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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.

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    326 EXAM 1 BLUEPRINT - SUMMER 2024 Topic/Nursing Concept Number of Items Bloom's Taxonomy Classification Remember, Understand, Application, Analysis, Evaluate, Create * Module 1: Chapters 1-3 □ Steps of nursing process □ Interview & health history □ Physical exam techniques 4 8 8 □ Understand (12) U Application (8) Module 2: Chapters 4-5, 9 n Validating & documenting data □ SBAR Steps of clinical judgment H Pain assessment 1 1 1 5 □ Understand (4) □ Application (4) Module 3: Chapters 6, 10, 11, 12 H Mental health □ Substance abuse □ Violence □ Culture □ Spirituality/Religion 5 2 2 3 3 U Understand (9) □ Application (6) Module 4: Chapters: 8, 9 □ Vital signs assessment 7 □ Understand (3) □ Application (4) Total Number of Items 50 MC= 45 FITB = 1 SATA = 2 NGN =2 * This can vary slightly. Module 1: Chapters 1-3

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    326 EXAM 1 BLUEPRINT - SUMMER 2024 □ Steps of nursing process □ A= Assessment: Collecting data is that subjective and objective n D= Diagnosis: Analyzing subjective and objective data to make and prioritize professional clinical judgements, (client concerns, collaborative problems, or referral) □ P= Planning: Generating solutions, developing a plan, and determining which outcomes need to be met first n 1= Implementation: Taking action. Prioritizing and implementing the planned interventions □ E= Evaluation: Assessing whether outcomes have been met and revising the plan if the interventions did not make a difference □ Interview & health history □ Phases of the interview: □ Preintroductory Phase= The nurse reviews the medical record before meeting with the client. Prior knowledge of the patient's biographical information can assist the nurse with conducting the interview. □ Introductory Phase= The nurse introduces themselves to the client, explains the purpose of the interview, discusses the type of questions that will be asked, explains the reason for taking notes, and ensures confidentiality (HIPAA). The nurse makes sure that the patient is comfortable (physically and emotionally) and has privacy. Interview is conducted at eye level demonstrating respect and that the nurse and client are at eye levels. The key is to develop a rapport to ensure that the client trusts you to fully disclose information. Developing rapport is influenced heavily on verbal and nonverbal communication. □ Working Phase= The nurse addresses the patients comments regarding important biographical data, reason for seeking care, history of present health concern, past health history, family history, review of body systems (ROS) for current health problems, lifestyle and health practices, and developmental level. The nurse then listens, observes cues, and applies critical thinking skills to interpret and validate information received from the patient. Then the nurse and patient collaborate to identify the clients problems and goals. This can be free flowing or more structured based on time and specific data needed to be collected. □ Summary and closing phase= The nurse summarizes the information collected during the working phase. Validates problems and goals with the patient. Identifies and discusses possible plans to resolve the problem. Finally, the nurse asks if there are any other concerns and if there are any further questions. □ Health History:

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    326 EXAM 1 BLUEPRINT - SUMMER 2024 □ COLDSPA= Used as a comprehensive analysis of any symptom to promote an accurate clinical judgement. Also used for history of present health concern o C=Character: Describe the signs and symptoms □ Feeling, appearance, sound, smell, taste, ect o O=Onset: when did it begin? o L= Location: where does it occur? o D=Duration: how long does it last? o S= Severity: on a scale 0-10 (0 being no pain and 10 being the worse pain you've experienced) what is the pain scale? o P= Pattern: what makes it better or worse? o A= Associated factors: what other symptoms occur with it? How does it affect you? □ Are there any other problems that seem related to your problem? □ Complete health history= excellent way to begin the health assessment because it provides the foundation for clinical judgments in identifying nursing problems, where to focus, and areas where a more detailed physical examination may be required. Health history data are used to identify clients' strengths and limitations in lifestyle and health status. Also provides specific cues to health problems that are most apparent to the client. H Head to toe physical assessment= collection of subjective data usually requires that the nurse take a complete health history. This can be modified or shortened when necessary. Taking a health history should begin with an explanation on why the information is being requested. o Biographical data: H Name □ Address □ Phone □ Gender □ Provider of history n Date of birth □ Place of birth □ Race or Ethnicity □ Primary or secondary language □ Marital status □ Religion □ Education n Occupation □ Significant other or next of kin o Reasons for seeking health care

