Exam 1 Study Guide 307

Question 1

What are the 4 types of assessments and when is each one indicated?

Answer 1

Comprehensive/Initial Assessment: Performed within a specified time upon administration to a healthcare facility (Going to establish a baseline

Focused Assessment: Ongoing care to determine status of pre-identified problem

Full Bedside Assessment: Head to toe assessment with subjective and objective assessment (Performed as part of the nurses shift assessment.)

Expedited Bedside Assessment: Done in an emergent situation to assess physiologic or psychological status

Question 2

When would you do a comprehensive assessment? When would you select a different assessment type? Why?

Answer 2

A comprehensive assessment is performed within a specified time frame upon admission to a healthcare facility. It contains a full health and physical exam.

Question 3

What are the 2 main components to a comprehensive health history?

Answer 3

Full health history (Symptoms)
Physical Exam (Signs)

Question 4

Define subjective data.

Answer 4

Anything that is not directly observed, an example would be how the patient describes what they are feeling.

Question 5

Define objective data.

Answer 5

Anything you observed, such as diaphoresis, lab values, grimacing

Question 6

What is meant by a General Survey?

Answer 6

First impression prior to exploring any systems in detail, Collecting objective data, helps to guide subjective questioning

Looking at physical appearance, body structure, mobility, behaviors, vital signs, etc

Question 7

What measurements and observations are included in the General Survey?

Answer 7

Vital signs may be a measurement included, also included may be the physical appearance (Maybe examining how diaphoretic someone is), looking at body structure and mobility (Do they need assistance, is the circumstance safe), as well as behaviors (are they agitated- which could be a sign a pain)

Question 8

What are the 4 primary techniques used in physical assessment?

Answer 8

Inspection: Using visual cues to perform an examination

Palpation: Using your sense of touch to make observations (Fingertips- fine tactile discrimination, grasping- feel shapes or consistency, Dorsal- Temperature, Base of fingers- Vibrations)

Percussion: Tapping the skin to assess underlying structures based on the vibration and sound produced. Gives information of location, size and density.

Auscultation: Using your ears and stethoscope to listen

Question 9

What is meant by “Oriented x 4”?

Answer 9

Someone is oriented to Person, Place, Time, Event

Question 10

What are the components of the adult health history?

Answer 10

A health history is a structured conversation to gather important details, and about background and current medical status
Components include, Demographics, Chief Concern (OLDCARTS), Past health history, Family History, Psychosocial history, health prevention behaviors, Review of symptoms

Question 11

What does SBARR stand for? What is the purpose of SBARR?

Answer 11

Identify: State name and title

Situation: What is happening that is requiring the communication

Background: Background data about the client and situation

Assessment: Recent Assessment findings, vital signs, labs, or anything else important to the situation

Recommendations: Suggestions you have

Read Back Orders: Clarify any unclear orders

Question 12

Understand which information would fall into which component of SBARR. Example – Current temperature would fall into the “A” (assessment) component.

Answer 12

I: Your name, Title

S: Client name, age, gender, Problem or symptoms, stable or unstable

B: Relevant details to clinical history, admitting diagnosis, medications/allergies

A: Current conditions, explain examination and test results

R: What should happen next, When does it need to happen

R: Clarify any unclear information

Question 13

Know the purposes of documentation.

Answer 13

Clear and accurate documentation is the best way to provide a precise and factual account of the status of the client.

Question 14

Understand the different types of therapeutic communication.

Answer 14

Open ended questions: Allowing the client to expand and elaborate on current questions

Close ended questions: Yes or No type of questions

Active listening, Clarifying questions, Back channeling, Probing, Summarizing

Question 15

What is the definition of a Closed-Ended and an Open-Ended question? When might you use each of these?

Answer 15

Open ended questions- Provide the opportunity for more than a one word answer. Allows the client to expand upon the current question asked. (How are you feeling today, are you interested in the cessation of smoking?) May use it in times of attempting to build rapport, or when assessing a problem on a deeper level

Close ended question: Typically are simple questions that result with a yes or no answer. (Does it hurt when I do this? Do you smoke?) May use it when clarifying responses to open ended questions.

