General Survey/ Vital Signs
An alert and oriented patient is admitted to the hospital. The nurse the ________will be the best source of primary health information.
Patient
This is the main contributing factor to deep vein thrombosis development after surgery.
What is immobility?
A patient tells the nurse "it feels like the room is spinning around." This is called _______.
What is vertigo?
A patient is admitted to a hospital for surgery for colon cancer. This assessment the nurse will most likely to perform on admission.
What is Comprehensive?
These primary nutrients are essential for optimal body function.
What are carbohydrates, proteins, and fats?
Identify whether the vital sign is normal or abnormal.
HR 87
RR 18
BP 136/78 mmHg
Temp 37.9 C
SpO2 91%
HR, RR normal
BP, Temp, SpO2 abnormal
When the nurse documents crackles in the right lower lobe of a patient, this best describes what the nurse is hearing.
What is a popping sound during inspiration?
This instruction is given when the nurse is assessing ankle eversion.
What is bend the ankle outwards away from the body?
When excessive bladder volume exceeds urethral pressure, it is known as this type of incontinence.
What is overflow incontinence?
This is the first step for a nurse to provide culturally competent care.
What is understanding one's own heritage and basis in cultural values?
During an interview, the nurse can avoid doing this during when the patient is telling their story.
What is avoiding interrupting the patient?
To assess the patient for jugular venous distention, the nurse will perform this action and instruct the patient to ________.
What is recline the bed to 30 degrees and ask the patient to turn their head to side to side?
This is how a nurse assesses for graphesthesia.
What is tracing the number 3 on the patient's hand?
When striking over the costovertebral angle of the back, the nurse is assessing this.
What is tenderness over the kidneys?
Identify 3 health promotion topics when teaching a patient how to maintain healthy skin.
1. Drink 6-8 glasses of water daily
2. Use Sunscreen with a sun protection
3. Use a mild soap
4. Keep skin clean and dry
5. Monitor for skin changes (using ABCDE)
6. See a Dermatologist yearly
What is hand hygiene?
Name 3 symptoms of peripheral vascular disease.
Pain in legs when walking, swelling of feet, a wound that is not healing on the back of the leg, claudification, numbness, pins and needles tingling
During an assessment, the patient complains of "always dropping things and falling down." The patient is unable to complete the rapid alternating movements appropriately, responding slow and missing patting knees. The nurse suspects this is damaged.
What is cerebellum?
Name 3 symptoms of colorectal cancer.
What are blood in stool, pain, abdominal cramping, change in bowel habits, iron deficiency, anemia, unexplained weight loss?
The nurse will advise this document for the patient when wanting specific care to be provided, with their wishes.
What is an advance directive?
Use OLDCART to assess pain. Include questions asked.
O: onset (When did the pain start?)
L: location (Can you point to where you feel the pain?)
D: duration (How long have you been feeling this pain?)
C: characteristics (Can you describe the pain? Is it aching, sharp, dull, etc?)
A: Associated features (What else happens during the pain? Any other symptoms?)
R: Relieving (What have you tried to stop the pain?)
T: Treatment (Have you seen a PCP? Any pharmacological or non pharmacological interventions?)
What is asking the patient to cough deeply and reassess?
Using the example of osteoporosis, identify one primary, secondary, and tertiary prevention.
Primary: Consume adequate amounts of Calcium and vitamin D, exercise three times a week
Secondary: Get DEXA scan regularly
Tertiary: Fall precautions in place to prevent fractures, physical and occupational therapy
This test is used to assess for appendicitis. It involves the patient lifting their leg and pushing against resistance which will result in pain.
What is iliopsoas muscle test?
Define Spiritual distress
What is a state of suffering related to the impaired ability to experience meaning in life through connections with self, others, the world, or a higher being