Exam 5 Ultimate Study Guide

Purpose of Nursing Assessment

Establishes the foundational database for individualized care plans and requires recognizing subtle cues and evaluating therapeutic responses.

Comprehensive Assessment

A complete evaluation performed at initial admission, including health history, vital signs, and head-to-toe physical examination.

Problem-Focused Assessment

Conducted for an admitted client, focusing on specific symptoms during each nursing shift.

Emergency Assessment

Rapid evaluation during acute life-threatening crises, concentrating on the ABCs and essential client data.

Chief Complaint (CC)

The client's primary reason for seeking healthcare, recorded in their own words.

Review of Systems (ROS)

A systematic head-to-toe inquiry evaluating current and recent symptoms across all physiological systems.

Infection Prevention in Assessments

Involves applying standard precautions and using PPE when necessary, along with hand hygiene before and after examinations.

Inspection in Physical Examination

A visual, olfactory, and auditory assessment performed systematically prior to any physical contact.

Palpation

The application of tactile pressure to assess tissue characteristics, including texture and tenderness.

Percussion

Tapping skin surfaces to evaluate underlying tissue density and generate sound.

Auscultation

Auditory assessment of physiological sounds produced by air, blood, or fluids within the body.

Frontal Lobe Function

Modulates cognitive function, motor activity, and emotional regulation.

Cranial Nerve VII

Facial Nerve; responsible for facial expressions and taste on the anterior two-thirds of the tongue.

Visual Acuity Test

Assesses central vision using a Snellen chart to measure distance vision.

Healing Stage 3 Pressure Injury

Documented as such during wound care; indicates that ulcer is healing but has not reverted to a lower stage.

Braden Scale

A tool used for assessing pressure injury risk based on sensory perception, moisture, activity, mobility, nutrition, and friction/shear.

Spiritual Distress

An acute or chronic impairment in an individual's ability to find meaning and purpose in life.

Braden Scale Risk Assessment Timing

Initial assessment must be performed immediately upon admission to evaluate pressure injury risk.

Stage 1 Pressure Injury

Intact skin with non-blanchable erythema, indicating potential pressure damage.

Assessment of Urine Characteristics

Evaluates color, clarity, specific gravity, and signs of dysuria or urinary incontinence.

Musculoskeletal ROM Assessment

Evaluates the active and passive range of motion, as well as muscle strength across joints.