Evidence-Based Assessment
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This is the Nursing Process.
What is Assessment, Diagnosis, Outcome identification, Planning, Implementation and Evaluation?
Gathering subjective and objective data. This occurs in which phase of the interview?
What is the working phase?
98.6F +/- 1F
What is the normal body suface temp (axillary, temporal, oral)?
List the parts of a General Survey.
1) Physical Appearance
2) Body Structure
3) Mobility
4) Behavior
This is learned, shared, adapted and dynamic.
What are culture characteristics?
When considering priority setting of problems, the nurse keeps in mind that second-level priority problems include which of these aspects?
a. Low self-esteem
b. Lack of knowledge
c. Abnormal laboratory values
d. Severely abnormal vital signs
What is C? Abnormal laboratory values
In an interview, the nurse may find it necessary to take notes to aid his or her memory later. Which statement is true regarding note-taking?
a. Note-taking may impede the nurses observation of the patients nonverbal behaviors.
b. Note-taking allows the patient to continue at his or her own pace as the nurse records what is said.
c. Note-taking allows the nurse to shift attention away from the patient, resulting in an increased comfort level.
d. Note-taking allows the nurse to break eye contact with the patient, which may increase his or her level of comfort.
What is A? Note-taking may impede the nurses observation of the patients nonverbal behaviors.
99.6F +/- 1F
What is the normal core temp (bladder, rectal, tympanic)?
The nurse has collected the following information on a patient: palpated blood pressure180 mm Hg; auscultated blood pressure 170/100 mm Hg; apical pulse 60 beats per minute; radial pulse 70 beats per minute. What is the patients pulse pressure?
a. 10
b. 70
c. 80
d. 100
What is B? 70
Remember: pulse pressure is the diff b/t systolic and diastolic blood pressure.
4 steps in a physical exam.
Hint: pneumonic IPPA.
What is Inspection (visual), Palpation (touch), Percussion (tap to produce sound and vibration), Auscultation (listen to sounds)?
The nurse knows that developing appropriate nursing interventions for a patient relies on the appropriateness of the __________ diagnosis.
a. Nursing
b. Medical
c. Admission
d. Collaborative
What is A?
During an interview, the nurse states, You mentioned having shortness of breath. Tell me more about that. Which verbal skill is used with this statement?
a. Reflection
b. Facilitation
c. Direct question
d. Open-ended question
What is D? Open-ended question
60 - 100 beats per min = _______.
50 - 95 beats per min = _______.
What is the normal Heart Rate?
What is the recent clinical evidence for Heart Rate?
The point at which the palpated pulse disappears.
What is the Auscultatory Gap?
What is the CAGE test?
Have you ever thought about Cutting down your drinking?
Annoyed by criticism of your drinking?
Felt Guilty for your drinking?
Drinking in the morning? Eye opener
A newly admitted patient is in acute pain, has not been sleeping well lately, and is having difficulty breathing. How should the nurse prioritize these problems?
a. Breathing, pain, and sleep
b. Breathing, sleep, and pain
c. Sleep, breathing, and pain
d. Sleep, pain, and breathing
What is A? Breathing, pain, and sleep
A man has been admitted to the observation unit for observation after being treated for a large cut on his forehead. As the nurse works through the interview, one of the standard questions has to do with alcohol, tobacco, and drug use. When the nurse asks him about tobacco use, he states, I quit smoking after my wife died 7 years ago. However, the nurse notices an open pack of cigarettes in his shirt pocket. Using confrontation, the nurse could say:
a. Mr. K., I know that you are lying.
b. Mr. K., come on, tell me how much you smoke.
c. Mr. K., I didnt realize your wife had died. It must be difficult for you at this time. Please tell me more about that.
d. Mr. K., you have said that you dont smoke, but I see that you have an open pack of cigarettes in your pocket.
What is D? Mr. K., you have said that you dont smoke, but I see that you have an open pack of cigarettes in your pocket.
_______ > 20 breaths per min.
_______ < 12 breaths per min.
What is Tachypnea?
What is Bradypnea?
The nurse is performing a general survey. Which action is a component of the general survey?
a. Observing the patients body stature and nutritional status
b. Interpreting the subjective information the patient has reported
c. Measuring the patients temperature, pulse, respirations, and blood pressure
d. Observing specific body systems while performing the physical assessment
What is A? Observing the patients body stature and nutritional status.
1) HEEADSS is the psychosocial interview used for which age group?
2) List what each letter stands for.
2)
Home
Education and employment
Eating
Activities
Drugs
Sexuality
Suicide and depression
Safety
A patient is brought by ambulance to the emergency department with multiple traumas received in an automobile accident. He is alert and cooperative, but his injuries are quite severe. How would the nurse proceed with data collection?
a. Collect history information first, then perform the physical examination and institute life-saving measures.
b. Simultaneously ask history questions while performing the examination and initiating life-saving measures.
c. Collect all information on the history form, including social support patterns, strengths, and coping patterns.
d. Perform life-saving measures and delay asking any history questions until the patient is transferred to the intensive care unit.
What is B? Simultaneously ask history questions while performing the examination and initiating life-saving measures.
2) Working Phase
3) Responses
4) Closing the interview
What are the parts of the patient interview?
Resonance
Hyperresonance
Tympanic
Dull
Flat
These are examples of what type of sounds heard during...?
What is Percussion?
**DOUBLE JEOPARDY:)
--> Where in the body do you hear these percussion sounds?
While measuring a patients blood pressure, the nurse uses the proper technique to obtain an accurate reading. Which of these situations will result in a falsely high blood pressure reading? Select all that apply.
a. The person supports his or her own arm during the blood pressure reading.
b. The blood pressure cuff is too narrow for the extremity.
c. The arm is held above level of the heart.
d. The cuff is loosely wrapped around the arm.
e. The person is sitting with his or her legs crossed.
f. The nurse does not inflate the cuff high enough.
What is A, B, D, E?
a. The person supports his or her own arm during the blood pressure reading.
b. The blood pressure cuff is too narrow for the extremity.
d. The cuff is loosely wrapped around the arm.
e. The person is sitting with his or her legs crossed.
Step 1: PES
Step 2: Goals/Objective
Step 3: Nursing interventions with selected rationales
Step 4: Outcome criteria