Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Health Assesment > Mod 1 > Flashcards

Mod 1 Flashcards

1
Q

What is normal temp for adults? (Oral range)

A

96.6 - 99.5

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Where can temps be taken?

A 
Oral
Axillary 
Temporal
Tympanic 
Rectal
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Axillary temp is not a core temp? True/false

A

True

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Normal rectal temperature is?

A

97.4 - 100.3 it is higher then oral

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Axillary temperature normal range is?

A

95.6 - 98.5 lower than oral

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Tympanic temperatures normal range is?

A

98.0 - 100.9 higher than oral

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Temporal range is?

A

97.4 - 100.3

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What is a normal temperature for and older adult?

A

95.0 - 97.5

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What is your temperature if you have hypothermia?

A

Below 98.0

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What is your temperature if you have hyperthermia?

A

Above 100.9

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

What is a normal pulse?

A

60- 100 beats per minute

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

It is considered tachycardia if the pulse is what?

A

Greater the 100 BPM

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

It is considered bradycardia if the pulse is what?

A

Less then 60 BPM

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

What order should vital signs be taken?

A 
Temperature
Pulse
Respiration 
Blood pressure 
Pain 5th vital
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

What is a disadvantage of a tympanic temperature?

A

Risk of injury to the membrane
Presence of cerumen ( ear wax)
Repeated measurement may vary

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Assessment

A

Collecting subjective and objective data

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Diagnosis

A

Analyzing subjective and objective data to make a professional nursing judgment (nursing diagnosis, collaborative problem, or referral

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Planning

A

Determining outcomes criteria and developing a plan

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Implemention

A

Carrying out the plan

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Evaluation

A

Assessing whether outcome criteria had been met and revising the plan as necessary

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

What is ADPIE?

A 
Assessment 
Diagnosis
Planning 
Implementation
Evaluation
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

What are the pulse sites?

A 
Temporal
Carotid 
Apical- 1 minute 
Brachial
Radial
Femoral 
Popliteal
Dorsalis pedis
Posterior tibial
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

What are normal respiratory rates?

A

Between 12 and 20

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

What is Eupnea?

A

Breathing that is normal in rate and depth

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

What is bradypnea?

A

Abnormally slow respirations

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

What is tachypnea?

A

Abnormally fast respirations

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

What is apnea?

A

Absence of breathing

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

What is Dyspnea?

A

Difficult and labored breathing SOB

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

What is Orthopnea?

A

Ability to breathe only in upright sitting or standing position

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

What is stridor?

A

A shrill, harsh sound heard during inspiration with with laryngeal

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

What is wheeze?

A

Continuous, high-pitched musical squeak or whistling sound occurring on expiration and sometimes on inspiration when air moves through a narrowed or partially obstructed airway

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

What is the normal respirations of an older adult?

A

15- 22

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

Where can blood pressures be taken?

A

Upper arm and in the thigh

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

What is the diaphragm of a stethoscope used for?

A

High pitched sounds

Normal heart
Breath
Bowel

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

What is the bell of a stethoscope used for?

A

Low pitched sounds

Abnormal heart sounds
Bruins- abnormal loud blowing or murmuring sounds

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
36
Q

What is a normal blood pressure?

A

> 120/80

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
37
Q

A blood pressure of 120-139 over 80-89 would be what?

A

Prehypertension recommend follow up 1 years

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
38
Q

Stage 1 hypertension would be what?

A

140-159 over 90-99

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
39
Q

What does COLDSPA stand for?

A 
Characters 
Onset
Location 
Duration 
Severity 
Patterns 
Associated factors
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
40
Q

When describing the characters of pain they should cover what?

A

How it feels dull, sharp, aching, throbbing

How does the area look shiny, bumpy, red, swollen, bruised

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
41
Q

When describing the onset of pain they should cover what?

A

When did it begin

42
Q

When describing the location of pain they should cover what?

A

Where is it

Does it radiate

43
Q

When describing the duration of pain they should cover what?

A

How long does it last?

44
Q

When describing the severity of pain they should cover what?

A

How bad is it

45
Q

When describing the associated factors of pain they should cover what?

A

What makes it better? What makes it worse? What other symptoms occur with it?

46
Q

When identifying Korotkoffs sounds how many phases are there

A

5

47
Q

When identifying Korotkoffs sounds when should you hear auscultatory gap?

A

Latter part of phase one and during phase two

48
Q

When identifying Korotkoffs sounds what should you hear durning phase one?

A

Faint, clear, repetitive tapping sounds that gradually intensify

49
Q

When identifying Korotkoffs sounds what should you hear in phase two?

A

Muffled or swishing

50
Q

When identifying Korotkoffs sounds what should you hear in phase three?

