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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?
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?
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?
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?
Comparison/contrast tasks or response to proverb questions are used to assess what client ability?
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?
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?
- 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?
- Episodic/follow up
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
- support system
- health beliefs
- activities to maintain health
What are the 4 phases of a patient interview?
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?
- 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
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?
What is the avg body temp?
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?
How long should you wait to take a temp after smoking or eating?
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?
What is the normal range of respirations in an adult?
What is the normal range for pulse oximetry?
What O2 saturation indicates respiratory failure and tissue damage?
What percentage of O2 sat. is normal for COPD patients?
At what O2 sat. level will cyanosis appear?
What is considered a life-threatening O2 sat?
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
What is the purpose of documentation?
communication between members of the health care team
Closed questions ask for what?
What are the different types of pain?
- deep somatic
What are the 7 dimensions of pain?
What is pain threshold?
the point at which a stimulus is perceived as pain
What should you use to assess pain?
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?
- cognitive function
- thought processes and perceptions
- level of consciousness
what are the levels of consciousness