-
What is the next step after data collection during a patient health history interview?
Summarize highlights of the interview and let the patient add or clarify information.
-
What sound comes from percussing lungs with emphysema?
Hyperresonance
-
What is one risk factor that is likely to contribute to an elevated blood pressure?
A high pressure job.
-
What is assessment finding of fluid volume deficit?
Tenting of the skin.
-
What is the normal range for capillary refill time?
1-3 seconds.
-
How would you test the gag reflex?
Touch the back of the throat with a cotton-tipped applicator.
-
Define pulse pressure.
The diff between systolic and diastolic blood pressure.
-
A visual acuity of 20/60 with a Snellen chart and the 60 indicates what?
This is the distance at which a person with normal vision could read the chart.
-
What should you do if there is no movement with a patellar reflex test?
Tap the tendon again while the patient is pulling against interlaced, locked fingers.
-
Would indications of anxiety or the presence of assistive devices for vision and hearing have a larger impact on a physical assessment?
The presence of the devices.
-
What are the characteristics of vesicular lung sounds?
Soft and low-pitched breezy sounds overmost of the periperal lung fields.
-
What is Nystagmus?
Involuntary rapid eye movement from side to side.
-
Where would you assess the pedal pulse?
On the top of the foot.
-
What are Cheyne-Stokes respirations?
Irregular patterns of rapid waxing and waning breathing alternating with periods of apnea.
-
What equipement is needed to assess a patients ears and hearing?
A tuning fork and na otoscope.
-
After collecting demographic data during an initial health history interview, what is the next area of assessment?
The reason the patient was seeking healthcare.
-
What is a clarity for urine?
yellow and clear.
-
What is the average pulse range for an adult?
60-100 bpm.
-
What is the correct procedure for examing a patient's pupil?
Compare the sizes of both pupilsand check the reaction to light.
-
What is the best response to a patient's question for the use of an oximetry probe?
It measure the amount of oxygen circulating in your blood.
-
Which part of the hand should you use when assessing for tactile fremitus?
The ulnar and palmar surface of each hand.
-
Which is the correct area to assess the apical pulse?
Fifth intercostal space at teh left midclavicular line.
-
What should be your first responding action to a patient's complaint of a rash?
Determine if the patient is taking any new medications.
-
What position should the patient be in for assessment of the abdomen?
A supine position with knees flexed.
-
What is the correct order of techniques for a physical assessment?
- Inspection
- Palpation
- Percussion
- Auscultation
-
Comparison/contrast tasks or response to proverb questions are used to assess what client ability?
Abstract reasoning.
-
What does an auscultation of a pleural friction rub sound like?
It is a grating sound or vibration heard during inspiration and expiration.
-
What is health assessment?
A systematic method of collecting data related to an individual's health state.
-
What are the components of a health assessment?
- Health history
- Physical Exam
- Documentation of data
-
What are the phases of the nursing process?
- Assessment
- Diagnosis
- Planning
- Implementation
- Evaluation
-
What is involved in the Assessment phase?
Collecting subjective and objective data and clustering that data.
-
What is involved in hte Diagnosis phase?
Analyzing the data to make a professional nursing judgement.
-
What is involved in the Planning phase?
Determining outcomes and developing a plan of care.
-
What is involved in the Implementation phase?
Carrying out the plan
-
What is involved in the Evaluation phase?
Assessing whether outcomes have been met and revising plan of care as necessary.
-
What is the purpose of Nursing Assessment?
To collect data.
-
What are some sources of data?
- Patient
- Family and significant others
- Members of the health care team
- Medical record
- Other records and literature
- Nurse's experience
-
What are clinical manisfestations?
The presenting signs and symptoms experienced by the patient.
-
What is the focus of Nursing Assessment?
To determine how the patient's health status affects their ability to perform ADLs
-
What are the types of Nursing Assessment?
- Comprehensive/Initial
- Problem-based/Focused
- Episodic/follow up
- Emergency
- Screening
-
When will a patient have an overnight stay in a hospital?
When they are admitted to the hospital.
-
When is a comprehensive assessment done?
