Comprehensive Nursing Exam Blueprint Key Concepts

Covers nursing process steps, interview phases, COLDSPA symptom analysis, health history components, and ROS across body systems—essential for accurate assessment, diagnosis, planning, intervention, and evaluation in nursing practice.

Mason Bennett
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326 EXAM 1 BLUEPRINT - SUMMER 2024Topic/Nursing ConceptNumber ofItemsBloom's TaxonomyClassificationRemember, Understand,Application, Analysis,Evaluate, Create *Module 1: Chapters 1-3Steps of nursing processInterview & health historyPhysical exam techniques488Understand (12)UApplication(8)Module 2: Chapters 4-5, 9nValidating & documenting dataSBARSteps of clinical judgmentHPain assessment1115Understand (4)Application (4)Module 3: Chapters 6, 10, 11, 12HMental healthSubstance abuseViolenceCultureSpirituality/Religion52233UUnderstand (9)Application (6)Module 4: Chapters: 8, 9Vital signs assessment7Understand (3)Application (4)Total Number of Items50MC= 45FITB = 1SATA= 2NGN =2* This can vary slightly.Module 1: Chapters 1-3

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326 EXAM 1 BLUEPRINT - SUMMER 2024Steps of nursing processA= Assessment: Collecting data is that subjective and objectivenD= Diagnosis: Analyzing subjective and objective data to make andprioritize professional clinical judgements, (client concerns, collaborativeproblems, or referral)P= Planning: Generating solutions, developing a plan, and determiningwhich outcomes need to be met firstn1= Implementation: Taking action. Prioritizing and implementing theplanned interventionsE= Evaluation: Assessing whether outcomes have been met and revisingthe plan if the interventions did not make a differenceInterview & health historyPhases of the interview:Preintroductory Phase= The nurse reviews the medical recordbefore meeting with the client. Prior knowledge of the patient'sbiographical information can assist the nurse with conducting theinterview.Introductory Phase= The nurse introduces themselves to theclient, explains the purpose of the interview, discusses the type ofquestions that will be asked, explains the reason for taking notes,and ensures confidentiality (HIPAA). The nurse makes sure thatthe patient is comfortable (physically and emotionally) and hasprivacy. Interview is conducted at eye level demonstrating respectand that the nurse and client are at eye levels. The key is todevelop a rapport to ensure that the client trusts you to fullydisclose information. Developing rapport is influenced heavily onverbal and nonverbal communication.Working Phase= The nurse addresses the patients commentsregarding important biographical data, reason for seeking care,history of present health concern, past health history, familyhistory, review of body systems (ROS) for current health problems,lifestyle and health practices, and developmental level. The nursethen listens, observes cues, and applies critical thinking skills tointerpret and validate information received from the patient. Thenthe nurse and patient collaborate to identify the clients problemsand goals. This can be free flowing or more structured based ontime and specific data needed to be collected.Summary and closing phase= The nurse summarizes theinformation collected during the working phase. Validatesproblems and goals with the patient. Identifies and discussespossible plans to resolve the problem. Finally, the nurse asks ifthere are any other concerns and if there are any furtherquestions.Health History:

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326 EXAM 1 BLUEPRINT - SUMMER 2024COLDSPA= Used as a comprehensive analysis of any symptom topromote an accurate clinical judgement. Also used for history ofpresent health concernoC=Character: Describe the signs and symptomsFeeling, appearance, sound, smell, taste, ectoO=Onset: when did it begin?oL= Location: where does it occur?oD=Duration: how long does it last?oS= Severity: on a scale 0-10 (0 being no pain and 10 beingthe worse pain you've experienced) what is the pain scale?oP= Pattern: what makes it better or worse?oA= Associated factors: what other symptoms occur with it?How does it affect you?Are there any other problems that seem related toyour problem?Complete health history= excellent way to begin the healthassessment because it provides the foundation for clinicaljudgments in identifying nursing problems, where to focus, andareas where a more detailed physical examination may berequired. Health history data are used to identify clients' strengthsand limitations in lifestyle and health status. Also provides specificcues to health problems that are most apparent to the client.HHead to toe physical assessment= collection of subjective datausually requires that the nurse take a complete health history. Thiscan be modified or shortened when necessary. Taking a healthhistory should begin with an explanation on why the informationis being requested.oBiographical data:HNameAddressPhoneGenderProvider of historynDate of birthPlace of birthRace or EthnicityPrimary or secondary languageMarital statusReligionEducationnOccupationSignificant other or next of kinoReasons for seeking health care

