Overall Process&History
Which function assessment is used to evaluate the ability to perform items like finances, shopping, etc. (IADLs - instrumental activities of daily living).Referring to the definition of nursing. What do nurses diagnose and treat?
What is Lawton scale?
What type of light is most appropriate for the physical exam?
What is natural/sunlight?
When performing the physical exam on which side of the patient should the nurse stand?
What is on the side of the nurse's dominant hand? (For example: if right handed, stand on the patient's right side).
In order to fully describe abnormal findings in narrative documentation what three (3) things should be included?
1. A description of the problem
2. Full description of the interventions used to alleviate the problem
3. Evaluation related to efficacy of the interventions
What is the minimum SPF necessary to protect skin?
What is at least SPF 30?
A patient complains of itching. What type of data is this?
What is subjective?
When assessing level of consciousness (LOC) the patient moans and does not fully arouse. The nurse would describe this as ___________.
What is stuporous?
Which physical exam technique requires the use of vision and smell, but not touching?
What is inspection?
When assessing the nails the nurse checks for capillary refill and notes color return after 4 seconds. How would the nurse interpret this finding?
What is the capillary refill is prolonged and the patient is likely dehydrated?
The skin appears yellow. What is the medical term for this color abnormality and what does it indicate?
What is jaundice and liver dysfunction?
After collecting data and clustering it to identify nursing diagnoses, the nurse needs to determine if the problem requires action or not. Problems (abnormal findings) that require action are referred to as what?
What is clinically significant?
For general auscultation, which part of the stethoscope will the nurse use most often?
What is diaphragm?
The nurse enters a room and finds a patient cyanotic and breathing 8/minute. What assessment should the nurse perform?
What is emergency (ABC focused)?
What is the most common pain assessment scale and for whom is it appropriate?
What is numeric (0-10) and it is only appropriate for persons who are cognitively intact and have no difficulty with verbal communication.
A flat color change of > 0.5 cm is referred to as:
What is patch?
A patient complains of chest pain. Using the OLDCARTS pneumonic what questions will you ask?
Onset - did it begin suddenly or slow onset?, Location - where does it hurt/does it radiate?, Duration - how long has it been hurting?, Characteristics - what does it feel like?, Aggravating - does anything make it worse?, Relieving- Anything make it better?, Treatment - have you taken any medications for it? Severity - is it affecting your ability to complete daily activities?
When percussing the nurse notes a flat sound. What type of tissue creates this sound? Dense or hallow?
What is dense?
What order are the exam techniques for the abdominal exam performed?
What is inspect, auscultate, percuss, palpate?
Name four (4) rules of documentation.
1. document in chronologic order
2. use phrases (not complete sentences)
3. appropriate grammar & spelling
4. document objectively, no opinions
5. avoid documenting "normal"
6. Record complete information and details
7. Support subjective complaints by patient with objective observations
8. Record patient understanding and perceptions. Direct quotes good.
Hemorrhages under skin >3mm that are related to platelet dysfunction are termed what?
What is purpura?
List four (4) barriers to communication.
Refer to p. 13
Leading the patient, using jargon, too many questions, making assumptions, taking responses personally, asking why questions, changing subject, giving advice, offering false reassurance, stereotyping, patronizing language
Which type of palpation would be appropriate for the breast?
What is bimanual?
A patient has just been admitted to the hospital. What type of assessment must the RN complete within 24 hours of admission?
What is comprehensive?
What are three (3) objective signs (physiologic) of acute pain.
What are increased blood pressure, pulse and respiratory rate; dilated pupils, sweaty skin, restlessness and moaning? (refer to table 7-2)
When assessing a pressure ulcer the nurse notes that bone and tendon are visible. The nurse will stage this as what?
What is stage IV?