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Nursing 101 & 102 > Assessment > Flashcards

Assessment Flashcards

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0
Q

What are the two main areas of assessment?

A

Health history and physical assessment

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1
Q

What begins the nursing process?

A

Assessment

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2
Q

What are the four major assessment activities?

A

Collection
Organization
Validation
Documentation

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3
Q

What is a collection or store of information?

A

Data base

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4
Q

Clients description of the problem

A

Subjective Data

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5
Q

Detectable by an observer. Something seen, heard, smelled, or felt.

A

Objective Data

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6
Q

Who states Administer assessment done to determine each persons need for nursing care?

A

Joint Commission

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7
Q

What is the purpose of assessment?

A

To enable the nurse to make a judgment or diagnosis about the patients health state.

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8
Q

What is identified as the purpose of assessment?

A
  1. The deviations from normal
  2. The clients health beliefs and patterns of health illness
  3. The presence of risk factors for physical and behavior health problems
  4. The patients resources for support and adaption
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9
Q

Is a continuous process carried out during all phases of the nursing process

A

Assessment

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10
Q

What are the 5 components of the nursing process?

A
  1. Assessment
  2. Nursing Diagnosis
  3. Planning
  4. Implementation
  5. Evaluation
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11
Q

What is collected so problems are identified?

A

Initial data

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12
Q

What are the 4 types of assessments?

A
  1. Initial
  2. Problem-focused
  3. Emergency
  4. Time-lapsed
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13
Q

All the information about a client including past history and current problems

A

Baseline data or database

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14
Q

What is the purpose of data collection?

A

To provide information or identify patient needs. It need to be continuous and symptomatic without omission.

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15
Q

Who is the primary source of data?

A

Client and they are the best source

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16
Q

Who is the secondary source of data?

A

Support people, medical charts, client records, diagnostic studies, record of therapies etc

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17
Q

What is the pupils normal size?

A

3-5mm

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18
Q

What does PERRLA stand for?

A

Pupils round reactive to light accommodation

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19
Q

Skin springs back

A

Elastic

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20
Q

Skin is slow to return

A

Tenting

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21
Q

20 - 30 seconds of skin tenting indicates what?

A

Dehydration

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22
Q

Decreased skin turgor is a late sign of what?

A

Dehydration

23
Q

What is anosmia?

A

Unable to smell

24
Q

Normal breath sounds are?

A

Soft and breezy

25
Q

What is the major breath sound?

A

Vesicular: best at the base of the lungs. Soft intensity. Low pitched.

26
Q

What are abnormal breath sounds?

A

Adventitous breath sounds

27
Q

Musical or constant pitch?

A

Continuous adventitous breath sounds

28
Q

Intermittent, cracking, bubbling

A

Discontinuous adventitous breath sounds

29
Q

Where does the heart lie?

A

Behind and to the left of the sternum

30
Q

PMI is found where?

A

At the apex of the heart

31
Q

Area of the chest above the heart is?

A

Precordial

32
Q

Aortic valve can hear?

A

S1

33
Q

Mitral valve can hear?

A

S2

34
Q

Which valves are responsible for LUB?

A

Atrioventricular (atrial, tricuspid)

35
Q

Which valves are responsible for DUB?

A

Semilunar (aortic and pulmonary)

36
Q

Systole

A

Ventricles contract

37
Q

Diastole

A

Ventricle relax

38
Q

What percentage is the atrial kick?

A

30% or more

39
Q

Bruit or thrill indicates what?

A

Turbulent blood flow

40
Q

You can ______ the bruit and ______ the thrill

A

Hear, feel

41
Q

Decrease or absent pulse and hair, pallor with elevation, nails thick, skin cool, shiny, and dry, ulcerations on bony points.

A

Arterial insufficiency

42
Q

Edema, ulcers, brownish color, warm, scaling eczema, pulse unaffected.

A

Venous insufficiency

43
Q

Inspect external jugular vein and interior jugular vein for JVD at what angle?

A

45 degree

44
Q

The abdomen is divided by:

A

A vertical line from Xiphoid process to Symphysis pubis and a horizontal line across the umbilicus

45
Q

High pitch and air-filled indicates

A

Tympany

46
Q

Dull and solid or fluid filled

A

Resonance

47
Q

Awake and responsive

A

Alert

48
Q

Sleepy but arousable

A

Lethargic

49
Q

Obtunded

A

Needs to be shaken

50
Q

Arouses with difficulty

A

Stuporous

51
Q

Not arousable

A

Comatose

52
Q

What is the babinski sign?

A

Toes bend = negative

Toes flair = positive (but is normal in a baby)

53
Q

What is validation of data?

A

Double checking

54
Q

SLIDE

A

Single line initial date error

55
Q

A head to toe assessment is called?

A

Cephalocaudal

Nursing 101 & 102 (19 decks)

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