Review 1
Assessment (The other phases are diagnosis, outcome identification, planning, implementation, and evaluation)
A client presents with shortness of breath, a productive cough and pallor. What type of assessment should the nurse complete?
Focused Assessment
Subjective
What type of question should the nurse utilize to gain a narrative of a problem from a patient
Open ended question
Asking a client to rate their pain on a 0-10 scale is assessing for what?
Pain Intensity
What is the most common site of breast cancer?
Upper outer quadrant of the breast
A patient heart rate is 110, what will this be documented as?
Tachycardia
What is the first piece of objective data the nurse collects in the acute setting.
Vital signs
What is a swooshing sound heard auscultated in a arterial vessel
Bruit
In a Rinne hearing test, the tuning fork is placed where?
Mastoid Process
You should always palpate the carotid pulses simultaneously to assess for symmetry....True or False
False
On the 0 to 3+ scale, what would a normal pulse be documented as?
2+
What lung sound is a sign of a constricted airway
Wheezing
What scale is used to assess for level of consciousness?
Glasgow Coma Scale
A condition that is characterized by a decrease in skeletal bone loss is what?
Osteoporosis
Multiple sexual partners, early age of intercourse, cigarette smoking, and undetected HPV virus are risk factors for what
Cervical Cancer
The sigmoid colon is located in what quadrant of the abdomen
Left lower quadrant
What heart sound is caused by closure of the AV valve?
First Heart Sound, S1
What is normal sign of aging of the eyes that causes farsightedness
Presbyopia
Neglect
The thyroid gland should be palpated with the patient's head flexed. True or False
False
A 180 degree nail bed angle that results from chronic lung disease is known as what
Clubbing
When testing response to light, both pupils should
Constrict
What is the best method for palpation to detect a breast mass
Vertical strip method
A lymph node is movable, discrete, soft and nontender. This is a sign of what?
Normal lymph node