General 1
Before starting a health assessment on a client what would the nurse consider with the physical environment?
The room should be private, quiet, and warm with adequate lighting.
The nurse observes a bluish tint to a client's skin. What is the name of this?
Cyanosis
The nurse observes a reddish tint to a client's skin. What is the name of this?
Erythema
The nurse observes a pale tint to a client's skin. What is the name of this?
Pallor
Describe a pulse amplitude of 1+
Weak, thready, diminished pulse
Nurse, you've just auscultated for bowel sounds on your client and they are absent, what will you do next?
Listen for 5 minutes
What PPE (personal protective equipment) would the nurse use to assess the oral mucosa of a client's mouth?
Gloves
What would be a nursing focus for a patient with diarrhea?
Hydration
Naming Pain on a 0-10 scale is called what?
Severity
The nurse is assessing the past health history of a patient with COPD. What would be most relevant?
Smoking History
The nurse observes a yellowish tint to a client's skin. What is the name of this?
Jaundice
What equipment would a nurse choose to complete a hearing exam?
What is the sequence of physical assessment of the abdomen?
Inspection, Auscultation, Palpation, and then Percussion.
Name 4 unexpected findings when palpating the abdomen.
Large masses
Hardness
Tenderness with guarding or rigidity
Rebound tenderness
Nurse, you are assessing the ears of your client. What equipment will you need?
Otoscope
Describe pulse amplitude of 4+
Bounding
What is addressed as part of the general survey? (8)
•Appearance
•Behavior
•Indicators of abuse/neglect/human trafficking
•Body structure
•Mobility
•Height/weight/BMI
•Vital signs
•Pain
Which nerve stimulates the muscles of the tongue.
Cranial Nerves IX glossopharyngeal and X vagus.
Symmetry
How would the nurse assess level of consciousness in their client?
Orientation to person, place, and time are among the essential components of LOC.
Name one unexpected finding of a client with COPD.
Nurse, you are assessing Graphesthesia on your client. Describe what an unexpected finding would be for this assessment.
If the patient cannot distinguish the number or letter, he or she may have a parietal lobe lesion.
Which Cranial Nerves identify taste?
CN VII & IX
Nurse, you are doing a screening for distant vision. What equipment do you need?
Snellen Chart
The nurse completes a head-to-toe assessment to do what after analyzing data and identifying problems.
Develop a Plan of Care