Terms
Inspection, Auscultation, Percussion, Palpation
Assessment
Listen to heart sounds
aortic, pulmonic, erbs, tricuspid, mitrl
inflamed tympanic membrane
ear infection
An exchange between providers or patients using verbal and non-verbal communication,
Therapeutic Communication
When communicating with a client who speaks a different language, which best practice should the nurse implement?
1. Speak loudly and slowly.
2. Arrange for an interpreter to translate.
3. Speak to the client and family together.
4. Stand close to the client and speak loudly.
Answer: 2
PMI: where? what is it?
5th intercostal space mid clavicular line. Location where cardiac impulse can best be auscultated on chest wall.
Assess ears for adults
Pull pinna up and back
warm, red and tender area in calf
DVT
Types of questions
open and closed ended
The ambulatory care nurse is discussing preoperative procedures with a Japanese American client who is scheduled for surgery the following week. During the discussion, the client continually smiles and nods the head. How should the nurse interpret this nonverbal behavior?
1. Reflecting cultural value
2. An acceptance of treatment
3. Client agreement to the required procedures
4. Client understanding of the preoperative procedures
Answer: 1
Affect
Expression of feeling
Assess abdomen (which quadrant first, how to assess bowel sounds)
RLQ, each quadrant 15 sec if no bowel sounds listen for up to 5 min.
light on tympanic membrane
cone of light
the practice of preparing to listen, observing what verbal and non-verbal messages are being sent, and then providing appropriate feedback for the sake of showing attentiveness to the message being presented
active listening
The nurse identifies low-risk therapies to a client and should include which therapy(s) in the discussion? Select all that apply.
1. Herbs
2. Prayer
3. Touch
4. Massage
5. Relaxation
6. Acupuncture
2,3,4,5
CAGE
Cut down, Annoyed , Guilt, Eye-opener
Draw up insulin
Always withdraw clear insulin first before withdrawing cloudy insulin. Ensure the total dose of clear and cloudy insulin is correct.
One pupil larger than the other
anisocoria
Methods of communication (list 4)
verbal, non-verbal, written, visual
The nurse is preparing a plan of care for a client who is a Jehovah's Witness. The client has been told the surgery is necessary. The nurse considers the client's religious preferences in developing the plan of care and should document which information?
1. The client believes the soul lives on after death.
2. Medication administration is not allowed.
3. Surgery is prohibited in this religious group.
4. The administration of blood and blood products is not allowed.
Answer: 4
Lung Consolidation
when the air in the small airways of the lungs is replaced with a fluid, solid, or other material such as pus, blood, water, stomach contents, or cells. It can be caused by conditions like aspiration, pneumonia, and lung cancer.
Assess for DVT
Observe calf for redness, feel for warmth, perform hoomans signs
dullness in abdomen
liver
Ways to build rapport during patient communication
smile, nod, eye contact, body language
Which meal tray should the nurse deliver to a client of Orthodox Judaism faith who follows a kosher diet?
1. Pork roast, rice, vegetables, mixed fruit, milk
2. Crab salad on a croissant, vegetables with dip, potato salad, milk
3. Sweet and sour chicken with rick and vegetables, mixed fruit, juice
4. Noodles and cream sauce with shrimp and vegetables, salad, mixed fruit, iced tea
Answer: 3