NR 304 Final Exam Concepts

Student Name

Chamberlain University

NR-304: Health Assessment II

Prof. Name

Date

Chapter 1

Identify Steps of Nursing Process: Evaluation

The evaluation phase in the nursing process involves systematically reassessing a patient to determine whether the previously established goals of care have been successfully achieved. This step is crucial for ensuring patient-centered outcomes, as it allows nurses to adjust or modify interventions based on observed progress. Effective evaluation ensures care remains aligned with the patient’s changing needs and facilitates continuous improvement in healthcare delivery.

Identify Tasks in Nursing Process: Diagnosis

During the diagnosis phase, nurses interpret collected patient data to identify an accurate NANDA-approved nursing diagnosis. This process involves clustering relevant data while disregarding irrelevant information. By systematically analyzing patient information, nurses can clearly define the patient’s health problems, forming a solid foundation for planning and implementing effective nursing interventions.

Types of Databases: Problem-Centered

A problem-centered database focuses on short-term or limited assessments, often addressing a specific issue or body system. This targeted approach allows for efficient evaluation and intervention across various healthcare settings.

Type of Database	Characteristics	Setting
Problem-Centered	Limited scope, short-term, focuses on one problem	All settings

Chapter 9

Identify Components of the General Survey

The general survey is an overall observational assessment that begins as soon as the patient enters the healthcare environment. It encompasses four key components:

Physical Appearance: Evaluates age, sex, level of consciousness, skin color, facial features, and any signs of distress.
Body Structure: Includes assessment of stature, nutritional status, symmetry, posture, body build, and presence of deformities.
Mobility: Observes gait, coordination, and range of motion.
Behavior: Examines facial expressions, mood, affect, speech patterns, dress, hygiene, and social interactions.

Chapter 10

Differentiate the Grading of Pulse Force

Grade	Description
3+	Full, bounding pulse
2+	Normal
1+	Weak, thready
0	Absent

Identify Hypotension Occurrences and Rationales

Hypotension can arise from various pathophysiological processes:

Acute myocardial infarction: decreased cardiac output
Shock: decreased cardiac output
Hemorrhage: decreased total blood volume
Vasodilation: decreased peripheral resistance
Addison disease: decreased circulating aldosterone

Recognize How to Count Respirations

When counting respirations, the patient should not be informed to avoid altering their natural breathing pattern. Typically, the nurse counts respirations for 30 seconds immediately after measuring the pulse, then multiplies by two. For suspected irregularities, count for a full minute.

Recognize the Effects of Smoking on Blood Pressure

Smoking is a major contributor to hypertension. It damages vascular endothelium, reduces arterial elasticity, and increases the risk of cardiovascular disease.

Chapter 11

Identify Physiologic Changes: Acute Pain Responses

Acute pain triggers both physical and behavioral responses, including grimacing, guarding, moaning, diaphoresis, restlessness, agitation, and notable alterations in vital signs. These indicators help nurses promptly assess and manage pain.

Chapter 13

Recognize the ABCDEF of Skin Lesions

The ABCDEF mnemonic aids in identifying concerning skin lesions:

A: Asymmetry
B: Border irregularity
C: Color variation
D: Diameter > 6 mm
E: Elevation or evolution
F: “Funny looking” lesion

Assessing Clubbing

Technique	Indication
Patient forms heart shape with hands	Observe gap between nails
Profile sign	Nail base angle should be ~160°

Detect Color Changes in Light and Dark Skin

Skin Type	Pallor	Cyanosis	Erythema	Jaundice
Light	Generalized/localized	Dusky blue; nail beds dusky	Bright red/pink	Yellow in sclera, palate, mucous membranes
Dark	Yellow-brown/ashen gray	Dark, dull; check mucosa and nail beds	Purplish tinge; assess warmth	Palate junction, palms

Characteristics of Pressure Injuries

Stage	Description
I	Non-blanchable redness
II	Partial-thickness skin loss, open blister, red-pink bed
III	Full-thickness skin loss, crater with visible fat
IV	Full-thickness tissue loss with exposed muscle, tendon, or bone

Chapter 14

Neck Assessment Techniques: ROM

To evaluate neck range of motion (ROM), instruct the patient to:

Flex the chin to the chest
Rotate the head side-to-side
Tilt the ear toward each shoulder
Extend the neck backward

Note any limitations for further assessment.