A

Return of distinct, crisp, and louder sound

51
Q

When identifying Korotkoffs sounds what should you hear in phase four?

A

Muffled, less distinct and softer

52
Q

When identifying Korotkoffs sounds what should you hear in phase five?

A

All sound disappearing completely

53
Q

What should you do if you get an abnormal reading while taking a pulse?

A

Preform cardiac auscultation of the apical pulse

54
Q

A blood pressure of 140-159 systolic and 90-99 diastolic would be what?

A

Stage 1 hypertension recommend follow up within two months

55
Q

Someone with stage 2 hypertension would have a blood pressure of what?

A

> 160- > 100 recommend follow up evaluate and treat immediately or within 1 week

56
Q

What are normal Oxygen saturation?

A

95%- 100%

57
Q

What O2 stats are life threatening?

A

70%

58
Q

When documenting the pulse amplitude what can you grade it as?

A

0 absent
1+ weak, diminished
2+ normal
3+ bounding

59
Q

Subjective data that can be obtained by the client?

A

Biographical information
History of past and present health
Health and lifestyle

60
Q

Objective data can be measured or observed such as?

A 
Physical characteristics 
Body functions 
Appearance
Behavior 
Measurements
Results of lab testing
61
Q

Steps of assessment are what?

A

Collection of data
Organizing data
Validating data
Documentation of data

62
Q

What are the for types of assessment?

A

Initial comprehensive assessment
Ongoing or partial assessment
Focused/problem oriented assessment
Emergency assessment

63
Q

What are the phases of the interview?

A

Pre introductory phase
Introductory
Working
Summary and closing

64
Q

What is included in the introductory phase of an interview?

A

The introduction
Explaining the purpose of the interview
Discussing the type of questions that will be asked
Explaining the reason for taking note
Assuring the client that confidential information will remain confidential
Making sure the client is comfortable/ has privacy
Developing trust/ rapport

65
Q

What takes place during the working phase?

A

Biographical data
Reasons for seeking care
History of present health concerns
Past history and family history
Review of body systems for current health lifestyle and health practices and development level
Listening observing cues and using critical thinking skills to interpret and validate information received from the client
Collaborating with the client to identify the client problem and goals

66
Q

What do you do in the summary and closing phase?

A

Summarizing information obtained during the working phase
Validating problem and goals
Identifying and discussing possible plans to resolve the problem with the client
Making sure to ask if anything else concerns the client and if there are any questions

67
Q

When interacting with an anxious client you should do what?

A 
Provide the client with simple organized information in a structured format
Explain who you are and your role
Ask simple questions
Avoid becoming anxious like the client 
Don't hurry
Decrease any external stimuli
68
Q

When interacting with an angry client you should do what?

A

Approach the client in a calm reassuring in control manner
Allow the client to vent feeling
Avoid any arguments with or touching the client
Obtain help from other health care professionals as needed
Facilitate personal space so that the client does not feel threatened or cornered

69
Q

When interacting with a depressed client you should do what?

A

Express interest in and understanding of the client and respond in a neutral manner
Take care not to communicate in an upbeat, encouraging manner

70
Q

When interacting with a manipulative client you should do what?

A

Provide structure and set limits
Differentiate between manipulation and a reasonable request
Obtain an objective opinion from other nursing colleagues

71
Q

When interacting with a seductive client you should do what?

A

Set firm limits on overt sexual client behavior and avoid responding to subtle seductive behaviors
Encourage client to use more appropriate methods of coping in relating to others

72
Q

When interacting with a sensitive client you should do what?

A

Be aware of your own thoughts and feelings regarding dying, spirituality, and sexuality
Ask simple in a nonjudgmental manner
Allow time for ventilation of the clients dealing as needed
If you do not feel comfortable or competent discussing personal, sensitive topics you may make referrals as appropriate

73
Q

When reviewing health history what information would you expect to find?

A 
Biographical data
Reasons for seeking health care 
History of present health concerns 
Past health history 
Family health history 
Review of systems for current health problems 
Developmental level
74
Q

When reviewing biographical data what information would you expect to find?

A 
Name
Address 
Phone
Gender
Providers of history 
Birth date
Place of birth 
Race of ethnic background 
Primary and secondary language 
Marital status 
Religion 
Education level 
Occupation 
Significant other or support person
75
Q

When reviewing lifestyle and health practices what information would you expect to find?

A 
Description of typical day
Nutrition and weight management 
Activity level and exercise 
Sleep and rest
Medications and substance use
Self concept and self care responsibilities 
Social activities 
Relationships values and belief system 
Education and work
Stress levels and coping style 
Environment
76
Q

What equipment is needed to take vital signs?