Question 16

What does normal skin look and feel like?

Answer 16

Uniform in color based on ethnicity, It is warm, dry, intact, with elastic turgor. No lesions, scaring, erythema (Redness), or edema

Question 17

Define pressure injury.

Answer 17

Occur in areas that are under pressure, usually over a bony prominence or related to medical devices

Question 18

Who is at greatest risk of developing A pressure injury?

Answer 18

Elderly individuals with thin skin, people who are bedridden, any individual who may experience incontinence (Too much moisture can assist in the breakdown of the skin). Also individuals with impaired sensory perception because they may not feel any pain with the injury.

Question 19

Know the stages of the Pressure Injury Staging system.

Answer 19

Stage 1: Skin is still intact, the skin does not blanch (Turn white) when pushed on.

Stage 2: Partial thickness loss of skin with exposed dermis. Wound bed is viable, its pink or red and moist.

Stage 3: Full thickness loss of skin in which adipose (Fat Tissue) is visible in the ulcer and possible granulation tissue and epibole are present.

Stage 4: Full thickness skin and tissue loss with palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer

Question 20

What is the Braden Scale?

Answer 20

The braden scale is a scale used to assess a clients risk of developing a pressure injury. It measures moisture, mobility, activity, nutrition, sensory perception and someone at risk for friction or shearing.

Question 21

What is a commonly used mnemonic for skin cancer screening? What does each letter stand for?

Answer 21

A: Asymmetry
B: Borders (Irregular)
C: Color (Change in color)
D: Diameter (Anything larger than 6mm)
E: Evolving (Changing in size, symptoms)

Question 22

Define skin lesions, primary and secondary.

Answer 22

A skin lesion is a part of the skin that has an abnormal growth or appearance compared to the skin around it.

Primary Lesion: Abnormal skin conditions that are present at birth or acquired over a person’s lifetime. Arise from healthy skin tissue (Mole)

Secondary Lesion: Result of alteration of a primary skin lesion (Melanoma)

Question 23

What are the characteristics used when describing skin lesions?

Answer 23

Location, Size, Shape, Color, Texture (Smooth, rough, scaly), Surface relationship, Exudate, Comfort

Question 24

What is turgor?

Answer 24

Turgor is the elasticity of the skin

Question 25

What does poor turgor suggest?

Answer 25

Dehydration

Question 26

When is the integumentary system assessment typically done?

Answer 26

One of the first tests performed upon admission in order to determine that the skin has remained in contact while during the stay at the healthcare facility.

Question 27

What is meant by blanching?

Answer 27

Applying pressure to the skin, removing the blood from the local capillaries. The skin (In fair skin individuals) will go from a pink-ish to a white and refill back to its original pink-ish state

Question 28

Why would a lesion or pressure injury not blanch?

Answer 28

An injury such as a pressure ulcer may have affected the integrity of the nearby capillaries and in severe cases blood vessels affecting the skin’s ability to be blanched.

Question 29

What is cyanosis?

Answer 29

Cyanosis is a result of the lack of oxygen reaching the body tissues resulting in a bluish color of the skin in areas such as finger tips, lips, and oral mucosa.

Question 30

What is jaundice?

Answer 30

Jaundice is a result of excess bilirubin in the blood causing the skin to become yellow. Areas that will be affected could range from the entire body but mainly palms of hands, soles of feet, sclera.

Question 31

What is erythema?

Answer 31

Erythema is when the skin is reddened. Although not expected in someone who is physically exerting themselves. In individuals with darker skin it may be hard to see, check for warmth associated with reddened skin.

Question 32

Understand the structure of the thorax and the lungs.

