cause of scales
c. Fissure
i. Common version: anal fissures
d. Ulcer
i. Most in hospital ulcers will be pressure ulcers
ii. Is classified as a pressure ulcer if it is in an area of pressure
e. Scar
i. Tissue that forms in any area where there has been previous injury
19. Pressure injuries (PI), Pressure ulcers, Decubitus ulcer
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a. Pressure prevents blood flow to an area
b. Stages:
i. Stage I: non-blanchable erythema
1. Remains red when under pressure
2. Press on red area with fingers to see if it is non-blanchable
ii. Stage II: partial-thickness skin loss
1. The top layer of the skin is broken, but no depth of wound
iii. Stage III: full-thickness skin loss
1. Some depth of wound, starting to form a crater
iv. Stage IV: full thickness skin and tissue loss
1. Some bone and ligaments (other structures) are visible/exposed in the
wound
v. Unstageable: wound is partially covered
1. Cannot tell by looking how deep the wound goes
20. Purpuric lesions
a. All result from bleeding under the skin
i. Petechiae
1. Small pinpoint bleeding spots
2. Tiny punctuate hemorrhages
ii. Ecchymosis
1. bruises
iii. Purpura
1. Larger confluent spot/blotches of bleeding
21. Lesions caused by trauma or abuse
a. Pattern injury
i. Lesions are unlikely to be caused by anything else
b. Hematoma
i. An injury causes blood to collect and pool under the skin
c. Contusion (bruise)
i. A type of hematoma
22. In children
a. Diaper dermatitis
b. Candidiasis
i. Can be distinguished: when you scrape it off, it creates small bleeding points
c. Eczema
d. Chicken pox
23. Nails
a. Assessment – check for
i. Brittleness
ii. Shaping/clubbing
iii. Coloring
1. Clubbing is typically related to cardiopulmonary disease
a. Ex. COPD
24. Hair
a. Assessment – check for
i. Color – consistent or patchy
ii. Texture – brittle, course, smooth
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iii. Appearance
Head, Face, Neck, and Lymphatics
1. Head
a. Check/palpate the patient’s head with gloves
b. Structure/function
i. Rigid – protection of the brain
ii. Temporal artery: anterior of ear
c. Shape
i. Normocephalic – round and symmetrical
ii. Check via palpation of scalp
iii. Molding in infants/children
iv. Fontanels
2. Neck
a. Structure/function
i. Conduit of many structures
1. Blood vessels, muscles, lymphatic, viscera of respiratory and digestive
systems
ii. Carotid
1. Internal: major vessels supply the brain with blood
2. External: supplies the face, salivary glands, temporal area
iii. Thyroid – 2 lobes
1. Stimulates the rate of cellular metabolism
2. Usually palpate if you are the primary care physician
a. Not for every assessment, unless it is a known problem
b. Lymphatics
i. Be cognizant of the damage that can be caused by palpating too firmly/too often
1. Check if the benefits outweigh the risks
ii. Feeling the lymph modes is mostly for the diagnosing care provider
c. Inspection
i. Head position
ii. Symmetry
iii. Held erect/still (age appropriate)
1. Some patients with Parkinson’s cannot hold their head still
2. Children may not hole their head still
iv. Range of motion
v. Palpation of lymph nodes
vi. Trachea – should be at the midline
1. Midline means the pressure inside the chest is normal
2. If abnormal, not midline- can indicate pressure pneumothorax
vii. Thyroid – difficult to palpate, unless enlarged
1. Typically palpate from the back standing behind the patient
3. Face
a. Always look for symmetry
b. Facial expressions
i. Drooping, rigid, swelling, involuntary movements
1. Tics – could be Parkinson’s
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ii. Having the patient smile is a good way to check for face drooping
4. Head, Face, and Lymphatics
a. Abnormal findings:
i. Headaches
ii. Hydrocephalus
iii. Down syndrome
iv. Goiter: enlarged thyroid
1. Do not palpate
v. Bell's palsy
vi. Stroke
1. Can look similar to Bell’s palsy on a patient’s face
2. Typically presents as one side of the face is paralyzed
5. Eyes
a. Structure
i. Eyelids – covering of eye
ii. Conjunctiva – transparent covering of the eye
iii. Cornea – covering that protects the iris and pupil
iv. Lacrimal apparatus – provides irrigation
v. Muscles: 6 different muscles to move the eyes
b. Subjective
i. Pain
ii. Strabismus – eyes are crossed
iii. Redness/swelling
iv. Watering/discharge
v. Glasses/contacts
c. Objective
i. Vision screening (Snellen)
ii. 6 fields of vision – look at movement of eyes/pupils
iii. Color vision
iv. Strabismus could also be objective
d. Pupils
i. Anisocoria – unequal pupil size
1. Genetic, people can be born with it
2. Only indicates a problem if it is a sudden change
ii. Miosis – constricted and fixed
iii. Mydriasis – dilated and fixed
1. Both miosis and mydriasis can be induced by drugs, brain injury or brain
death
e. Abnormal:
i. Color blindness
ii. Cataracts
iii. Glaucoma
iv. Macular degeneration
1. Know it is M.D. if the patient's vision starts to deteriorate
6. Ears
a. Structures
i. Pinna – outer ear
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ii. Tympanic membrane
1. Pearly gray color
iii. Inner ear – labyrinth
1. Feeds information to the brain regarding body position
2. Normal function essential for patients keeping their body upright
3. Abnormal: vertigo, staggered gait
b. Subjective
i. Earache
ii. Infections
iii. Discharge
iv. Tinnitus – ringing of the ears
v. Vertigo - Sensation of irregular motion
1. Caused by issues with the inner ear
2. Patients tend to feel like they are spinning
a. Dizziness feels like the world is spinning around the patient
3. Doesn’t fade away like dizziness
c. Objective:
i. Visual
1. Look at tympanic membrane and cerumen
d. Abnormalities
i. Otitis media (OM)
1. Obstruction of Eustachian tube
2. Most common illness of the ear
3. Common in patients who have the common sold
4. A common infection in children
ii. External infections - Ex swimmer’s ear
7. Nose, Mouth and Throat
a. Structure:
i. First segment of the respiratory system
ii. The first defense against pathogens in the respiratory pathway
b. Subjective
i. Discharge
ii. Upper respiratory infections
iii. Trauma
1. Ex broken nose
iv. Sinus pain
v. Epistaxis – nose bleeds
vi. Allergies
vii. Tooth aches
1. Can be caused by nose trauma/obstructions
c. Objective
i. Discharge
ii. Symmetry
d. Abnormalities
i. Rhinitis – runny nose
ii. Foreign body
iii. Perforated septum
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iv. Nasal polyps
8. Throat
a. Assessment
i. Check tonsils
ii. Classify tonsils based on level of swelling
1. Swelling can lead to obstruction of the airway
iii. If the patient sounds like their nose is blocked or their voice changes, check their
tonsils
9. Mouth
a. Structures/function
i. First segment of the digestive system
ii. Lips, cheeks, palates, oral cavity, tongue, teeth, salivary glands
b. Lip abnormalities:
i. Carcinoma
ii. Herpes simplex
iii. Cleft lip
c. Teeth/gum abnormalities
i. Baby bottle tooth decay
1. Occurs when babies fall asleep with the bottle in their mouth
ii. Gingivitis
iii. Dental caries
iv. Candidiasis – an opportunistic yeast infection
1. Increased risk if the patient is immunocompromised
2. Increased risk if their normal mouth flora is disrupted
a. Ex disrupted with antibiotics
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