A 
Sphygmomanometer- blood pressure 
Stethoscope- auscultate
Thermometer- temp
Watch with second hand- pulse, respirations 
Pain scale
77
Q

What equipment is needed for nutritional status examination ?

A

Skin fold calipers
Flexible tape
Skin marking pen
Scale

78
Q

What equipment is needed for skin, hair and nails examination?

A 
Examination light
Pen light
Mirror
Metric ruler
Magnifying glass 
Wood's light to test for fungus 
Braden scale for predicting pressure sore risk
79
Q

What equipment is needed for head and neck examination?

A

Stethoscope to auscultate the thyroid

A small cup of water to help clients swallow

80
Q

What equipment is needed for eye examination?

A 
Penlight 
Smelled E chart- distant vision 
Newspapers to test near vision
Opaque card to test for strabismus 
Ophthalmoscope to view red reflex and to examine the retina of the eye
81
Q

What equipment is needed for ear examination?

A

Tuning fork test for bone and air conduction is sound

Otoscope to view the ear canal and tympanic membrane

82
Q

What equipment is needed for mouth, throat nose, and sinus examination?

A

Penlight
4x4 gauze to grasp tongue
Tongue depressor

83
Q

What equipment is needed for thoracic and lung examination?

A

Stethoscope
metric ruler
Pen

84
Q

What equipment is needed for heart and neck vessel examination?

A

Stethoscope

Two metric rulers

85
Q

What equipment is needed for peripheral vascular examination?

A

Sphygmomanometer and stethoscope
Flexible metric tape
Tuning fork
Doppler ultrasound device

86
Q

What equipment is needed for abdominal examination?

A

Stethoscope
flex metric tape and pen
Two small pillows

87
Q

What equipment is needed for musculoskeletal examination?

A

Flexible metric tape

Goniometer to measure degree of flexibility

88
Q

What equipment is needed for necrologic examination?

A 
Cotton tipped applicator
Newspapers 
Ophthalmoscope 
Flexible metric tape 
An object to feel such as a key or coin
Percussion hammer 
Cotton ball
Paper clip
Salt/ sugar
Coffee/ soap
Smelled E chart
Penlight 
Tongue depressor 
Running fork
89
Q

What equipment is needed for male genitalia and rectum examination?

A

Gloves
Water based lubricant
Penlight
Specimen card

90
Q

What equipment is needed for female genitalia and rectum examination?

A 
Vaginal speculum
Large swabs
Bifid spatula 
Endocervical broom
Liquid pap medium 
Oh paper 
Feminine napkins
91
Q

What is supine position?

A

Lying done flat on back with leg together and arms to side

92
Q

What is dorsal recumbent position?

A

Flat on back knees bent leg separate and feet flat on table with arms at an angle upward

93
Q

What type of palpitations do you use during a physical examination?

A

Light palpation- little or no depression of the skin- pulse, tenderness, temperature

Moderate palpation- depress skin surface 1-2 cm body organs, body masses

Deep palpation- depress the skin surface between 2.5 and 5 cm- deep organs

Bimanual- palpation- requires use of two hands

94
Q

What is percussion?

A

The act of striking ( tapping) the body to elicit sounds that can be heard or vibrations tha can be felt

Eliciting pain
Determining location,size, and shape
Determining density 
Detecting abnormal masses
Eliciting reflexes
95
Q

What are the different types of percussion?

A

Direct-tapping a part of the body with one or two finger tips
Blunt- used to detect tenderness over organs by placing hand flat against the body part and use of the fist strike the flat hand
Indirect or mediate- place a finger flat against the body area and use a finger of the other hand to tap the finger

96
Q

What sounds are elicited by percussion?

A

Resonance ( heard over part air and part solid) normal lung
Hyper-resonance( heard over mostly air) lung with emphysema
Tympany (heard over air) puffed. Out chest gastric bubble
Dullness ( heard over more solid tissue) diaphragm, pleural, effusion, liver
Flatness(heard over very dense tissue) muscle bone, sternum, thigh

97
Q

Durning a physical examination when using auscultation you do what?

A

Eliminate distracting noise
Expose body part being auscultated
Diaphragm is pressed firmly
Bell is pressed lightly

98
Q

What is SBAR used for?

A

It is used as a standardized method of data communications to avoid error durning report

99
Q

What does SBAR stand for?

A

Situation-what’s going with who
Background -events leading up to situation
Assessment-state objective and subjective data you ha collected
Recommendations- what needs to be done

100
Q

What are the 7 steps to analyzing data?

A 
Identify abnormal data and strengths
Cluster data
Draw inferences
Propose possible nursing diagnoses 
Check for defining characteristic 
Confirm or rule out diagnoses 
Document conclusion

Health Assesment (7 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions