Mod 1 Flashcards
1
Q
What is normal temp for adults? (Oral range)
A
96.6 - 99.5
2
Q
Where can temps be taken?
A
Oral Axillary Temporal Tympanic Rectal
3
Q
Axillary temp is not a core temp? True/false
A
True
4
Q
Normal rectal temperature is?
A
97.4 - 100.3 it is higher then oral
5
Q
Axillary temperature normal range is?
A
95.6 - 98.5 lower than oral
6
Q
Tympanic temperatures normal range is?
A
98.0 - 100.9 higher than oral
7
Q
Temporal range is?
A
97.4 - 100.3
8
Q
What is a normal temperature for and older adult?
A
95.0 - 97.5
9
Q
What is your temperature if you have hypothermia?
A
Below 98.0
10
Q
What is your temperature if you have hyperthermia?
A
Above 100.9
11
Q
What is a normal pulse?
A
60- 100 beats per minute
12
Q
It is considered tachycardia if the pulse is what?
A
Greater the 100 BPM
13
Q
It is considered bradycardia if the pulse is what?
A
Less then 60 BPM
14
Q
What order should vital signs be taken?
A
Temperature Pulse Respiration Blood pressure Pain 5th vital
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
16
Q
Assessment
A
Collecting subjective and objective data
17
Q
Diagnosis
A
Analyzing subjective and objective data to make a professional nursing judgment (nursing diagnosis, collaborative problem, or referral
18
Q
Planning
A
Determining outcomes criteria and developing a plan
19
Q
Implemention
A
Carrying out the plan
20
Q
Evaluation
A
Assessing whether outcome criteria had been met and revising the plan as necessary
21
Q
What is ADPIE?
A
Assessment Diagnosis Planning Implementation Evaluation
22
Q
What are the pulse sites?
A
Temporal Carotid Apical- 1 minute Brachial Radial Femoral Popliteal Dorsalis pedis Posterior tibial
23
Q
What are normal respiratory rates?
A
Between 12 and 20
24
Q
What is Eupnea?
A
Breathing that is normal in rate and depth
25
What is bradypnea?
Abnormally slow respirations
26
What is tachypnea?
Abnormally fast respirations
27
What is apnea?
Absence of breathing
28
What is Dyspnea?
Difficult and labored breathing SOB
29
What is Orthopnea?
Ability to breathe only in upright sitting or standing position
30
What is stridor?
A shrill, harsh sound heard during inspiration with with laryngeal
31
What is wheeze?
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
32
What is the normal respirations of an older adult?
15- 22
33
Where can blood pressures be taken?
Upper arm and in the thigh
34
What is the diaphragm of a stethoscope used for?
High pitched sounds
Normal heart
Breath
Bowel
35
What is the bell of a stethoscope used for?
Low pitched sounds
Abnormal heart sounds
Bruins- abnormal loud blowing or murmuring sounds
36
What is a normal blood pressure?
> 120/80
37
A blood pressure of 120-139 over 80-89 would be what?
Prehypertension recommend follow up 1 years
38
Stage 1 hypertension would be what?
140-159 over 90-99
39
What does COLDSPA stand for?
```
Characters
Onset
Location
Duration
Severity
Patterns
Associated factors
```
40
When describing the characters of pain they should cover what?
How it feels dull, sharp, aching, throbbing
| How does the area look shiny, bumpy, red, swollen, bruised
41
When describing the onset of pain they should cover what?
When did it begin
42
When describing the location of pain they should cover what?
Where is it
| Does it radiate
43
When describing the duration of pain they should cover what?
How long does it last?
44
When describing the severity of pain they should cover what?
How bad is it
45
When describing the associated factors of pain they should cover what?
What makes it better? What makes it worse? What other symptoms occur with it?
46
When identifying Korotkoffs sounds how many phases are there
5
47
When identifying Korotkoffs sounds when should you hear auscultatory gap?
Latter part of phase one and during phase two
48
When identifying Korotkoffs sounds what should you hear durning phase one?
Faint, clear, repetitive tapping sounds that gradually intensify
49
When identifying Korotkoffs sounds what should you hear in phase two?
Muffled or swishing
50
When identifying Korotkoffs sounds what should you hear in phase three?
Return of distinct, crisp, and louder sound
51
When identifying Korotkoffs sounds what should you hear in phase four?
Muffled, less distinct and softer
52
When identifying Korotkoffs sounds what should you hear in phase five?
All sound disappearing completely
53
What should you do if you get an abnormal reading while taking a pulse?
