Interactions & Vital Signs

Question 1

temperature: expected value

Answer 1

98.6F / 37C (adult)

Question 2

pulse: expected value

Answer 2

60 - 100 bpm (adult)

Question 3

pulse: character

Answer 3

0+ absent
1+ diminished/barely palpable
2+ expected
3+ full/strong
4+ bounding

Question 4

respiratory rate: expected

Answer 4

12 - 20 respirations per minute (resting)

Question 5

BP - cuff too wide

Answer 5

false low

Question 6

BP - cuff too narrow

Answer 6

false high

Question 7

BP - deflate cuff too quickly

Answer 7

false low systolic, false high diastolic

Question 8

BP - arm below heart level

Answer 8

false high reading

Question 9

BP - arm above heart level

Answer 9

false low

Question 10

BP - cuff or stethoscope placed over clothing

Answer 10

false high

Question 11

History of Present Illness: 7 dimensions

Answer 11

1 location
2 quality
3 quantity (pain, use scale)
4 timing/setting
5 aggravating factors
6 alleviating factors
7 associated data

Question 12

physiologic indicator of pain (mnemonic!)

Answer 12

FLACC
Facial expression
Leg movement
Activity (other body movement)
Crying (or other vocalization)
Consolability

Question 13

When do you use FLACC?

Answer 13

cognitive disability, unconscious, head trauma, children

Question 14

BMI

Answer 14

weight / height^2

Question 15

AIDET

Answer 15

A cknowledge
I ntroduce
D uration
E xpectation
T hank you

Question 16

SOAPIE (assessment in action)

Answer 16

S ubjective
O bjective
A nalysis
P lan (goal + Expected Client Outcomes)
I mplement interventions
E valuation

Question 17

physical exam: assessment techniques

Answer 17

I nspection
P ercussion
P alpation
A uscultation

Question 18

stethoscope diagphragm

Answer 18

high pitch sounds (ex: lungs, bowels)

Question 19

stethoscope bell

Answer 19

low pitch sounds (ex: some heart, vascular)

Question 20

SOAP (documentation)

Answer 20

S ubjective
O bjective
A nalysis
P lan

Question 21

percussion character of sound

Answer 21

tympany: air or fluid
dull: solid tissue

Question 22

ECO + SMART

Answer 22

Expected Client Outcome

specific, measurable, attainable, realistic, timely

Question 23

Hi 5s - P H I V ES

Answer 23

P rocedure
H ands
ID/V erify
E quipment
S afety

Question 24

Bye 5s

Answer 24

1. Wash hands
2. Equipment
3. Safety
4. Teach
5. Chart

Question 25

SBAR

Answer 25

S ituation B ackground A ssessment R ecommendations

Question 26

The Nursing Process (5)

Answer 26

``` Assessment > Nursing Diagnosis > Planning > Implementation > Evaluation > ``` So what? Was it effective? Always analysis.