Asepsis
Which age group shows subtle signs of infection?
Older adults - their first sign of infection is acute confusion
You take your patient's temperature orally, how would you document this assessment method on the patient's chart?
O for Oral
(Other examples include AX for axillary or R for rectally)
What does PERRLA mean?
Pupils, equal, round, reactive to light, and accomodate
TRUE or FALSE
The carotid pulse coincides with s2
FALSE
The carotid pulse coincides with s1
When assessing moles, what acronym is used to determine if the mole is concerning?
A - asymmetry
B - border
C - color
D - diameter
E - evolution
What is the number one way healthcare professionals can reduce the spread of infection?
hand washing!
TRUE OR FALSE:
The first Korotkoff sound is associated with the patient's systolic blood pressure
TRUE
The last sound heard, final Korotkoff sound, is associated with the patient's diastolic blood pressure
What is the correct order to conduct a nursing assessment?
For most assessments:
1) Inspect or observe
2) Palpate
3) Percuss
4) Auscultate
The correct order for abdominal assessment is:
1) Inspect
2) Auscultate
3) Percuss
4) Palpate
What lung changes do older adults experience?
Lung tissue becomes less elastic as adults age
What is the number one reason for providing daily baths to patients?
Circulation stimulation
Ways to reduce infection include:
1) Hand washing
2) Proper cough etiquette
3) Promoting adequate nutrition
When preparing to take a person's temperature, what is the first step the nurse takes to ensure they are going to get an accurate temperature reading?
Make sure the equipment is working properly
When should you wear gloves during the HEENT examination & why?
Scalp and Mouth - you may come in contact with body fluids in these areas
When listening to lung sounds, what part of the stethoscope is used to auscultate?
The diaphragm
Describe the scale used to grade pitting edema
1+ 2mm indentation
2+ 4mm indentation
3+ 6 mm indentation
4+ 8 mm indentation
Localized signs of infection include:
Redness
Edema
Pain
Heat
TRUE OR FALSE?
Older clients have higher oral temperature readings than young or middle aged adults
FALSE
Older adults tend to have lower temperature readings as subcutaneous fat is lost as we age
Lymph nodes in a healthy adult should be palpable
FALSE
In a healthy adult, lymph nodes are usually non-palpable and non-tender
*Occasionally, some patients have palpable lymph nodes. In this case, make sure they are mobile, non-tender, soft and less than 1cm*
In what position should the nurse assess a patient's breast tissue?
in the supine position with arms above the head
What area of the body should the nurse pay particular attention to when providing skin care to a diabetic patient?
Systemic signs of infection include:
1) Fever
2) Increased pulse
3) Increased respirations
4) Enlarged lymph nodes
5) Increased white blood cell counts
2) If you use a blood pressure cuff that is too big you will get a ____blood pressure.
1) A false high blood pressure
2) A false low blood pressure
What are Cranial Nerves III, IV, and VI responsible for?
The extraocular movements (remember 3, 4, 6 make your eyes do tricks!)
Name three abnormal breast assessment findings
1) discharge
2) significant asymmetry
3) redness
4) peau d'orange (found in inflammatory breast cancer)
TRUE or FALSE
Bathing can be delegated to an unlicensed assistive personnel
TRUE