Performed at the onset of care in a primary care facility
-
When is a problem based assessment done?
Performed in walk-in clinics or in the emergency department
-
When is a episodic/follow up assessment done?
During follow up doctor appointments for specific problems or conditions.
-
When are emergency assessments done?
During a patient crisis.
-
When is a screening assessment done?
During an examination that will focus on the detection of a disease
-
What is a shift assessment and when is it performed?
A focused assessment done every 8 hours, based on patient's condition and treatment response.
-
Outcome of Nursing Assessment includes:
- physical status
- strengths and weaknesses
- abilities
- support system
- health beliefs
- activities to maintain health
-
What are the 4 phases of a patient interview?
- Preparation
- Introduction/orientation
- Discussion/working
- Summary/termination
-
What data will be collected during the interview?
Complete health history.
-
What do you need to do to prepare for the interview?
- Gather all equipment
- Review known information
- Prepare the physical environment
-
What is included in the introduction phase?
- Introduce yourself to the pt
- Describe the purpose
- Describe the process
-
What is the focus of the discussion phase?
Client centered and nurse facilitated
-
The summary phase includes
- summarization of data
- clarification of data
- validation of understanding
-
What is the method for assessing patient complaints?
- Charater
- Observation
- Location
- Duration
- Severity
- Pattern
- Associated factors
-
When does collecting objective data begin?
The moment you meet the patient and begin a general survey
-
What are the components of a general survey?
- Physical appearance
- Body structure
- Mobility
- Behavior
-
What does supine mean?
laying face up
-
What does prone mean?
laying face down
-
When does data need to be validated?
when a discrepency or gap exists between data
-
What is the normal temperature range?
96.4-99.*F
-
What is the avg body temp?
98.6*F
-
What is the difference with rectal and axillary temps?
- Rectal temps are 1 degree higher= -1
- Axillary temps are 1 degree lower= +1
-
What are the assessment sites for temp?
- mouth
- axilla
- ear
- rectal
- forhead
-
How long should you wait to take a temp after smoking or eating?
15 min
-
Who are rectal temps recommended for?
infants and young children, but not newborns
-
what is the sims position?
pt laying on left side, left leg straight, right knee bent
-
the tympanic membrane temp is easiest to meaure in whom?
children under 6
-
in electronic thermometers which probe is used for what?
- blue for oral and axilla
- red for rectal
-
What type of pulse feels weak?
A thready pulse, 1+ or less
-
Which pulse feels strong?
A bounding pulse, 3+
-
What is the indication of a normal pulse?
2+
-
What is the normal range of respirations in an adult?
12-20
-
What is the normal range for pulse oximetry?
above 92%
-
What O2 saturation indicates respiratory failure and tissue damage?
85%-90%
-
What percentage of O2 sat. is normal for COPD patients?
87%
-
At what O2 sat. level will cyanosis appear?
75%
-
What is considered a life-threatening O2 sat?
below 70%
-
What is a normal pulse pressure range?
btwn 30-40 mmHg
-
What are the false readings for wrong cuff sizes?
- too small: false high
- too big: false low
-
When should you not take a BP in an arm?
If that arm has a fistula or it is on the same side as a mastectomy
-
How many lbs are in 1 kg
2.2
-
What is the purpose of documentation?
communication between members of the health care team
-
Closed questions ask for what?
specific information
-
What are the different types of pain?
- acute
- chronic
- deep somatic
- cutaneous
- visceral
- referred
-
What are the 7 dimensions of pain?
- physical
- sensory
- behavioral
- cognitive
- spiritual
- affective
- sociocultural
-
What is pain threshold?
the point at which a stimulus is perceived as pain
-
What should you use to assess pain?
COLDSPA
-
What are the different pain assessment tools?
- visual analog scale
- numeric rating scale
- wong-baker FACES pain rating scale
- FLACC pediatric pain assessment
- PAINAD dementia pain assessment
-
What are the components of a mental status exam?
- appearance
- behavior
- cognitive function
- thought processes and perceptions
- orientation
- level of consciousness
-
what are the levels of consciousness
- alert
- lethargic
- obtunded
- stupor
- coma
|
|