Answer 32

Thoracic cage consists of the sternum (Top part is called the manubrium), Ribs, Thoracic vertebrae connect the ribs in the back, and the diaphragm which is a large skeletal muscle which aids in chest expansion for breathing
Lungs- Right lung consists of three lobes, Upper, Middle, and Lower Lung (Right middle lung can only be heard on the anterior portion of the body). The Left lung is composed of two lobes, Upper and lower.
Breathing- Air enters the lungs through the mouth or nose, travels through the pharynx down the trachea and to the two primary bronchi (Left and Right, Right bronchi being larger and straighter which typically causes problems when it comes to aspiration). Oxygen goes through the primary bronchi, to secondary bronchus and then to tertiary bronchus and into the alveoli where gas exchange can occur

Question 33

What are anatomical landmarks to assist with assessment of the thorax and lungs?

Answer 33

Angle of Louis is a small bump on/below the manubrium (Upper sternum) is indicative of the second intercostal space.
Midclavicular line
Mid axillary line

Question 34

What are the 4 normal breath sounds and where are they best auscultated?

Answer 34

Tracheal (Over the Trachea and neck)
Vesicular (Over the larger portion of the lungs, more lateral)
Bronchial vesicular (More medial than vesicular closer to the sternum)
Bronchial (Heard over the upper sternum and neck)

Question 35

What is tactile fremitus?

Answer 35

Palpation (Feeling) the chest for vibrations when the client is talking. If there is vibration its indicative of lung consolidation

Question 35

How is gas exchange evaluated (non-invasive and invasive)?

Answer 35

Non-invasive: SpO2 monitors (95% or greater is considered normal), Inspection for cyanosis
Invasive: ABG (Arterial Blood Gas), Hemoglobin and Hematocrit

Question 36

What are 3 types of vocal fremitus?

Answer 36

Bronchophony: Increasing in intensity and clarity of spoken sounds when auscultating with the stethoscope (Have the client say “ninety-nine”
Egophony: Have the client say E-E-E-E, if it sounds like A-A-A-A, lung consolidation is present
Whispered pectoriloquy: Unusually clear transmission of whispered words indicating lung consolidation (Have the client say ninety-Nine)

Question 37

What are normal findings when inspecting the thorax?

Answer 37

Chest AP diameter is less than the Transverse chest diameter (The chest is longer side to side than it is front to back), Skin is warm, dry, and intact. Equal expansion of the lungs, equal sounds bilaterally, no use of accessory muscles, no nasal flaring.

Question 38

What is the normal adult respiratory rate and SaO2?

Answer 38

The normal respiratory rate is between 12-20, and the SaO2 is 95% and above

Question 38

What are adventitious breath sounds?

Answer 38

Adventitious breath sounds are unexpected or abnormal sounds heard while auscultating the lungs.
The names of the adventitious sounds are,
Crackling (Course: Breathing through large mucous filled airways, Fine: Alveoli popping open),
Wheezing: (High pitched, continuous sounds produced by narrowing of the airways),
Friction Rub (Usually continuous, dry rubbing sounds, like leather, heard on inspiration and expiration)
Stridor: Continuous high pitched sounds due to the narrowing of airways in the upper respiratory tract
Rhonchi: Low-Pitched, continuous sounds resembling snoring. Airway is very narrow almost closed

Question 38

What is meant by the AP diameter?

Answer 38

AP diameter represents Anteroposterior diameter which is represented by the diameter of the chest from front to back.

Question 39

What are signs suggestive of breast cancer?

Answer 39

Masses or lumps that are hard, irregular in shape, fixed to tissue and/or tender
Dimpling of skin
Change in breast shape
Edema
Nipple discharge

Question 40

List risk factors for breast cancer.

Answer 40

Nonmodifiable risk factors: Age and Gender, Family History, Race, Breast density, previous breast cancer, early menarche, late menopause, genetics
Modifiable risk factors: Postmenopausal obesity, hormone replacement, alcohol use, physical inactivity, no children.

Question 40

What is the function of the lymphatic system?

Answer 40

Designed to fight off pathogenic microorganisms, also removes excess fluids in between cells and returns it to the bloodstream. Lymph is also responsible for the absorption of fats.

Question 41

Define lymphedema.

Answer 41

An accumulation of fluid that is normally drained through the lymphatic system but isn’t either due to a blockage or removal of lymph nodes.