combined nur 215 & 216 with 100% accurate solutions + rationales 2026-2027

General survey components

Appearance (alert, distress, hygiene), behavior (mood/affect), mobility (gait/posture), body structure (nutrition/symmetry)

Normal general survey findings

Alert, oriented, appropriate mood, steady gait

Abnormal general survey findings

Confusion, distress, poor hygiene, unsteady gait

Types of questions in assessment

Open-ended, closed-ended, probing (avoid leading)

Open-ended questions

Allow patient to explain (best for history)

Closed-ended questions

Yes/no or specific details

Normal temperature range

36-38°C

Fever definition

>38°C

Hypothermia definition

<35°C

Normal heart rate

60-100 bpm

Tachycardia

>100 bpm

Bradycardia

<60 bpm

Normal respiratory rate

12-20 breaths/min

Tachypnea

>20 breaths/min

Normal blood pressure

<120/80

Hypotension

<90 systolic

Normal SpO2

≥95%

Critical SpO2

<90%

BMI underweight

<18.5

BMI normal

18.5-24.9

BMI overweight

25-29.9

BMI obese

≥30

Braden Scale categories

Sensory perception, moisture, activity, mobility, nutrition, friction/shear

Pressure ulcer Stage 1

Non-blanchable redness (skin intact)

Pressure ulcer Stage 2

Partial thickness, blister

Pressure ulcer Stage 3

Full thickness, fat visible

Pressure ulcer Stage 4

Bone/muscle exposed

Unstageable pressure ulcer

Covered with eschar/slough

Deep tissue injury

Purple/maroon discoloration

Test trick for Stage 1 ulcer

Must be NON-blanchable

Signs of dehydration

Dry mucous membranes, poor turgor, tachycardia, hypotension, dark urine

Signs of fluid overload

Edema, crackles, weight gain

ABCDE skin assessment

Asymmetry, Border, Color, Diameter, Evolving

Serous drainage

Clear fluid

Sanguineous drainage

Blood

Serosanguineous drainage

Pink mixture

Purulent drainage

Pus → infection

Signs of wound infection

Redness, warmth, swelling, pain, purulent drainage

Anemia signs

Fatigue, pallor, SOB, tachycardia, dizziness

Why tachycardia occurs in anemia

Compensation for low oxygen

Normal breath sounds

Vesicular (soft), bronchial (loud)

Wheezes

Airway narrowing (asthma)

Crackles

Fluid in lungs (CHF, pneumonia)

Stridor

Upper airway obstruction (EMERGENCY)

Rhonchi

Secretions in airway

Kussmaul breathing

Deep rapid breathing (metabolic acidosis)

Cheyne-Stokes breathing

Alternating apnea and rapid breathing

Most common cause of COPD

Smoking

COPD findings

Chronic cough, wheezing, barrel chest, low O2

Central cyanosis location

Lips and tongue

Heart sound S1

AV valves close (start systole)

Heart sound S2

Semilunar valves close (end systole)

Left-sided heart failure signs

SOB, crackles, pulmonary edema

Right-sided heart failure signs

Edema, JVD, weight gain

Key HF test trick

Breathing problems = LEFT sided

Orthostatic hypotension

BP drop when standing causing dizziness

Blood flow through heart

RA → RV → lungs → LA → LV → body

Arterial insufficiency signs

Cool, pale, pain with activity

Venous insufficiency signs

Warm, edema, aching

Test trick arterial vs venous

Edema = venous

FAST stroke signs

Face droop, arm weakness, slurred speech

Abdominal assessment order

Inspect → auscultate → percuss → palpate

Why auscultate before palpation

Palpation alters bowel sounds

Absent bowel sounds rule

Listen for full 5 minutes

Normal abdominal findings

Soft, non-tender, active bowel sounds

Abnormal abdominal findings

Rigid, absent sounds, distention

Normal older adult changes

Kyphosis, slower reflexes

Abnormal older adult finding

Confusion (think infection)

Eye normal finding

PERRLA

Eye abnormal finding

Unequal pupils, no reaction

Ear normal finding

Pearly gray tympanic membrane

Ear abnormal finding

Red, bulging TM

Weber test purpose

Detect conductive vs sensorineural hearing loss

Normal lymph nodes

Nonpalpable, small, mobile, non-tender

Abnormal lymph nodes

Enlarged, hard, fixed, tender

Fall prevention interventions

Clear hazards, assistive devices, good lighting

Priority rule ABCs

Airway, breathing, circulation first

Priority rule acute vs chronic

Acute first

Priority rule stable vs unstable

Unstable first

First sign of respiratory distress

Increased respiratory rate

Most critical respiratory finding

Stridor

Worst asthma finding

Silent chest

Chest pain priority

Always high priority

Low oxygen priority

Treat before pain

Crackles meaning

Fluid

Stage 1 ulcer vs normal redness

Must not blanch to be stage 1

Documentation in nursing

Accurate and timely recording of patient findings and care

Equipment for head-to-toe assessment

Stethoscope, BP cuff, thermometer, penlight, otoscope, ophthalmoscope, tuning fork, reflex hammer, measuring tape

Inclusive care definition

Respecting cultural, linguistic, and personal patient needs

Health assessment purpose

Collect data to identify health problems and guide care

Tools for HEENT assessment

Snellen chart, otoscope, tongue depressor

Skin assessment components

Inspection and palpation of skin, hair, nails

Skin temperature regulation function

Maintains body heat balance

Skin sensation function

Detects touch, pain, temperature

Skin excretion function

Releases sweat and waste

Common respiratory diseases

Asthma, COPD, pneumonia

Bronchovesicular breath sounds

Equal inspiration and expiration, heard over main bronchi

Cardiovascular assessment components

Heart rate, BP, JVP, pulse palpation

Heart sound locations

Aortic, pulmonic, tricuspid, mitral areas

Aortic valve location

2nd right intercostal space