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NU 305 final exam Flashcards

1
Q

When would you use a focused assessment?

A

occurs in settings that need a smaller scope, but with increased depth. Example: before treatment, postop.
-focused on one system or one problem
-usually used in the ER

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2
Q

When would you use a comprehensive assessment?

A

Complete health and physical assessment is performed.

Used on things such as
- yearly check-ups
-admissions

used to check for cognitive development, emotional development, and physical growth

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3
Q

What is subjective data?

A

-what the patient tells you.
-things that only the patient can feel

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4
Q

What is objective data?

A

-what you can see as the nurse
-how the skin looks
-what you hear when auscultating
-visual appearance
-measurable info (V/S)

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5
Q

How do you state a chief complaint?

A

-In the patients own words
-their statement about what they are feeling
- “My head feels like its going to explode”

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6
Q

What is a review of systems?

A

-a way to assess the whole body
-helps to determine which systems need more focus than others
-involves critical thinking

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7
Q

Opening and closing interview :
Pre-interaction phase

A

-collecting information from their medical record
-previous hx of medical procedures, illness, allergies, and surgeries
- current medication list
- used to help detect medical patterns of illness

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8
Q

Opening and closing interview :
Opening phase

A

-beginning phase
-introducing yourself
-basic hellos

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9
Q

Opening and closing interview :
Working phase

A

-collecting data by asking questions about the pt.
- asking open ended questions
-can use close ended questions to help pt identify pain

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10
Q

Opening and closing interview :
Closing phase

A

-summarizing what the pt is there for
-letting pt know plan or next steps
- asking pt if they need anything else
-reviewing completeness of notes and letting the pt know they have been heard

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11
Q

When does discharge planning begin?

A

nurse starts planning discharge on admission

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12
Q

Use of an interpreter

A

-look at pt, not the interpreter
-provide written material in their language
- DON’T use family members as interpreter

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13
Q

What are some examples of therapeutic communication?

A

-interaction focuses on the pt
- caring
-empathy and connection with the pt
- self concept; being aware of self biases

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14
Q

How do you check for skin abnormalities on different ethnicities?

A

check the eyes, mucous membranes, palm of hands for darker ethnicities; this is checking for cyanosis

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15
Q

What is flushing of the skin?

A

increased permeability of the peripheral capillaries as with a fever

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16
Q

What is pallor of the skin?

A

decreased arterial blood flow of arterial insufficiency

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17
Q

What is Rubor or Brawny skin?

A

decreased venous return in venous insufficiency

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18
Q

What is the cause of fingernail clubbing?

A

long periods of hypoxia

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19
Q

what is jaundice?

A

Yellow discolouration of the skin or sclera
- liver disease

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20
Q

what would you expect with perfusion arterial issues?

A

White

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21
Q

What would you expect with arterial issues?

A

-ulcers on distal extremities
-cool to touch
-red
-Wound edges are DEFINED

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22
Q

What would you expect with venous issues?

A

-blue
- warm to touch
-brownish discoloration of lower leg
-edges of wounds are IRREGULAR

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23
Q

Common nursing diagnosis associated with the integumentary system?

A

-Impaired skin integrity
-impaired tissue integrity
-pain
-risk for infection

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24
Q

what are symptoms of dehydration?

