Vital Signs/Cardiac
The patients blood pressure reading is 160/90. What does this mean?
The patients heart rate is 60bpm. What does this mean?
Hypertensive
Heart rate is within normal limits
Proper order in which the nurse completes and abdominal assessment
1. Inspection
2. Auscultation
3. Palpation
What is a normal finding of theanteroposterior diameter of the chest?
The anteroposterior diameter of the chest should be less than the transverse diameter. The normal ratio of anteroposterior to transverse diameter is approximately 1:2.
The name of the assessment tool that monitors a patients level of consciousness
Glascow Coma Scale
____ _____ is the most important and most basic technique in preventing the transmission of infections.
Hand hygiene
The patients left lower leg is reddened and swollen. What is potentially occurring with this patient?
DVT (clot)
Landmark your abdomen into four quadrants using proper terminology
Xyphoid process, umbilicus, pubis symphysis
True/False: The right middle lung lobe is found between the supraclavicular line and the 6th rib
False
Right middle lung lobe: Between the 4th-6th rib
A patient has continuous pain, hears continuous call bells and is unable to disregard stimuli. What is this patient at risk for?
Sensory overload- When a patient receives multiple sensory stimuli and cannot perceptually disregard or selectively ignore some stimuli
The patient is having visceral pain in their colon from recent surgery. The patient states that when it's almost time for their next pain medication, the pain is already 10/10. What type of pain is this?
Break-through
Name the four valves for landmarking the cardiac assessment and in the correct order
1. Aortic
2. Pulmonic
3. Tricuspid
4. Mitral
What is the normal pitch for bowel sounds? Approx how many bowel sounds should you hear in a minute?
Bowel sounds are high-pitched, occurring irregularly anywhere from 5 to 30 times per minute.
What is the breath name called that is found over the trachea?
Bronchial
High pitched and loud
Inspiration < expiration
When working with adults who are caring for older parents, the nurse should monitor for signs of caregiver role _____
Role Strain – associated with a single role; feeling inadequate or unsuitable for a role
When performing a health assessment on a patient, the patient states "I only have one glass of wine before bed and only rarely do a take a Benadryl with it." Which health pattern is the nurse assessing? Is this a functional or dysfunctional health pattern?
Dysfunctional
Sleep/Rest Pattern
An abnormal "whooshing" sound heard when there is backflow through an incomplete valve
murmur
4 subjective questions to ask a patient before their abdominal assessment?
A wheeze (adventitious breath sound) can be found in a patient with which illness?
Wheezes (or rhonchi) are a result of asthma and emphysema
A person employed in an organization was just promoted, however they are not understanding what the role of their new job is. This is an example of role _____
Role ambiguity involves unclear role expectations. When expectations are unclear, people may be unsure about what to do or how to behave.
True/False
Spirituality is an organized system of beliefs and practices often associated with worship of a God or gods
False
Spirituality can be defined as an individual’s sense of peace, purpose, and connection to others as well as the person’s beliefs about the meaning of life.
What is another word for pyrexia
Fever
You are monitoring the patients intake/output for each meal. Calculate the patients intake for breakfast:
250cc orange juice, 200cc coffee, 1 cup of oatmeal, 1 egg, 100cc jello, 150g bacon, 200cc ice cream
750cc
The anterior left and right lower lung sounds can be found at which landmark?
6th intercostal space and the midaxillary line
A patient is in an isolated room with C-diff. Nurses and family must gown and glove prior to entering the room. The patient is bed bound and not able to leave the room. The patient is at risk for what?
Delirium
When a person experiences an inadequate quality or quantity of stimulation, sensory deprivation occurs.
Gender identity is the individual’s:
a. Sexual behaviour
b. Sexual orientation
c. Sense of being a woman, man, non-binary, or gender-fluid
d. Sense of preferring one gender over another
e. Sexual identity
c. Sense of being a woman, man, non-binary, or gender-fluid