Nursing Exam Study Guide

Chapter 21 – Physical Assessment

• Purpose of Physical Assessment:

  • To collect baseline data.
  • To identify health problems.
  • To monitor changes in a patient's condition.
  • To evaluate the effectiveness of treatments.

• Types of Assessments:

  • Comprehensive Assessment: A thorough evaluation of a patient's overall health status.
  • Focused Assessment: A concentrated evaluation on a specific health issue or problem.
  • Ongoing Assessment: Continuous monitoring of a patient's health status over time.
  • Emergency Assessment: A rapid evaluation performed when a patient is in immediate danger or distress.

• Primary Assessment (ABCD):

  • A: Airway
  • B: Breathing
  • C: Circulation
  • D: Disability

• Four Techniques of Physical Assessment:

  • Inspection: Visual examination of a patient.
  • Palpation: Using hands to feel body parts for abnormalities.
  • Percussion: Tapping on body parts to assess internal conditions.
  • Auscultation: Listening to the sounds made by internal organs.

• Exception for Abdomen Assessment:

  • The order of techniques is different: Inspection → Auscultation → Percussion → Palpation.

• Common Normal vs. Abnormal Findings:

  • Skin:
  • Normal: Warm and dry
  • Abnormal: Cyanosis (bluish discoloration) or pallor (paleness)
  • Lungs:
  • Normal: Clear breath sounds
  • Abnormal: Crackles or wheezes
  • Heart:
  • Normal: Regular rhythm
  • Abnormal: Murmur
  • Abdomen:
  • Normal: Soft
  • Abnormal: Distention

• Red Flag Findings:

  • Cyanosis: Indicates low oxygen levels.
  • Edema: Suggests fluid accumulation in tissues.
  • Crackles: Indicates fluid presence in the lungs.
  • Absent Bowel Sounds: May indicate possible bowel obstruction.
  • Unequal Pupils: Considered a neurological emergency.

Chapter 23 – Nutrition

• Macronutrients:

  • Carbohydrates:
  • Primary function is to provide energy.
  • Protein:
  • Essential for tissue repair and regeneration.
  • Key sources include meat, eggs, beans, and dairy products.
  • Fat:
  • Functions as energy storage.

• Micronutrients:

  • Include vitamins and minerals vital for various bodily functions.

• Important Vitamins:

  • Vitamin C: Essential for wound healing.
  • Vitamin D: Important for bone health.
  • Vitamin A: Crucial for vision.
  • Vitamin K: Necessary for blood clotting.

• Important Minerals:

  • Calcium: Vital for the strength of bones and teeth.
  • Iron: Necessary for oxygen transport in the blood.
  • Potassium: Supports heart function and regulates blood pressure.
  • Sodium: Maintains fluid balance in the body.

• Factors Affecting Nutrition:

  • Age
  • Culture
  • Illness
  • Medications
  • Income
  • Psychological factors
  • Activity level

• Signs of Malnutrition:

  • Weight loss
  • Weakness
  • Fatigue
  • Hair loss
  • Muscle wasting
  • Poor wound healing

• Body Mass Index (BMI) Categories:

  • < 18.5: Underweight
  • 18.5 – 24.9: Normal
  • 25 – 29.9: Overweight
  • ≥ 30: Obese

• Therapeutic Diets:

  • Low Sodium Diet: Used for managing hypertension.
  • Diabetic Diet: Aimed at controlling blood sugar levels.
  • High Protein Diet: Supports wound healing and tissue repair.
  • Clear Liquid Diet: Often used in preparation for surgery.

10 Quick Exam Facts

• ABCD Assessment: Stands for airway, breathing, circulation, disability.
• Physical Assessment Order: Inspection → Palpation → Percussion → Auscultation.
• Abdominal Assessment Order: Auscultate before palpation.
• Role of Protein: Critical for tissue repair.
• Vitamin C Function: Supports wound healing.
• Iron Role: Responsible for carrying oxygen in the bloodstream.
• Normal BMI Range: 18.5 – 24.9 considered normal.
• Impact of Malnutrition: Can significantly slow healing processes.
• Indicators of Fluid Retention: Edema represents fluid retention in the body.
• Crackles in Lungs: Indicate possible fluid presence within the lungs.