Physical Assessment and Documentation

Assessment 1

100

True or False: T:AP is 1:2

False T:AP is 2:1 

200

Sequence of abdominal assessment 

Inspection, auscultation, percussion, palpation

300

Cardiac landmark located at the apex of the heart 

Mitral Valve

400

Lung sounds that result from narrowing of the upper airway or presence of a foreign body

Stridor

500

Seven Lymph Node Areas to Palpate

Preauricular

2. Tonsillar

3. Submental

4. Submandibular

5. Anterior Cervical

6. Posterior Cervical

7. Supraclavicular

600

Targeted evaluation of specific systems based on patient complaints or identified problems.

Focused Assessment

Cranial Nerves

100

Cranial Nerve responsible for smell 

CNI Olfactory

200

Cranial nerve responsible for taste: salt & sugar

VII Facial Nerve

300

Cranial nerve responsible for speech

Vagus Nerve

400

Cranial nerves that are classified as sensory 

I Olfactory

II Optic

VIII Acoustic

500

Cranial Nerves that are classified as Motor

III Oculomotor

IV Trochlear

VI Abducens

XI Spinal Accessory

XII Hypoglossal

600

Cranial classified as both sensory and motor

V Trigeminal

VII Facial

IX Glossopharyngeal

X Vagus

Documentation 1

100

The primary purpose of documentation

Communication

200

True or False: It is okay to leave blank spaces when documenting a nurses' note. 

False

300

Hand-off communication technique used to improve hand-off communication, bedside shift report, teamwork, and the perception of patient safety culture

ISBARR

400

Part of SBAR technique that explain significant details of the patient’s history related to the current situation—brief patient information.  

Background

500

Medications that are documented in nurse’s notes when given. 

Stat, PRN, Now, one-time orders or drugs requiring special documentation (i.e. new medication, lab values, etc.)

600

Describes effective goal criteria

Goals should be: measurable, realistic and time bound

Documentation 2

100

True or False: It is okay for students to take a photo in the clinical setting as long as the client provides verbal consent. 

False- It is NEVER okay for a student to take a picture in the clinical setting.

200

Part of SBAR used to communicate concisely what is occurring with the client and why you are consulting the health care provider—what is happening.

Situation

300

Part of the SBAR technique used to explain the action requested or the health care provider’s recommendation regarding the current situation—what you want.

Recommendation

400

Proper documentation of a client's gold ruby ring.

Yellow metal or gold-colored ring with a red stone

500

Characteristics of Effective Documentation

❖Consistent with professional and agency/facility standards

❖Complete

❖Accurate

❖Concise

❖Factual

❖Organized and timely

❖Legally prudent

❖Confidential

600

Hand-off communication that includes the oncoming and outgoing nurse assessing the patient together, reviewing medication records and the health care provider’s and nursing orders, and establishing patient goals for the shift while also involving the patient and family. 

Bedside shift report

Care Planning

100

Part of the nursing process that collects subjective and objective data 

Assessment

200

Part of the nursing process that is the RN's clinical judgement about actual or potential health problems to help prioritize and plan care. 

Diagnosis

300

Part of the nursing process in which goals and outcomes are formulated and personalized to individual client needs 

Planning

400

Part of the nursing process in which interventions are carried out. 

Implementation

500

Part of the nursing process used to ensure desired outcomes has been met or are revised.

Evaluation 

600

Based on Maslow’s Hierarchy of Human Needs, this need is #1 priority. 

Physiologic needs

Misc

100

A structured guide that outlines the nursing care a patient needs, based on a comprehensive assessment and includes components such as nursing diagnoses, specific goals, planned interventions, and methods for evaluation.

Care Plan 

200

A systematic process of collecting, validating, and communicating patient data that forms the foundation of nursing care.

Health Assessment

300

Comprehensive evaluation upon admission to establish baseline data and identify immediate needs.

Initial Assessment

400

Correct or Incorrect: 

Insulin 10U ACHS

Incorrect

Insulin Aspart 10units SQ ACHS

500

Percussion Sound heard over areas of enclosed air (air in bowel)

Tympany

600

Percussion sound heard of areas of part air and part solid (Normal Lung)

Resonance