NR 302/ NR302 FINAL EXAM: (NEW 2025/ 2026 UPDATE) HEALTH ASSESSMENT I REVIEW | Qs & As, Exams of Nursing

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NR 302/ NR302 FINAL EXAM: (NEW 2025/ 2026 UPDATE)

HEALTH ASSESSMENT I REVIEW | QUESTIONS & ANSWERS| GRADE

A| 100% CORRECT (VERIFIED SOLUTIONS)- CHAMBERLAIN

A patient is in the emergency department with nausea and vomiting. Which would you include in the database? a. A complete health history and full physical examination b. A diet and GI history c. Previously identified problems d. Start collection of data in conjunction with lifesaving measure - ANS ✓b. A diet and GI history Which best describes evidence-based nursing practice? a. Combining clinical expertise with the use of nursing research to provide the best care for patients while considering the patient's values and circumstances b. Appraising and looking at the implications of one or two articles as they relate to the culture and ethnicity of the patient c. Completing a literature search to find relevant articles that use nursing research to encourage nurses to use good practices d. Finding value-based resources to justify nursing actions when working with patients of diverse cultural backgrounds - ANS ✓a. Combining clinical expertise with the use of nursing research to provide the best care for patients while considering the patient's values and circumstances A patient says she is very nervous and nauseated, and she feels as if she will vomit. This data would be what type of data? a. Objective b. Reflective c. Subjective d. Introspection - ANS ✓c. Subjective Which statement is true in regard to pain? a. Nurses' attitudes toward their patients' pain are unrelated to their own experiences with pain. b. The cultural background of a patient is important in a nurse's assessment of that patient's pain.

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c. A nurse's area of clinical practice is most likely to determine his or her assessment of a patient's pain. d. A nurse's years of clinical experience and current position are a strong indicator of his or her response to patient pain. - ANS ✓a. Nurses' attitudes toward their patients' pain are unrelated to their own experiences with pain. The first step to cultural competency by a nurse is to: a. Identify the meaning of health to the patient. b. Understand how a health care delivery system works. c. Develop a frame of reference to traditional health care practices. d. Understand your own heritage and its basis in cultural values - ANS ✓d. Understand your own heritage and its basis in cultural values Which factor is identified as a priority influence on a patient's health status? a. Poverty b. Lifestyle factors c. Legislative action d. Occupational status - ANS ✓a. Poverty Which category is appropriate in a cultural assessment? a. Family history b. Chief complaint c. Past medical history d. Health-related beliefs - ANS ✓d. Health-related beliefs The practitioner, entering the examining room to meet a patient for the first time, states: "Hello, I'm M.M., and I'm here to gather some information from you and to perform your examination. This will take about 30 minutes. D.D. is a student working with me. If it's all right with you, she will remain during the examination." Which of the following must be added to cover all aspects of the interview contract? a. A statement regarding confidentiality, patient costs, and the expectations of each person b. The purpose of the interview and the role of the interviewer c. Time and place of the interview and a confidentiality statement d. An explicit purpose of the interview and a description of the physical examination, including diagnostic studies - ANS ✓a. A statement regarding confidentiality, patient costs, and the expectations of each person

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b. A documentation of the problem as described by the patient c. The recording of the objective findings of the practitioner d. A statement that describes the overall health state of the patient - ANS ✓a. The evaluation of the past and present health state of each body system Although a full mental status examination may not be required, you must be aware of the 4 main headings of the assessment while performing the interview and physical examination. These headings are: a. Mood, affect, consciousness, and orientation. b. Memory, attention, thought content, and perceptions. c. Language, orientation, attention, and abstract reasoning. d. Appearance, behavior, cognition, and thought process. - ANS ✓d. Appearance, behavior, cognition, and thought process. After assessing the patient's pulse, the practitioner determines it to be "normal." This would be recorded as: a. 3+. b. 2+. c. 1+. d. 0 - ANS ✓b. 2+. Which BMI category in adults is indicative of obesity? a. 18.5 to 24.9 kg/m b. 25.0 to 29.9 kg/m c. 30.0 to 39.9 kg/m d. <18.5 kg/m - ANS ✓c. 30.0 to 39.9 kg/m Which older adult is at lowest risk for alteration in nutritional status? a. 80-year-old widow who lives alone b. 65-year-old widower who visits a senior center with a meal program 5 days per week c. 70-year-old person with poor dentition who lives with a son d. 73-year-old couple with low income and no transportation - ANS ✓b. 65- year-old widower who visits a senior center with a meal program 5 days per week Which is a normal expected change with aging? a. Increase in energy needs b. Increase in body water c. Decrease in height d. Increase in AP diameter of the chest - ANS ✓c. Decrease in height

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What four ways do you begin to assess a patient and in what order do you go? - ANS ✓1. Inspection

2. Palpatation
3. Percussion
4. Auscultation what part of the hand is used to feel temperature? - ANS ✓dorsal surface what part of the hand is used to feel vibrations such as tactile fremitus? - ANS ✓ulnar surface or ball of palms what part of the hand is used for fine sensations like pulses or edema? - ANS ✓Finger tips/pads Describe a tympany sound and give an example where you would hear it? - ANS ✓Loud, High pitched, medium, drum like Example- organ filled with air like stomach Hint- Tympany over tummy Describe the dullness sound and where you would hear it? - ANS ✓High pitched, soft and short Example- solid organs liver, spleen, tumors Tip- dullness end in two ss for soft and short Describe resonance and where you would hear it? - ANS ✓Loud, low pitched,long Example- Lungs Describe hyperresonance and where it would be heard? - ANS ✓Same as resonance but longer hyper-Resonance is the longest word therefore longest sound Lungs but if air is trapped

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Where is the apical pulse located? - ANS ✓Heart, 5th intercostal space left midclavicular line, Auscultate for FULL 1 minute What is the wong-baker scale and who will use it? - ANS ✓the "faces" pain scale used for children 3 and up What does ABCT stand for in terms of mental status assessment? - ANS ✓A- appearance B-Behavior C- Cognitive function T- Thought processes and perceptions What are the levels of consciousness? - ANS ✓alert= awake lethargic= people waking up obtunded= Might have to shout of provide touch to wake Stupor= might have to provide painful stimuli to awake coma= not going to wake, unconsciousness Whats the difference between a symptom and a sign? - ANS ✓a symtom is subjective and a sign is objective. Whats the difference between ADLS and IADLs? - ANS ✓ADLs are just doing self care of physical health, IADLs (instrumental) are whats needed for independent living like housekeeping, cooking, laundry, shopping What is a nursing diagnosis? - ANS ✓The patients response to the situation they are in. Example- Pt has a fractured arm. Acute pain from fracture arm. Fractured arm is the medical diagnosis. Acute pain related to fracture arm is the nursing diagnosis. nursing diagnosis sticks within our scope of treatment. What are the parts to an actual diagnosis? - ANS ✓Actual diagnosis_______ Related factors__________ and as evidence by(AEB)_________ Hint- If it doesnt start with an R like Actual diagnosis it needs an R (Related factors)

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what are the parts to an at Risk for diagnosis? - ANS ✓Risk for________as evidence by(AEB)________ Hint- if it starts with an R like risk for or readiness for it doesnt need another R as in related factors What are the part for readiness for diagnosis? - ANS ✓Readiness for_________as evidence by(AEB)___________ Hint- if it starts with an R like risk for or readiness for it doesnt need another R as in related factors What is breakthrough pain? - ANS ✓Can occur with acute or chronic it is a spike in pain level or reoccurrence of pain before next medication What is cutaneous pain? - ANS ✓pain originating from skin surface or subcutaneous structures Hint- Cutaneous think cut like paper cut What is somatic pain? - ANS ✓originating from muscle, bone, joints, tendons, or blood vessels Example-High ankle spain What is visceral pain? - ANS ✓Originating from interior organs Aching, burning Example- Obstructed bowl or appendicitis What is referred pain? - ANS ✓pain felt in a part of the body other than its actual source Example- I have a bad gallbladder but my shoulder hurts