Respiratory System
What are 2 assessment findings associated with increased respiratory effort?
Accessory muscle use
Retractions
What is the definition of Subjective Data Collection?
What the client is stating
When assessing the PMI, what landmarks does the nurse use to auscultate?
5th Intercostal Space, Mid-Clavicular.
What is the name of the inexpensive test sometimes used to identify non-visible blood in the stool?
Guaic Test
What are the 5 assessment findings a nurse should evaluate during an Integumentary Examination?
Color
Temperature
Moisture
Turgor
Lesions
Where are thick mucus secretions from Cystic Fibrosis found primarily in the body?
Lungs
Pancreas
What is the difference between a Comprehensive vs a Focused Assessment?
Comprehensive is full head to toe systemic assessment including Maslow's Hierarchy of needs.
Focused is the assessing the specific body system of complaint
What are the 3 essential assessment findings the nurse should evaluating when assessing a client's pulses?
Presence of Pulse
Strength of Pulse (0 - 3+)
Equality of Pulse Opposites
What part of the Colon is being auscultated when listening to the right and left upper quadrants of the abdomen?
Transverse Colon
What is the name of tool used to identify risk of pressure ulcer development?
Braden Scale
What are the 3 variations determined by utilizing the Percussion technique?
Air
Fluid
Solid Structure (organ)
What 4 findings should be assessed for when examining your client's eyes?
Conjunctiva color
Sclera color
Presence of drainage
Cloudiness
What do Systole & Diastole measure when a BP is assessed?
Systole - Pressure of blood on artery walls when heart is at rest
Diastole - Pressure of blood on artery walls when heart contracts
What is the definition of Peritonitis?
When contents of the bowel have leaked into the abdominal cavity causing inflammation & infection.
What are the 5 assessment findings that should be evaluated & documented when the nurse assesses a wound?
Location
Size
Surrounding Skin
Color
Drainage
What are the 5 steps of a Respiratory Nursing Assessment, in order.
Inspection
Palpation
Percussion
Auscultation
Olfaction
Why is it important to perform a cultural assessment when collecting a medical history?
Identify things like food, bathing & personal care preferences
What 4 cardiac valves are auscultated with a focused cardiac examination?
Aortic
Pulmonic
Tricuspid
Mitral (Apex)
What would the presence of pale white or gray colored stool indicate?
Absence of bile, likely related to obstruction of the hepato-biliary system.
What factors could negatively affect how a wound heals?
Age
PVD
Decreased Immune Function
Nutrition
Lifestyle
Infections
Chronic Illness
Decreased lung function
What is the proper medical term used to described inappropriate sounds when auscultating the lungs?
Adventitious
What are the 4 general purposes of a full head to toe assessment?
Identifies the baseline of health status
Identify potential health problems
Monitor progress or change in condition
Guide for treatment planning
What is the assessment finding associated with Jugular Vein Distention (JVD)?
When there is distention of the jugular veins in the neck, often checked when the client is sitting at a 45 degree angle.
What is the rationale behind a diagnosis of Paralytic Ileus post-operatively?
Decreased muscular contractility related to anesthetic induced paralysis impedes digestion leading to functional bowel obstruction
What are the 7 types of Open Wounds?
Incision
Laceration
Abrasion
Puncture
Penetrating
Avulsion
Ulceration