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326 EXAM 1 BLUEPRINT - SUMMER 2024Major health problem or concernFeelings about seeking health care (fears and pastexperiences)oHistory of present health concernCOLDSPA:£= Character: how does it look, smell,sound, ect0= Onset: when did it begin? Is it better,worse, or the same since it began?L= Location: where is it? Does it radiate?D= Duration: how long does it last? Does itrecur?S= Severity: how bad is it on a scale of 0-10.0= no pain & 10= worse pain everP= Pattern: what make it better and whatmakes it worse?A= Associated factors: what othersymptoms do you have with it? Will you beable to continue doing your work or otheractivates (leisure or exercise)?oPersonal health historyProblems at birthChildhood illnessesUImmunizations to dateAdult illnesses (physical, emotional, mental)SurgeriesAccidentsProlonged pain or pain patternsnAllergiesPhysical, emotional, social, or spiritual weaknessesUPhysical, emotional, social, or spiritual strengthsoFamily historyAge of parents (living/ date of death)Parents' illnesses and longevityHChildren's ages and illnesses or handicaps andlongevityoROS for current health practices profileSkin, heair and nails:color, temperature, condition,rashes, lesions, excessive sweating, hair loss,dandruffHead and neck: headache, stiffness, difficultyswallowing, enlarged lymph nodes, sore throat

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326 EXAM 1 BLUEPRINT - SUMMER 2024Eyes:pain, infections, impaired vision, redness,tearing, halos, blurring, black spots, flashes, doublevisionMouth, throat, nose, and sinuses:mouth pain, sorethroat, lesions, hoarseness, nasal obstruction,sneezing, coughing, snoring, nosebleedsThorax, and lungs: pain, difficulty breathing,shortness of breath with activities, orthopnea,cough, sputum, hemoptysis, respiratory infectionsBreasts and regional lymphatics: pain, lumps,discharge from nipples, dimpling or changes inbreast size, swollen and tender lymph nodes inaxillaHeart and neck vessels: chest pain or pressure,palpitations, edema, last blood pressure, lastelectrocardiogram (ECG)Peripheral vascular: leg or feet pain, swelling of feetor legs, sores on feet or legs, color of feet and legsAbdomen: pain, indigestion, difficulty swallowing,nausea and vomiting, gas, jaundice, herniasMale genitalia: painful urination, frequency ordifficulty starting or maintaining urinary system,blood in urine, sexual problems, penile lesions,penile pain, scrotal swelling, difficulty with erectionor ejaculation, exposure to STI'sFemale genitalia: pelvic pain, voiding pain, sexualpain, voiding problems (dribbling, incontinence),age of menarche or menopause (date of lastmenstrual period), pregnancies and types ofproblems, abortions, STI's, hormone replacementtherapy (HRT), birth control methodsAnus, rectum, and prostate: pain, with defecation,hemorrhoids, bowel habits, constipation, diarrhea,blood in stoolnMusculoskeletal: pain, swelling, redness, stiff joints,strength of extremities, abilities to care for self andworkNeurologic: mood, behavior, depression, anger,headaches, concussions, loss of strength orsensation, coordination, difficulty with speech,memory problems, strange thoughts or actions,difficulty reading or learningoLifestyle and health practicesDescription of a typical day (AM to PM)

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326 EXAM 1 BLUEPRINT - SUMMER 2024Nutrition and weight management24 hour dietary intake (foods and fluids)Who purchases and prepares mealsActivities on a typical dayExercise habits and patternsSleep and rest habits and patternsUse of medications and other substances (caffeine,nicotine, alcohol, recreational dings)Self- conceptSelf-care responsibilitiesSocial activities for fun and relaxationSocial activities contributing to societyRelationships with family, significant others, andpetsValues, religious affiliation, spiritualtyPast, current, and future plans for educationType of work, level of job satisfaction, workstressorsFinancesStressors in life, coping strategies usedResidency, type of environment, neighborhood,environmental risksoDevelopmental levelUYoung adult: intimacy versus isolationMiddle scent: generativity versus stagnationOlder adult: ego integrity versus despairHead to toe physical assessment= collection of subjective data usuallyrequires that the nurse take a complete health history. This can bemodified or shortened when necessary.Physical exam techniquesH4 physical examination techniques must be mastered before you canperform a thorough and complete assessment of the clientTechniqueDefinitionGuidelineInspectionInvolves the use of the senses(smell, vision, hearing) to observe anddetect any normal or abnormal findings.This begins the moment you meet theclient and continues throughout theexamination.Ensure roomtemperature iscomfortable. Too hot ortoo cold can alter thenormal behavior of thepatient and theappearance of the skinUGood lightingLook and observebefore touching
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