Download Exam 1: NUR101/ NUR 101(Latest 2025/ 2026 Update) Health Assessment | Guide with Q&As and more Exams Nursing in PDF only on Docsity!
Exam 1: NUR101/ NUR 101(Latest 202 5 /
2026 Update) Health Assessment | Guide with
Questions and Verified Answers| 100%
Correct| Grade A – Fortis
Q: Nursing process
Answer: five-step systematic method for giving patient care; involves assessing, (analysis) diagnosing, planning, implementing, and evaluating (1) assess pt to determine need for nursing care (2) determine nursing diagnoses for actual and potential health problems and needs (3) identify expected outcomes and place care (4) implement the care (5) evaluate the results
Q: ADPIE of nursing process
Answer: Assessing, (Analysis) Diagnosis, Planning, Implementation, Evaluation
Q: Assessment
Answer: Subjective & Objective Systematically collecting, validating and communicating pt data
Q: Diagnosis (analysis)
Answer: Nursing diagnosis Clearly identify pt strengths and actual and potential health problems and needs
Q: Planning
Answer: Goals — "SMART; specific, measurable, attainable, realistic, time based (pt-centered)" Develop a holistic plan of individualized care that specifies the desired pt goals and related outcomes and the nursing interventions most likely to assist the pt to meet those expected outcomes
Q: Implementation/intervention
Answer: Execute the plan of care
Q: Evaluation
Answer: Pt response Evaluate effectiveness of plan of care in terms of pt goal achievement
Q: Purpose of nursing observation, interview, and physical assessment
Answer: Appraisal of health status Identification of health problems Establishment of a database for nursing interventions
Q: How to obtain nursing history using effective interviewing techniques
Q: Study preparatory
Answer: Pre-interaction, collects background info in the chart
Q: Introduction
Answer: Orientation, introduce self, purpose, process, expectations, duration
Q: Working
Answer: interview, proper client centered discussion, therapeutic communication techniques
Q: Termination phase
Answer: Closing, summarize, clarify, validate, answer questions, set follow-up appointments
Q: Common problem encountered in data collection
Answer: Inappropriate organization of the database Omission of pertinent data Inclusion of irrelevant or duplicate data, erroneous or misinterpreted data Failure to establish rapport and partnership Recording an interpretation of data rather than observed behavior Failure to update database
Q: When data needs to be validated
Answer: When there is a discrepancy between what the person is saying and what the nurse is observing When data is lacking objectivity
Q: How to validate data
Answer: Identify cues —> make inferences about cues —> validate cues and inferences Performing a physical examination using proper equipment and procedure Using clarifying statements Sharing inferences with other team members Checking findings with research reports Comparing cues to knowledge base of normal function Checking consistency of cues
Q: Privacy, Confidentiality, and Professionalism
Answer:
- One of the nurse's primary ethical responsibilities is safeguarding the privacy of patients.
- Nurses must be familiar with their institution's policies on privacy and on the requirements of the Health Insurance Portability and Accountability Act (HIPAA).
- Recently the American Nurses Association and the National Council of State Boards of Nursing united to provide guidelines on social media for nurses.
