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What are the documentation guidelines you should follow?
Content, Timing, Format, Accountability, Confidentiality
What are some permitted disclosures of PHI?
Public health activities (disease outbreaks, infection control, stats r/t dangerous probs with drugs/medical equip)
Law enforcement and judicial proceedings (Prosecution of crime, id victims of crime or disasters, subpoena)
Deceased (coroners, med examiners, funeral directors, organ donations, death from potential crime)
When can verbal orders be given?
ONLY under medical emergent situations, where the physician, PA, NP finds it impossible to write the order due to the nature of the situation.
What does SOAP stand for (a type of documentation process)? Which documentation method is this used for?
Used in Problem-Oriented Medical Records
What are a few variations to the SOAP acronym?
SOAPE, SOAPIE, SOAPIER
(Intervention, evaluation, response)
What is nursing informatics?
specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge into nursing practice
which drugs require a physician signature w/in 24 hrs if order is given via telephone or fax?
restraints, anticoagulants, antibiotics, narcotics
What does DAR stand for, and what form of documentation is it used in?
It is used in Focus Charting
What is the difference between crisis and lysis when referring to fever
- Crisis: Fever returns to normal suddenly
- Lysis: Fever returns to normal gradually
T or F
It is okay to give a 2 year old child Aspirin if she has a really high fever
False. Aspirin should also NOT be given to children and teens with chickenpox or influenza because of a possible association of Reye's syndrome
What regulates pulse?
Sinoatrial (SA) node. Aka pacemaker.
Parasympathetic stimulation -> vagus nerve= decreased <3 rate
sympathetic stimulation= increased <3 rate
Which systolic and diastolic values are considered pre-hypertensive?
- S: between 120's and 130's
- D: in the 80's
Which systolic and diastolic values are considered stage 1 HTN
- S: between the 140's and 150's
- D: In the 90's
Which systolic and diastolic values are considered stage 2 HTN?
- S: greater than 160
- D: greater than 100
What are Korotkoff sounds?
The sounds the nurse listens for when taking manual BP
Why would rectal thermometers potentially be contraindicated for pt w/ cardiac problems?
The insertion of the rectal thermometer can stimulate the vagus nerve, which can DECREASE heart rate.
Is it normal for a pt to have different systolic readings in each arm? What should the nurse do if he/she encounters this issue?
It is normal to have a 5-10mm Hg difference in systolic readings for each arm. The nurse should use the highest reading.
What is Orthopnea?
The condition where a pt who is experiencing dyspnea can breathe easier in an upright or sitting position
What BP cuff width is appropriate?
40% the limb to be used
A result of an apical-radial test shows two different values. What could this indicate?
Peripheral vascular disease
What is Rhonchi lung sounds?
A coarse rattling sound, somewhat like snoring. Usually caused by secretion in a bronchial airway
What are the components of a health history?
Biographical data, reason for visit, history of present health concern, medical history, family history, lifestyle
What are the risk factors for cancer?
- Change in bowl/bladder habits
- A sore that does not heal
- Unusual bleeding or discharge
- Thickening or lump in breast or elsewhere
- Indigestion or difficulty swallowing
- Obvious change in wart/mole
- Nagging cough or hoarseness
What characteristics should be noted about palpated masses?
Shape, Size, consistency, surface, mobility, tenderness, pulsatile
What is the difference between primary and secondary lesions?
Primary: Lesions from previously normal skin
Secondary: Changes in primary lesions
What is the purpose of asking a pt to follow a pencil with their eyes as you move it side to side and up and down?
To test extraocular movements
What is stertorous breathing?
noisy, strenuous respirations
How does the nurse document pulse amplitude?
- 0 no pulse
- 1+ thready
- 2+ weak
- 3+ normal
- 4+ bounding
What is the normal order of physical assessment? Why is this different for assessing the abd?
Inspection, palpation, percussion, ascultation
In abd assessment it is inspection, ascultation, percussion, palpation. This is because palpation and percussion stimulate bowl movements.
What type of sounds would the nurse use the bell of the stethoscope for?
To ascultate low pitch sounds like a heart murmurs. The diaphram is for high ptiched sounds like a normal heart sound
How would one describe lung crackles?
bubbling or popping sounds
What are the raised dark areas older adults may have on their skin?
What are the flat brown age spots older adults sometimes have on their skin?
What is the Weber's test?
Used to assess for bone conduction of sound. The sound is normally heard in both ears, or it is localized at the center of the head.
Pts with conductive hearing loss(tympanic/ossicles) hear the sound best in the affected ear
If the sounds is heard better in the ear w/out a problem, it indicates damage to the inner ear or a nerve disorder.
What is Rinne's test?
Used to compare bone and air conduction. Hearing air conduction is usually grater than bone conduction. If the hearing loss is conductive, sound of bone conduction will be the same or greater than air conduction
- Normal: AC>BC
- Conduction loss: AC<=BC