Collect the data
What assessment technique involves looking at the patient's body?
Inspection
What is subjective data?
Information that the patient reports or describes, such as symptoms, feelings, perceptions, or experiences.
Where is the apical pulse best auscultated in an adult?
The left fifth intercostal space at the midclavicular line.
What are the three components of the Glasgow Coma Scale?
Eye opening, Verbal response, and Motor response (E + V + M).
the nurse is preparing to assess vital signs. Name the vital signs.
Temperature
Respiratory Rate
Blood Pressure
Oxygen Saturations
Heart Rate
What are the four basic techniques of physical assessment?
Inspection, palpation, percussion, and auscultation.
“My stomach hurts.” What type of data is this?
Subjective data
Which documentation is the best example of objective data?
A. “Patient appears uncomfortable.”
B. “Patient states pain is severe.”
C. “Patient ambulated 10 feet with an unsteady gait.”
D. “Patient reports feeling weak.”
C
What is the lowest possible GCS score?
Eye = 1
Verbal = 1
Motor = 1
A nurse documents a client's radial pulse as 2+, indicates what?
This is a normal finding
When assessing the abdomen, what technique is performed first? followed by.....
Inspection, followed by auscultation, percussion, and palpation.
Which statement is subjective data?
A. Blood pressure is 150/90 mmHg.
B. Temperature is 38.2°C.
C. “I feel nauseated.”
D. Respirations are 24/min.
C. "I feel nauseated"
A patient reports severe abdominal pain. The nurse observes guarding, abdominal rigidity, and a temperature of 39°C (102.2°F).
Identify the objective findings
Guarding
Abdominal rigidity
Temperature of 39°C (102.2°F)
the nurse is assessing a client using the Glasgow coma scale. The client demonstrates eye opening to verbal command, responds using inappropriate language, and is able to obey verbal commands when the nurse asks the client to move the arm. What total score should the nurse document for the client?
12
A patient's blood pressure is 86/52 mmHg, and they report dizziness when standing. What condition should the nurse recognize?
Hypotension, with symptoms suggestive of orthostatic hypotension if the drop occurs with position change.
What lung sound is often described as a low-pitched, coarse, or “snoring” sound?
Rhonchi
A patient says, “I feel short of breath,” but the nurse observes a respiratory rate of 28/min and oxygen saturation of 89%. Which findings are subjective?
“I feel short of breath.”
Which three findings are objective data?
A. Patient reports nausea.
B. Oxygen saturation is 88%.
C. Patient is diaphoretic.
D. Patient states, “I feel dizzy.”
E. Respiratory rate is 32/min.
F. Patient reports chest tightness.
B, C, E
A patient opens their eyes when you call their name, answers questions inappropriately, and localizes painful stimuli.
Eye: 3
Verbal: 3
Motor: 5
GCS = 11
the nurse palpates a client's pulse and notes that the rate is 71 beats per minute, with an irregular rhythm. How should the nurse follow up this assessment findings?
Auscultate the client's apical pulse for one minute
A 38-year-old client has been admitted to the ER with reports of abdominal pain and vomiting for the past 6 hours. Which type of the assessment will the nurse complete on this client?
Focused assessment
The patient says, “My pain is a 9/10.” The nurse observes that the patient is smiling and talking with a family member.
Which pain assessment should the nurse document?
The nurse should document the patient's reported pain as 9/10.
A nurse assesses a patient who reports, “I feel extremely weak and dizzy.” The nurse observes pallor and diaphoresis. Vital signs are:
BP: 82/48 mmHg
HR: 132/min
RR: 28/min
SpO₂: 91%
Objective data:
Pallor
Diaphoresis
BP 82/48 mmHg
HR 132/min
RR 28/min
SpO₂ 91%
A patient after a motor vehicle collision has the following findings:
Eyes open only after painful stimulation
Makes incomprehensible sounds
Pulls the arm away when a painful stimulus is applied
Question: What is the patient's GCS, and what does it indicate?
Eye = 2 → opens to pain
Verbal = 2 → incomprehensible sounds
Motor = 4 → withdraws from pain
GCS = 8
the nurse reviews temperature measurements for assigned clients. Which measurement should the nurse identify as being elevated?
99.5 F oral, 100.5 rectal, 97.9 axillary, 100.1 temporal
100.5 rectal