Manifestations of Hypothyroidism

Common signs include goiter, eyelid retraction, and exophthalmos. Early detection is crucial to prevent systemic complications.

Chapter 18

Clinical Manifestations of Breast Cancer

Patients may present with lumps, nipple discharge, nipple inversion, or localized discomfort. Early recognition and prompt diagnostic evaluation are critical.

Complications of Mastectomy

Post-mastectomy complications include bleeding, infection, lymphedema, shoulder stiffness, pain, and numbness due to lymph node removal. Early interventions, including physiotherapy, can mitigate functional impairment.

Chapter 19

Thorax and Lung Inspection Techniques

Thoracic inspection involves observing chest wall shape, spinal alignment, thoracic symmetry, skin color, and breathing patterns.

Adventitious Breath Sounds

Sound	Characteristics
Wheezes	High-pitched: squeaking; Low-pitched: snoring or moaning; may clear with coughing
Crackles	Fine: high-pitched, discontinuous, inspiration only, not cleared by cough; Coarse: low-pitched, bubbling, may decrease with cough

Clinical Examples of Crackles

Type	Condition
Fine	Pneumonia, heart failure, fibrosis, chronic bronchitis, asthma, emphysema
Coarse	Pulmonary edema, pneumonia, pulmonary fibrosis, terminal illness

Tachypnea Indications

A respiratory rate >24 breaths/min may indicate fever, anxiety, exercise, pneumonia, alkalosis, respiratory insufficiency, pleurisy, or pontine lesions.

Pulmonary Embolism Manifestations

Method	Findings
Subjective	Chest pain with inspiration, dyspnea
Inspection	Apprehension, cyanosis, tachypnea, cough
Palpation	Diaphoresis, hypotension
Auscultation	Tachycardia, crackles, wheezes

Asthma Manifestations

Method	Findings
Inspection	Increased RR, shortness of breath, accessory muscle use, cyanosis, barrel chest (chronic)
Palpation	Decreased tactile fremitus, tachycardia
Auscultation	Diminished air movement, prolonged expiration, bilateral wheezing

Chapter 20

Heart Failure Manifestations

Heart failure signs may include dilated pupils, cyanosis, dyspnea, orthopnea, wheezes or crackles, cough, hypotension, edema, fatigue, weak pulse, anxiety, jugular vein distention, hepatosplenomegaly, cool skin, and low oxygen saturation.

Health Promotion Tips

Strategies include aspirin therapy, controlling blood pressure and cholesterol, smoking cessation, and adopting healthy lifestyle habits, including diet and exercise.

Acute Coronary Syndrome Symptoms

Symptoms may include indigestion, nausea, vomiting, dizziness, flushing, palpitations, perspiration, dyspnea, and fatigue. Rapid recognition and intervention are crucial.

Chapter 21

Peripheral Vascular System Assessment

Assessment	Findings
Subjective	Leg pain/cramps, swelling, skin changes, lymph node enlargement, smoking history, medications
Inspection/Palpation	Pulses, capillary refill, clubbing

Nursing Diagnosis for Lymphedema

Lymphedema occurs due to inadequate lymphatic drainage, resulting in limb swelling and tissue changes.

Alleviating Factors for Venous Insufficiency

Symptoms may be relieved by leg elevation, walking, or resting in a supine position.

Varicose Veins Manifestations

Type	Findings
Subjective	Aching, heaviness, fatigue, restless legs, burning, cramping
Objective	Dilated, tortuous veins

DVT Manifestations

Type	Findings
Subjective	Sudden, deep muscle pain
Objective	Warmth, swelling, redness, tenderness

Venous Return Mechanisms

Venous return is supported by skeletal muscle contractions, breathing pressure gradients, and the presence of intraluminal valves.

