NUR 202 Objectives TEST 1

Question 1

Differentiate between subjective and objective data.

(Wk 1: Ch. 1, 9, 10)

Answer 1

Subjective: Information that can only be obtained from patient. (i.e “Tell me about…”)

Objective:
information we gather during our physical examination.

Question 2

Define factors that affect nursing assessment, data collection and organization.

(Wk 1: Ch. 1, 9, 10)

Answer 2

Is the info: accurate, relevant, normal/abnormal, organized, systematic, complete.

Did we: review clinical record, labs, interview, ask about health history, do a physical exam, functional assessment (physical, mental), consult, review.

Question 3

Explain how to approach the physical assessment including ways to put the client at ease and
provide for privacy and confidentiality.

(Wk 1: Ch. 1, 9, 10)

Question 4

Describe cues to be observed during the general survey.

(Wk 1: Ch. 1, 9, 10)

Answer 4

1. Physical Appearance: age, sex, level of consciousness, skin color, facial features).
2. Body Structure: (stature, nutrition, symmetry, posture, position, body build, contour).
3. Mobility: gait, range of motion.
4. Behavior: facial expression, mood and affect, speech, dress, personal hygiene.

Question 5

Identify the normal ranges for each vital sign.

(Wk 1: Ch. 1, 9, 10)

Answer 5

Temperature: 35.8-37.3C (96.4-99.1F)

Pulse: 60-100 bpm

Respirations: 12-20

Blood Pressure: <120mmHg and <80mmHg

SpO2: 97%-99%

Question 6

Describe factors that affect accurate measurement of vital signs.

(Wk 1: Ch. 1, 9, 10)

Answer 6

Temp: route (rectal +1), age, exercise, hot/cold liquids, smoker, medications, trends, time of day, environmental temp.

Pulse: site, time (60 sec vs. 30x2 vs 15x4), fever, meds, anxiety, cardiac history, athlete, activity, etc.

Respirations: (RESP. DISTRESS IS 1st LEVEL PRIORITY). Count for 1 full minute if abnormal. Narcotics, head injury, heart failure and activity intolerance, anesthesia, exercise, sleep, anxiety. position, etc.

Blood pressure: wrong placement/size cuff, legs crossed, arm tense or up, eyes not level with manometer, failure to palpate for level of inflation, deflate too fast/slow

Oxygen: anemia, lung disease, heart disease, inadequate O2 given or method of delivery, COPD, asthma.

Question 7

Demonstrate how to assess and document vital sign.

(Wk 1: Ch. 1, 9, 10)

Question 8

Relate the concept of health to the process of data collection.

(Wk 2: Ch 5 & 8)

Question 9

Define factors that affect nursing assessment, data collection and organization.

(Wk 2. Ch. 5 & 8)

Question 10

Explain how to approach the physical assessment including ways to put the client at ease,
provide for privacy and confidentiality.

(Wk 2: Ch. 5 & 8)

Question 11

Perform inspection of the skin, palpate the skin, assess and document skin lesions.

(Wk 3: Ch. 11, 13 & 33)

Question 12

Assess and palpate the hair and nails.

(Wk 3: Ch. 11, 13 & 33)

Question 13

Assess skin turgor and describe its purpose.

(Wk 3: Ch. 11, 13 & 33)

Answer 13

Turgor: the fullness or elasticity of the skin.

It is usually assessed on the sternum or under the clavicle by lifting a fold of skin with the thumb and first finger.

Skin tiger is considered normal in the fold returns to its usual shape when released.

When the patient is dehydrated, the skins elasticity is decreased, and the skin folds slowly.

Decreased skin turgor may be a normal, finding in older adults, as as a result of decreased elasticity and thinning of the dermis as a person ages.

Difficulty and lifting a skin fold may indicate (excess fluid in the tissues). Edema is characterized by swelling, with tight and shiny skin over the edematous area.

Question 14

Identify components of the Braden Scale and how it is used to assess pressure ulcer risk.

(Wk 3: Ch. 11, 13 & 33)

Answer 14

The Braden scale is a pressure, injury assessment. It measures sensory perception, moisture, activity, mobility, nutrition, and friction and shear.

Provides efficacious, predictive information. The critically ill patient demonstrates a higher propensity for oxygenation and perfusion issues.

Scores:
19 to 23: indicates no risk
15 to 18: mild risk
13 to 14: moderate risk
10 to 12: high risk
9 or lower: very high risk

**Good nursing judgment may reveal the need for a higher intensity of preventative intervention than what may be identified by the scale alone.

Question 15

Teach skin self-examination.

(Wk 3: Ch. 11, 13 & 33)