It's worth a shot
What is considered the fifth vital sign?
Name the purposes for documentation:
-Establish a basis for screening
-Determines educational needs of family and patient
-Permanent legal record of care
-Provides chronological source of pt. assessment
-information to help diagnose current problem
-Ensures easily accessible information
What is is called when a nurse verifies subjective data and objective data are reliable?
Validation of Data
Give examples of subjective data:
-Rated Pain level
-Health history
-Present illness or concern
-Lifestyle and health practices
What is the assessment tool used to assess for a pt.'s risk for pressure ulcers?
Braden Scale
What does PERRLA stand for?
Pupils are Equal, Round, and Reactive to Light and Accommodation
A patient comes in complaining of having difficulty seeing far away. What assessment test can you as the nurse use to test their long-distance vision?
Snellen Chart
What should never be done when assessing a patient's carotid arteries? Why?
Never assess them both at the same time. This can cut off blood flow to the brain and make them lose consciousness.
What are some interventions that could be done to help a pt. with a migraine?
Quiet dark room, allow them to rest
What are the numbers associated with Hyperactive bowel sounds and hypoactive bowel sounds?
Hyperactive: >30 bowel sounds/minute
Hypoactive: <5 bowel sounds/minute
What are the functions of the skin?
-Physical barrier (protects tissues and organs)
-Temperature maintenance
-Fluid and Electrolyte balance
-Absorbes/Excretes substances
-Allows for sensation
-Vitamin D synthesis
-Immunity
What are 3 S/S of over-hydration?
-Weight gain (6-10 lbs in one week)
-Pitting edema
-Visible neck veins
-Crackling lung sounds
-Elevated pulse rate and BP
What does COLDSPA stand for? What questions should you ask for each step?
Characteristic: what does your pain feel like?
Onset: when did it start?
Location: where is the pain located? does it spread?
Duration: how long has it lasted?
Severity: 0-10 scale rating
Pattern: is the pain continuous or intermittent?
Associated factors: what makes the pain better or worse?
What is Orthostatic Hypotension? (give me numbers too)
Drop of 20+ mmHg in blood pressure when going fro a sitting to standing position.
Name 4 things that can be identified during a general survey.
-Physical development and body build
-Gender and sexual development
-Apparent age vs. Stated age
-Skin condition and color
-Dress and hygiene
-Posture and gait
-LOC
-Behaviors, body movements, and affect
-Facial expression
-Speech
-Vital signs
What is Raynaud Disease? What does it look like?
-Vascular disorder that causes intermittent interruption of blood flow to the extremities
-Some fingers will be very pale or blanched
Dull, tight diffused, band-like pain. Occurs with stress, anxiety, and depression. Lasts days, months, or years. Relieved by local heat, massage, or medication. What am I?
Tension Headache
Full thickness tissue loss, slough may be present, possible tunneling, bone and tendon is not visible yet. What stage of pressure injury is this?
Stage 3
What are S/S of DVT (Deep Vein Thrombosis)?
-inflammation
-Cyanosis
-Edema
-Tender
-Sharp, deep muscle pain that increases with sharp dorsiflexion of the foot
Which part of the female breast is the site of most breast tumors?
Tail of Spence
In relation to a stroke, what does FAST stand for?
-Face: smile, does one side droop?
-Arms: raise both arms, does one drift down?
-Speech- repeat simple phrase, is it slurred or strange?
-Time: is any signs are observed call 911!
High pitched musical sounds caused by air passing through constricted passages.
Sibilant Wheezes
This is the system that contains Fight, Flight, or Freeze response that is activated during stress.
Sympathetic System
What is Lordosis?
Inward curve of the lumbar spine "Sway Back"
What are the steps of the Diagnostic Reasoning Process? (There are 7)
1. Identify strengths and abnormal data
2. Cluster data
3. Draw inferences
4. Propose possible nursing diagnoses
5. Check for defining characteristics
6. Confirm or rule out diagnosis
7. Document conclusions