Edema Grading

Grade	Description
1+	Mild pitting, slight indentation, no swelling
2+	Moderate pitting, indentation subsides quickly
3+	Deep pitting, leg swollen, indentation remains briefly
4+	Very deep pitting, prolonged indentation, gross swelling

Chronic Arterial Symptoms

Arterial disease may present with low ankle-brachial index, pale or cool skin, diminished pulses, and pallor when legs are elevated.

Peripheral Vascular Changes: Aging Adult

Older adults may experience arteriosclerosis, loss of lymphatic tissue, and enlarged calf veins.

Chapter 22

Abdominal Distension Assessment: Obesity

Method	Findings
Inspection	Uniformly rounded abdomen, sunken umbilicus
Auscultation	Normal bowel sounds
Palpation	Normal, though abdominal wall may feel thick

Hypoactive Bowel Sound Causes

Causes include peritonitis, paralytic ileus post-surgery, or late-stage bowel obstruction.

Intestinal/Bowel Obstruction Findings

Type	Findings
Laboratory	Dehydration, electrolyte imbalance, possible sepsis
Radiology	Fluid/gas accumulation proximal to obstruction
Physical Exam	Distension, tenderness, hyperactive early, hypoactive late, hypovolemic shock

Positive Murphy Sign Indication

A positive Murphy sign suggests gallbladder inflammation, evidenced by inspiratory arrest upon palpation.

Involuntary Rigidity vs Voluntary Guarding

Involuntary rigidity: Constant, boardlike abdominal hardness due to peritoneal inflammation.
Voluntary guarding: Bilateral tension that relaxes with exhalation, often due to patient anxiety or cold.

Chapter 23

Late Rheumatoid Arthritis Manifestations

Advanced rheumatoid arthritis may cause ulnar deviation or drift of the fingers.

Osteoarthritis Spinal Deformities

Common spinal deformities include kyphosis and reduced range of motion.

Osteoporosis Risks

Risk factors include postmenopausal status, small body frame, early menopause, estrogen deficiency, and lack of physical activity.

Chapter 24

Cranial Nerve I–XII Assessment

Nerve	Test
I	Present familiar scent with eyes closed
II	Visual field test by confrontation
III, IV, VI	Assess pupil response, gaze, and eye movements
V	Motor: palpate jaw muscles; Sensory: cotton touch
VII	Assess facial mobility: smile, frown, puff cheeks
VIII	Whispered voice test
IX, X	Tongue depressor, say “ahhh”; uvula rises
XI	Shoulder shrug, head turn against resistance
XII	Inspect tongue, say “light, tight, dynamite”

Glasgow Coma Scale Score

A normal score is 15; scores ≤7 indicate coma.

FAST Plan for Stroke

F: Face drooping
A: Arm weakness
S: Speech difficulty
T: Time to call 911

Stroke Risks and Manifestations

Type	Findings
Risks	Hypertension, smoking, cardiac disorders
Manifestations	One-sided weakness, confusion, dizziness, loss of balance, headache, vision changes

Positive Romberg Test

A positive Romberg test suggests cerebellar ataxia or vestibular dysfunction, indicated by loss of balance when eyes are closed.

Chapter 25

Urinary Retention Manifestations

Urinary retention is characterized by difficulty or inability to pass urine, increasing the risk for urinary tract infections (UTIs).

Chapter 26

BPH Manifestations

Type	Findings
Subjective	Frequency, urgency, hesitancy, weak stream, nocturia
Objective	Symmetric, nontender prostate enlargement with smooth, firm surface

Chapter 27

Older Adult UTI Symptoms

In older adults, UTIs may present atypically, with confusion, lethargy, or communication difficulties, rather than classic urinary symptoms.

References

Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nursing care plans: Guidelines for individualizing client care across the life span (9th ed.). F.A. Davis Company.

Ignatavicius, D. D., Workman, M. L., & Rebar, C. R. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care (8th ed.). Elsevier.

Jarvis, C. (2020). Physical examination and health assessment (8th ed.). Elsevier.

NR 304 Final Exam Concepts

Smeltzer, S. C., Bare, B. G., Hinkle, J. L., & Cheever, K. H. (2017). Brunner & Suddarth’s textbook of medical-surgical nursing (14th ed.). Wolters Kluwer.