Validating Documents

Definitions

100

Severity Scale 

1-10 

200

Define Bell and Diaphragm 

• Diaphragm: Used for high itched sounds ex: Breath, Bowel, NORMAL heart sounds
•  Bell: Soft, low-pitched sounds and murmurs

300

Signs Versus Symptoms 

• Sign is a manifestation of the disease.
• Symptoms are what the patient feels

400

What is COLDSPA and define them 

• Character: How does it look, smell, sound.. etc? Basically an observation
• Onset: When did it begin; Is it better or worse then when it started?
• Location: Where is it? Does it go anywhere else?
• Duration: How long does it last
• Severity: On sale to 1-10
• Pattern: What makes it better or worse?
• Associated Factors: What other symptoms do you have with it?

500

What is the ABCDE assessment of skin lesions & moles

Asymmetry 

Border

Color

Diameter

Evolving 

Practice Questions

100

Which of the following techniques are used in a physical assessment? Select all that apply.

•  Palpation
•  Inspection
•  Questioning
•  Auscultation
•  Subjectivity

Palpation 

Inspection

Auscultation 

200

When focusing on the client's perspective of a symptom or problem, the nurse will ask which questions? Select all that apply.  

•  "Do the headaches negatively impact your day-to-day life?"
•  "Can you tell me when the headaches first began?"
•  "Do you have any fears about the headaches you experience?"
•  "What do you do to make the headaches go away?"
•  "Do you have any idea concerning why you are experiencing these headaches?"

"Do you have any fears about the headaches you experience?"
"Do you have any idea concerning why you are experiencing these headaches?"
"Do the headaches negatively impact your day-to-day life?"

300

Is the following question true or false?

The nurse should take time to ensure all data agree with the subjective and objective findings.

True 

400

Which is a feature of an open-ended documentation form?

A. Consists of check boxes

B. Promotes use by different caregivers

C. Promotes rapid documentation

D. Provides narrative description

D

500

This question is an example of "Is the pain severe, dull, sharp, cutting or piercing? "

Laundry LIst 

Validating Documents

100

While recording the subjective data of an adult client who complains of pain in his lower back, the nurse should include the location of the pain and the 

Pain Relief Measures

200

What is SBAR Reports

S: Situation

B:Background

A:Assessment

R:Recommendation 

300

What is SOAP notes 

S: Subjective; Patients complaint

O:Objective: What you observed ? 

A: Assessment; Nursing Diagnosis

P: Plan

400

What is the primary purpose of the client record?

•  Communication
•  Research
•  Education
•  Advocacy

Communication 

500

An inexperienced nurse has just performed percussion on a client's chest and detected hyper-resonance, which would tend to indicate emphysema. However, the client is 35 years old, appears healthy otherwise, and denies ever having smoked. The nurse realizes that the data need to be validated. Which method of validation would be most appropriate in this case?

• Repeat the percussion using the nondominant hand.
•  Clarify the data by asking whether the client has experienced any trouble breathing lately.
•  Confirm that the client has truly never been a smoker by asking him.
•  Verify the data by having another nurse come in to perform the percussion

 Verify the data by having another nurse come in to perform the percussion.

Practice Questions

100

During a physical examination of a client, the nurse assesses the size of the liver. Which of the following techniques should the nurse use for this assessment?

Palpation 

200

What does the term bradycardia mean? 

Slow heartrate 

300

A nursing instructor is discussing the purposes of health assessment. What is one purpose of health assessment? 

• To establish a database against which subsequent assessments can be measured
•  To quantify the degree of pain a client may be experiencing
•  To establish rapport with the client and family
•  To gather information for specialists to whom the client might be referred

• To establish a database against which subsequent assessments can be measured

400

While examining a client, the nurse plans to palpate temperature of the skin by using the:

•  dorsal surface of the hand.
•  fingertips of the hand.
•  ulnar surface of the hand.
•  palmar surface of the hand.

•  dorsal surface of the hand.

500

The nurse is reviewing the client's medical record. Which component of the medical record would provide the nurse the broadest overview of the health care team members' perspective of the client's status?

•  Plan of care
•  Progress notes
•  Clinical pathway
•  Flow sheets

Progress Notes 

Vital Signs/Health Interview

100

What are the five vital signs?

Blood Pressure

Pain

Temperature

Respitory Rate 

O2 saturation 

200

What is the difference between subjective data versus objective data?

Subjective Data: What is said?

Objective Data: What is observed? 

300

What are the four phases of an interview? 

Pre-Introductory

Introductory 

The Working Phase

Summary 

400

What are the important facts about non-verbal communication?

Appearance 

Demeanor 

Facial Expression

Attitude

Silence

Listening 

500

The nurse is preparing to interview an adult client for the first time. The nurse observes that the client appears very the client appears very anxious. The nurse should 

•  allow the client time to calm down.
•  avoid discussing sensitive issues.
•  set time limits with the client.
•  explain the role and purpose of the nurse.

Explain the role and purpose of the nurse