Preform cardiac auscultation of the apical pulse
54
A blood pressure of 140-159 systolic and 90-99 diastolic would be what?
Stage 1 hypertension recommend follow up within two months
55
Someone with stage 2 hypertension would have a blood pressure of what?
>160- > 100 recommend follow up evaluate and treat immediately or within 1 week
56
What are normal Oxygen saturation?
95%- 100%
57
What O2 stats are life threatening?
70%
58
When documenting the pulse amplitude what can you grade it as?
0 absent
1+ weak, diminished
2+ normal
3+ bounding
59
Subjective data that can be obtained by the client?
Biographical information
History of past and present health
Health and lifestyle
60
Objective data can be measured or observed such as?
```
Physical characteristics
Body functions
Appearance
Behavior
Measurements
Results of lab testing
```
61
Steps of assessment are what?
Collection of data
Organizing data
Validating data
Documentation of data
62
What are the for types of assessment?
Initial comprehensive assessment
Ongoing or partial assessment
Focused/problem oriented assessment
Emergency assessment
63
What are the phases of the interview?
Pre introductory phase
Introductory
Working
Summary and closing
64
What is included in the introductory phase of an interview?
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
What takes place during the working phase?
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
What do you do in the summary and closing phase?
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
When interacting with an anxious client you should do what?
```
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
When interacting with an angry client you should do what?
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
When interacting with a depressed client you should do what?
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
When interacting with a manipulative client you should do what?
Provide structure and set limits
Differentiate between manipulation and a reasonable request
Obtain an objective opinion from other nursing colleagues
71
When interacting with a seductive client you should do what?
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
When interacting with a sensitive client you should do what?
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
When reviewing health history what information would you expect to find?
```
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
When reviewing biographical data what information would you expect to find?
```
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
When reviewing lifestyle and health practices what information would you expect to find?
```
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
What equipment is needed to take vital signs?
```
Sphygmomanometer- blood pressure
Stethoscope- auscultate
Thermometer- temp
Watch with second hand- pulse, respirations
Pain scale
```
77
What equipment is needed for nutritional status examination ?
Skin fold calipers
Flexible tape
Skin marking pen
Scale
78
What equipment is needed for skin, hair and nails examination?
```
Examination light
Pen light
Mirror
Metric ruler
Magnifying glass
Wood's light to test for fungus
Braden scale for predicting pressure sore risk
```
79
What equipment is needed for head and neck examination?
Stethoscope to auscultate the thyroid
| A small cup of water to help clients swallow
80
What equipment is needed for eye examination?
```
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
What equipment is needed for ear examination?
Tuning fork test for bone and air conduction is sound
| Otoscope to view the ear canal and tympanic membrane
82
What equipment is needed for mouth, throat nose, and sinus examination?
Penlight
4x4 gauze to grasp tongue
Tongue depressor
83
What equipment is needed for thoracic and lung examination?
Stethoscope
metric ruler
Pen
84
What equipment is needed for heart and neck vessel examination?
Stethoscope
| Two metric rulers
85
What equipment is needed for peripheral vascular examination?
Sphygmomanometer and stethoscope
Flexible metric tape
Tuning fork
Doppler ultrasound device
86
What equipment is needed for abdominal examination?
Stethoscope
flex metric tape and pen
Two small pillows
87
What equipment is needed for musculoskeletal examination?
Flexible metric tape
| Goniometer to measure degree of flexibility
88
What equipment is needed for necrologic examination?
```
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
What equipment is needed for male genitalia and rectum examination?
Gloves
Water based lubricant
Penlight
Specimen card
90
What equipment is needed for female genitalia and rectum examination?
```
Vaginal speculum
Large swabs
Bifid spatula
Endocervical broom
Liquid pap medium
Oh paper
Feminine napkins
```
91
What is supine position?
Lying done flat on back with leg together and arms to side
92
What is dorsal recumbent position?
Flat on back knees bent leg separate and feet flat on table with arms at an angle upward
93
What type of palpitations do you use during a physical examination?
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
What is percussion?
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
What are the different types of percussion?
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
What sounds are elicited by percussion?
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
Durning a physical examination when using auscultation you do what?
Eliminate distracting noise
Expose body part being auscultated
Diaphragm is pressed firmly
Bell is pressed lightly
98
What is SBAR used for?
It is used as a standardized method of data communications to avoid error durning report
99
What does SBAR stand for?
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
What are the 7 steps to analyzing data?
```
Identify abnormal data and strengths
Cluster data
Draw inferences
Propose possible nursing diagnoses
Check for defining characteristic
Confirm or rule out diagnoses
Document conclusion
```