Q: Health Insurance Portability and Accountability Act (HIPAA)
Answer: A comprehensive set of standards and practices designed to give patients specific rights regarding their personal health information. Pts have the right to:
- see and copy their health record
- update their health record
Consider physiologic and psychological needs Explain process to pt Explain physical assessment will not be painful to decrease fear and anxiety Explain each procedure in detail as conducted Ask pt to change into gown and empty bladder Answer pt questions directly and honestly Prepare environment: Agree on time for assessment—not to interfere with meals, daily routines, or visiting hours Make sure pt is free of pain if possible Prepare examination table Provide gown and drape Gather supplies and instruments needed Provide curtain or screen if area is open to others
Q: Equipment used during physical assessment & purposes
Answer: Thermometer, oscillometric BP device or sphygmomanometer, scale, flash light or pen light, stethoscope, metric tape measure and ruler, eye chart
Q: Vitals signs
Answer: Temperature, pulse, respirations, blood pressure, oxygen saturation, pain
Q: Temperature
Answer: Oral core body temp: 36.5C - 37.7C Lowest in the am and highest in the pm For most accurate core body temp—> rectally
Q: Routes for Temperature
Answer: Oral, axillary, temporal, tympanic, rectal **only use rectal if other methods are not practical
Q: Hypothermia
Answer: <36.5C or 96.0F Abnormally low temperature Potential causes: prolonged exposure to cold, hypoglycemia, hypothyroidism, starvation
Q: Hyperthermia
Answer:
38.0C or 100F Abnormally high temperature Potential causes: viral or bacterial infections, malignancies, trauma, and various blood, endocrine, and immune disorders
Q: Pulse
Answer: rate, rhythm, amplitude, contour, and elasticity Normal adult pulse: 60 - 100 beats/minute (children/infants tends to run higher, ranging 70 - 140 beats/minute depending on age)
Q: Pulse amplitude
<8- 12 breaths/min Causes: sedation, intracranial pressure or neurological disorders
Q: Hypoventilation
Answer: Slow shallow breaths Causes: sedation or increased intracranial pressure
Q: Apnea
Answer: Absence of respirations for > 10 seconds
Q: Tachypnea
Answer: rapid breathing
24 breaths/min Causes: exercise, fever, anxiety, anemia
Q: Hyperventilation
Answer: Rapid deep breaths Causes: metabolic acidosis, hypoxia, anxiety, or exercise
Q: Dyspnea
Answer: Difficult or labored respirations
Q: Blood pressure
Answer: Systolic (ventricles contracted)/diastolic (ventricles relaxed) Check both arms and compare; use proper cuff size Can be affected by cardiac output, elasticity of arteries, blood volume, blood velocity (HR), blood viscosity Normal adults: <120/<80 mmHg w/ 10 mmHg pressure difference in arms (Children tend to run lower depending on age; 110-60/65-40 mmHg)
Q: Hypotension
Answer: low blood pressure persistently lower than 90/60 mm Hg
Q: Orthostatic hypotension
Answer: low blood pressure that occurs upon standing up Drop of <20mmHg
Q: Hypertension
Answer: high blood pressure
Q: COLDSPA
Answer: characteristics, onset, location, duration, severity, pattern, associated factors
Q: Inspection
Answer: Performing deliberate, purposeful observations in a systematic manner Hear and smell Assessment appearance, behavior, and movement Assess each area of body for size, color, shape, position, movement, and symmetry
Q: Palpation
Answer: Sense of touch Temperature of skin, tugor, texture, moisture, vibrations, shape, and structures (bones) Dorsum (back) of hand and fingers —> temperature Palmar (front) surfaces of fingers and fingerpads —> firmness, contour, shape, tenderness, and consistency
Q: Percussion
Answer: Striking one object against another to produce sound Fingertips are used to tap body over body tissues to produce vibrations and sound waves
Q: Auscultation
Answer: Listening with a stethoscope to sounds produced by the body (Done last when assessing the stomach)
Q: Review of Systems
Answer: physical examination of all body systems in a systematic manner as part of the nursing assessment
Q: Integumentary Assessment
Answer: Skin, nails, hair scalp, and sweat & sebaceous glands Look for color variations, skin vascularity & lesions, temp, texture, moisture, and tugor Melanoma ABCDES: asymmetry, border, color, diameter, evolving
Q: Skin tugor assessment
Answer: Assessment of hydration level; skin fold is pulled up and time to flatten is noted. @ back of hand and under clavicle
Q: Edema Assessment
Answer: observe/inspect and palpate for fluid build up in tissues Pitting V Non-pitting
Tugor: fullness or elasticity of skin Edema: excess fluid in tissue
Q: Assessing Head and Neck
Answer: Inspect and palpate head and face Inspect eyes Assess visual acuity, extra ocular movements and peripheral vision Inspect/Palpate external ear for shape, size, lesions Inspect nose Palpate Sinuses for pain or edema Inspect mouth and pharynx Inspect and palpate neck for venous distention Inspect and palpate trachea Inspect and palate thyroid gland Palpate lymph nodes
Q: Jugular vein distension (JVD)
Answer: swelling of the jugular vein (usually seen in heart failure patients) Have pt lay at a 45 degree angle and turn head to left to assess right side of neck for bulging
Q: Areas of palpation for pulse
Answer: Carotid artery Brachial artery Radial artery Femoral artery Popliteal artery Dorsalis pedis artery Tibial artery Abdominal aorta
Q: PERRLA
Answer: pupils equal, round, reactive to light and accommodation
Q: Assess thorax and lungs
Answer: Lungs, rib cage, cartridge, and intercostal muscles Inspect thorax for chest color, shape, or contour, breathing patterns and muscle development Palpate thorax for chest expansion, sensitivity, and vibrations Auscultate lungs for breathing sounds
Q: Bronchial Breath Sounds
Answer: Heard over larynx and trachea High pitched Harsh "blowing" sounds Expiration longer than inspiration "Hollow sounds"
Q: Bronchovesicular breath sounds
Answer: Heard over main bronchus and moderate blowing sounds Inspiration equal to expiration Medium, high-pitched intensity
Palpate peripheral pulses and capillary refill (carotid, brachial, radial, femoral, popliteal, dorsalis pedis, posterior tibial pulse)
Q: S1 v S
Answer: S1 first sound ("lub") heard loudest at mitral and tricuspid (valves closing) S2 second sound ("dub") heart loudest at aortic and pulmonic (valves closing)
Q: Assessing Neurovascular Status
Answer: Musculoskeletal trauma, crash injuries, orthopedic surgery and external pressure from cast or tight fitting bandage can cause damage to vessels and nerves Assess pain Pallor (perfusion)—comparing affected and unaffected limb Peripheral pulses Paresthesia (sensation)—numbness, tingling, pin and needles Paralysis (movement) Pressure Blood loss/ooze
Q: Assessing breasts and axillae
Answer: Inspect breasts for size, shape, symmetry, color, texture, skin lesions Inspect areola and nipples for size, shape, and discharge, crusting or inversion Palpate breasts in 4 quadrants (upper outer, lower outer, upper inner and lower inner) Palpate axillary areas for lymph nodes, usually non-palpable and non-tender
Q: Assessing abdomen
Answer:
Stomach, small intestine, large intestine, liver, gallbladder, pancreas, spleen, kidneys, and urinary bladder (+female reproductive organs) Inspect skin color, surface characteristics Auscultate bowel sounds and vascular sounds—gurgles and clicks (occurs usually every 5 - 30 seconds) Auscultate over abdominal aorta, femoral arteries, and iliac arteries for bruits Palpate abdomen by applying pressure and depressing skin 1 to 2 cm
Q: Quadrants of the Abdomen
Answer: RUQ- pylorus, duodenum, liver, rt kidney and adrenal gland, hepatic flexors of colon, head of pancreas LUQ- stomach, spleen, lt kidney and adrenal gland, splenic flexors of colon, body of pancreas RLQ- cecum, appendix, rt ovary and fallopian tube, rt ureter and lower kidney pole, rt spermatic cord (male) LLQ- sigmoid colon, lt ovary and fallopian tube, lt ureter and lower kidney pole, lt spermatic cord (male) Midline- urinary bladder, urethra (F)
Q: Assessing female genitalia
Answer: Monspubis, labia Majora and minora, clitoris, vestibular glands, vaginal vestibule, vaginal orifice, and urethal opening Inspect and palpate external genitalia for color, size, lesions, discharge Inspect internal genitalia
Q: Assessing male genitalia
Answer: Penis, testicles, epididymis, scrotum, prostate gland, and seminal vesicles Inspect and palpate external genitalia for size, placement, contour, appearance of skin, redness, edema, and discharge
