Chapters 1-3

Question 1

Name the 5 phases of the nursing process.

Answer 1

Assessment, Diagnosis, Planning, Intervention/ Implementation, Evaluation (ADPIE)

Question 2

Assessment

Answer 2

The collection of subjective and objective data

Question 3

Diagnosis

Answer 3

The analysis of subjective and objective data to make a professional nursing judgment

Question 4

Planning

Answer 4

Determination of outcomes/ goals and intervention plan

Question 5

Implementation

Answer 5

Carrying out the plan

Question 6

Evaluation

Answer 6

Assess whether outcomes/ goals have been met; revising plan as necessary

Question 7

Name 4 basic types of nursing assessment

Answer 7

1) Initial comprehensive, 2) Ongoing or Partial, 3) Focus/ Problem-Oriented, 4) Emergency

Question 8

Initial Comprehensive

Answer 8

Collection of subjective data about the client’s perception of health of all body systems, PMH, family history, lifestyle and health practices.

Question 9

Ongoing, Partial

Answer 9

Data collection that occurs after comprehensive database is established, or transfer to another unit

Question 10

Focused/ Problem Oriented

Answer 10

Full assessment of a particular problem, not inclusive of other systems

Question 11

Emergency

Answer 11

Rapid assessment in a life threatening event/ situation

Question 12

2 assessment types essential for complete patient care

Answer 12

Holistic nursing assessment and physical medical assessment

Question 13

Holistic nursing assessment

Answer 13

Includes holistic subjective and objective data to determine overall level of functioning

Question 14

Physical medical assessment

Answer 14

Focuses primarily on physiologic development status

Question 15

6 components of subjective data assessment

Answer 15

1) Biographical
2) HPI (and CC)
3) PMH
4) family history
5) health & lifestyle practices
6) review of systems (ROS)

Question 16

5 components of objective data assessment

Answer 16

1) Measurements (height, weight, BMI)
2) Vital signs (Temperature, HR, BP, RR)
3) General survey (appearance, behavior)
4) Physical findings, characteristics (inspection, palpation, percussion, auscultation; head-to-toe)
5) Results from lab, radiology, procedure testing

Question 17

3 phases of subjective interviewing

Answer 17

1) Introduction
2) Working
3) Summary/ Closing

Question 18

The 6 components of subjective data assessment occur during which phase of subjective interviewing?

Answer 18

2, working

Question 19

List 4 objective physical exam techniques

Answer 19

1) Inspection
2) Palpation
3) Percussion
4) Auscultation

Question 20

What is the general order of body system review?

Answer 20

General survey; skin, hair, nails; head, neck; eyes; ears; mouth, throat, nose, sinuses; thorax, lungs; breasts, lymph; heart, neck vessels; peripheral vascular; abdomen; genitalia; anus, rectum, prostate; musculoskeletal; neurologic

Question 21

Which part of the hand should you use when you’re palpating for pulse, texture, size, consistency, shape?

Answer 21

Fingerpads

Question 22

Which part of the hand should you use when you’re palpating for vibrations, thrills, fremitus?

Answer 22

Ulnar or palmar surface

Question 23

Which part of the hand should you use when you’re palpating for temperature?

Answer 23

Dorsal (back) surface

Question 24

Define percussion

Answer 24

Directly tapping an area or body part with one or two fingers to elicit possible sounds, size/ shape, vibrations or tenderness

Question 25

Define palpation

Answer 25

Using parts of the hand to touch/ feel for various characteristics, including texture, temperature, moisture, mobility, consistency, pulse strength, size, shape, tenderness

Question 26

Define auscultation

Answer 26

Listening for heart sounds, movement of blood through the cardiovascular system movement of the bowel, and movement of air through respiratory tract

Question 27

Define diaphragm

Answer 27

High-pitched sounds (breath sounds)

Question 28

Define bell

Answer 28

Light pressure for low-pitched sounds (bruits)