A

-poor skin turgor
-dry mucous membranes
- decreased urinary output
-low BP

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25
What is a pressure ulcer?
localized damage to the skin or underlying soft tissue usually over a bony prominence or related to medical or other device
26
Stage 1 Pressure ulcer
-skin may appear darker -non blanch-able redness
27
Stage 2 Pressure ulcer
-partial thickness loss of skin with exposed dermis -wound bed is viable
28
Stage 3 Pressure ulcer
-full thickness skin loss -tunnelling may occur - bone and cartilage is NOT exposed
29
Stage 4 Pressure ulcer
-full thickness and tissue loss - rolled edge - tunneling
30
Stage 5 Pressure ulcer
-unstageable -extent of damage cannot be confirmed because it is obscured by slough or eschar
31
Normal findings of the lungs: Inspection
-AP diameter ratio 1:2 -chest expansion is symmetrical -no accessory muscle use -retractions are absent
32
Normal findings of the lungs: Palpitation
-thorax is non tender without any lesion -tactile remits is equal bilaterally (say 99)
33
Normal findings of the lungs: Auscultation
-breath sounds are louder and coarser in larger airways - smaller airways are softer and finer -no adventitious sounds (crackles, wheezes, and rhon chi)
34
What do wheezes sounds like?
-narrowed airway -asthma -high pitch -musical sounds
35
What does rhonchi sound like?
-mucous, large airways, gurgling or bubbling sounds -low pitched -snoring -tell pt to cough -pneumonia
36
What does stridor sound like?
-airway obstruction - medical emergency - can hear without stethoscope
37
What does crackles sound like?
-fluid in the alveoli -pneumonia and fluid overload -Fine sounds or course sounds
38
Bronchial sounds
-loud and high pitched -course or tubular - heard more on expiration -larynx and trachea
39
bronchovesicular sounds
-intermediate pitched - inspiration and expiration equal - between 1st and 2nd intercostal spaces
40
vesicular sounds
-soft and low pitched - whispering undertones -inspiration greater than expiration -heard over most of the lung fields
41
Cardiovascular risk factors
HONEST H-heritage O-obesity N-nicotine E-exercise (lack of) S- sugar greater than 130 or dx of diabetes T- triglycerides/ LDL - if LDL is high = bad cholestrol
42
What happens in systole?
-Lub sound -S1 -ventricle contracting- semilunar valves open
43
What happen in diastole?
-Dub sound -s2 -relaxing and feeling -semilunar valves are closed
44
Nursing diagnosis for CV
-decreased cardiac output -risk for decreased cardiac tissue perfusion
45
Evaluation of the carotid
-auscultate 1 at a time -instruct pt to hold breath while listening -use bell of stethescope -listen for bruits/ swooshing sounds
46
what does a murmur sound like?
-low pitched -swoosh -issue with the valve
47
top nursing diagnosis for peripheral vascular system
-ineffective peripheral tissue perfusion -risk for peripheral neurovascular dysfunction - activity intolerance
48
grading of pulses
-0: absent -1+: thready -2+: normal -3+: increased -4+: bounding
49
Pulse sites
radial femoral popliteal dorsalis pedis posterior tibialis
50
Way to assess the abdomen in order
-inspection -auscultation -percussion -palpitation
51
Top nursing diagnosis for abdomen
-imbalanced nutrition -less than body requirements -diarrhea -constipation -impaired urinary elimination -urinary retention
52
What is the Murphy's sign?
-inflammation of the gallbladder -sharp pain when the liver pushes into the gallbladder - hook them in the liver to see if pain occurs in the RUQ
53
What is the Blumberg sign
-AKA rebound tenderness -indicates appendicitis - press on it and it hurts when you let go
54
What is obturator sign?
-internal rotation of the hip -appendix is inflammed - pt is lying down, pt raises leg and there is pain in RLQ
55
McBurneys point
RLQ- appendicitis
56
Normal finding of the abdomen: Inspection
-flat and symmetrical -no pulsations -no hernias noted - no distension -urine is clear and pale yellow
57
Normal finding of the abdomen: Auscultation
-use the diaphragm -5-30 gurgles per min -a sound every 5-15 sec -listen to up to 5 min if you do not hear any sounds -vascular sounds with the bell -listen for bruits over the aorta, renal, and iliac arteries -listen over spleen and liver for friction rubs
58
Normal finding of the abdomen: Percussion
-dullness over RUQ over liver -tympanic over LUQ -slight to no pain -spleen is dull -bladder is nonpalpable
59
Normal finding of the abdomen: Palpitation
-no tenderness -no masses -no ascites -no guarding -nothing enlarged
60
What is referred pain
pain that comes from something else
61
How to perform abdominal aorta assessment
-should be less than 3 cm (if more could be aneurism) -listen for bruit -palpate to see for significant pulse -hear a murmer, feel a thrill
62
Osteoporosis prevention
-30 min, 3 times a week for weight bearing exercises - bone screenings at age 65 for women -decrease caffeine -dont smoke and drink -increase calcium intake - vitamin D
63
Top nursing diagnosis for Musculoskeletal
-impaired physical ability -activity tolerance -readiness for advance self-care -impaired walking - risk for frail elderly syndrome
64
Normal finding for the musculoskeletal system: Inspection
-jaw is symmetrical -cervical spine is straight -no swelling or redness in joints -feet are same color as rest of body
65
Rating scale for muscle strength
5/5 - normal 4/5-good 3/5- fair 2/5-poor 1/5- trace 0/5-zero
66
Deep tendon reflex grading
4+ very brisk, hyperactive with clonus 3+ brisker than average 2+ average normal 1+diminished, low normal 0 absent
67
How to asses for LOC
-Glascow coma (eye opening, verbal response, motor response) -oriented to time, place, person, situation
68
Cranial nerves saying
Oh, Oh, Oh, To Touch And Feel A Girl's Vagina, Ah, Heaven
69
Cranial nerve I
olfactory - smell test
70
Cranial nerve II
optic - sight/visual activity - Snellen Chart
71
Cranial nerve III
Oculomotor - eyeball movement/ pupil dilation - check size and shape of pupils
72
Cranial nerve IV
trochlear- vertical eyeball movement- 6 cardinal fields of gaze
73
Cranial nerve V
trigeminal - facial sensation - touch face with cotton ball
74
Cranial nerve VI
abducens - lateral eyeball movement - nystagmus
75
Cranial nerve VII
facial - taste , facial expressions. smile. clench teeth
76
Cranial nerve VIII
acoustic - hearing -- whisper test or Rinne test
77
Cranial nerve IX
Glossopharyngeal- taste, swallow, saliva, gag reflex
78
Cranial nerve X
Vagus- swallowing, cough, gag use tongue blade
79
Cranial nerve XI
accessory - head turning, shoulder movement
80
Cranial nerve XII
Hypoglossal - tongue movement - light, tight, dynamite
81
Top nursing diagnosis for Neuro
-impaired verbal communication -acute confusion -impaired memory - unilateral neglect -risk for aspiration - decrease inter cranial adaptive capacity - risk for ineffective cerebral tissue perfusion
82
Vertigo
-severe - inner ear problem - room spinning
83
what are the extra ocular muscle evaluation
6 cardinal fields of gaze

NU 305 (1 decks)

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