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    326 EXAM 1 BLUEPRINT - SUMMER 2024 □ Major health problem or concern □ Feelings about seeking health care (fears and past experiences) o History of present health concern □ COLDSPA: □ £= Character: how does it look, smell, sound, ect □ 0= 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 it recur? □ S= Severity: how bad is it on a scale of 0-10. 0= no pain & 10= worse pain ever □ P= Pattern: what make it better and what makes it worse? □ A= Associated factors: what other symptoms do you have with it? Will you be able to continue doing your work or other activates (leisure or exercise)? o Personal health history □ Problems at birth □ Childhood illnesses U Immunizations to date □ Adult illnesses (physical, emotional, mental) □ Surgeries □ Accidents □ Prolonged pain or pain patterns n Allergies □ Physical, emotional, social, or spiritual weaknesses U Physical, emotional, social, or spiritual strengths o Family history □ Age of parents (living/ date of death) □ Parents' illnesses and longevity H Children's ages and illnesses or handicaps and longevity o ROS for current health practices profile □ Skin, heair and nails: color, temperature, condition, rashes, lesions, excessive sweating, hair loss, dandruff □ Head and neck: headache, stiffness, difficulty swallowing, enlarged lymph nodes, sore throat

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    326 EXAM 1 BLUEPRINT - SUMMER 2024 □ Eyes:pain, infections, impaired vision, redness, tearing, halos, blurring, black spots, flashes, double vision □ Mouth, throat, nose, and sinuses: mouth pain, sore throat, lesions, hoarseness, nasal obstruction, sneezing, coughing, snoring, nosebleeds □ Thorax, and lungs: pain, difficulty breathing, shortness of breath with activities, orthopnea, cough, sputum, hemoptysis, respiratory infections □ Breasts and regional lymphatics: pain, lumps, discharge from nipples, dimpling or changes in breast size, swollen and tender lymph nodes in axilla □ Heart and neck vessels: chest pain or pressure, palpitations, edema, last blood pressure, last electrocardiogram (ECG) □ Peripheral vascular: leg or feet pain, swelling of feet or legs, sores on feet or legs, color of feet and legs □ Abdomen: pain, indigestion, difficulty swallowing, nausea and vomiting, gas, jaundice, hernias □ Male genitalia: painful urination, frequency or difficulty starting or maintaining urinary system, blood in urine, sexual problems, penile lesions, penile pain, scrotal swelling, difficulty with erection or ejaculation, exposure to STI's □ Female genitalia: pelvic pain, voiding pain, sexual pain, voiding problems (dribbling, incontinence), age of menarche or menopause (date of last menstrual period), pregnancies and types of problems, abortions, STI's, hormone replacement therapy (HRT), birth control methods □ Anus, rectum, and prostate: pain, with defecation, hemorrhoids, bowel habits, constipation, diarrhea, blood in stool n Musculoskeletal: pain, swelling, redness, stiff joints, strength of extremities, abilities to care for self and work □ Neurologic: mood, behavior, depression, anger, headaches, concussions, loss of strength or sensation, coordination, difficulty with speech, memory problems, strange thoughts or actions, difficulty reading or learning o Lifestyle and health practices □ Description of a typical day (AM to PM)

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    326 EXAM 1 BLUEPRINT - SUMMER 2024 □ Nutrition and weight management □ 24 hour dietary intake (foods and fluids) □ Who purchases and prepares meals □ Activities on a typical day □ Exercise habits and patterns □ Sleep and rest habits and patterns □ Use of medications and other substances (caffeine, nicotine, alcohol, recreational dings) □ Self- concept □ Self-care responsibilities □ Social activities for fun and relaxation □ Social activities contributing to society □ Relationships with family, significant others, and pets □ Values, religious affiliation, spiritualty □ Past, current, and future plans for education □ Type of work, level of job satisfaction, work stressors □ Finances □ Stressors in life, coping strategies used □ Residency, type of environment, neighborhood, environmental risks o Developmental level U Young adult: intimacy versus isolation □ Middle scent: generativity versus stagnation □ Older adult: ego integrity versus despair □ Head to toe physical assessment= collection of subjective data usually requires that the nurse take a complete health history. This can be modified or shortened when necessary. □ Physical exam techniques H 4 physical examination techniques must be mastered before you can perform a thorough and complete assessment of the client □ Technique □ Definition □ Guideline □ Inspection □ Involves the use of the senses (smell, vision, hearing) to observe and detect any normal or abnormal findings. This begins the moment you meet the client and continues throughout the examination. □ Ensure room temperature is comfortable. Too hot or too cold can alter the normal behavior of the patient and the appearance of the skin U Good lighting □ Look and observe before touching

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