NUR 220 - Quiz 1

Question 1

What is a health assessment?

Answer 1

systematic method of collecting + analyzing data

Question 2

what is a health assessment used to create?

Answer 2

plan-of-care

Question 3

5 primary components of a health assessment:

Answer 3

1. History
2. Physical exam
3. Documentation of Data
4. Analyze + interpret data
5. Develope plan-of-care

Question 4

ANA 6 Standards of Practice:

Answer 4

1. Assessment
2. Diagnosis
3. Outcome identification
4. Planning
5. Implementation
6. Evaluation

Question 5

Benefit of clustering data:

Answer 5

problems more clearly apparent

Question 6

what is the body system format?

Answer 6

organizing data based on body system ex. cardiovascular

Question 7

what is conceptual format?

Answer 7

organize based on concept ex. oxygen, perfusion, mmobility

Question 8

difference between health promotion vs. protection?

Answer 8

promotion is when patient already has illness so we try to increase well-being vs. protection is when we try to avoid illness altogether

Question 9

what is primary health promotion?

Answer 9

preventing disease through healthy lifestyle

Question 10

what is secondary health promotion?

Answer 10

screening for early detection

Question 11

what is tertiary health promotion?

Answer 11

already have illness but prevent further diabilities

Question 12

what areas are assessed in lateral recumbant position?

Answer 12

heart, rectum, vagina

Question 13

what areas are assessed in prone position?

Answer 13

musculoskeletal system

Question 14

what areas are assessed in dorsal recumbant position?

Answer 14

head and neck, anterior thorax and lungs, breasts, axillae, heart, abdomen

Question 15

what areas are assessed in supine position?

Answer 15

head and neck, anterior thorax and lungs, breasts, axillae, heart, abdoment, extremities, pulses

Question 16

what areas are assessed in sitting?

Answer 16

head and neck, back, thorax and lungs, breasts, axillae, heart, vital signs, upper extremities

Question 17

what is included in the palpation part of assessment?

Answer 17

touching, light pressing- feeling for consistency, size, shape, tender/painful areas

Question 18

what is palmar used to feel?

Answer 18

vibrations

Question 19

what is dorsal hand used to feel?

Answer 19

temperature

Question 20

light palpation depth

Answer 20

1/2 inch

Question 21

deep palpation depth

Answer 21

2 inches

Question 22

what is assessed in percussion?

Answer 22

light tapping, sound is what is being observed

Question 23

how would you do percussion for obese patients?

Answer 23

stronger percussion

Question 24

how many times should you tap in one area?

Answer 24

2-3x before moving onto next area

Question 25

tymphany

Answer 25

lound, high pitched - abdomen

Question 26

resonance

Answer 26

normal lung sound

Question 27

hyperesonance

Answer 27

overinflated lungs - higher pitched

Question 28

dullness

Answer 28

liver

Question 29

flatness

Answer 29

bones + muscle

Question 30

what is auscultation?

Answer 30

stethescope usage to assess pitch, intensity, duration, and quality

Question 31

whats the most common type of stethoscope?

Answer 31

acoustin

Question 32

what are the binurals?

Answer 32

metal parts that connect stethoscope

Question 33

whats the diaphragm (stethoscope)?

Answer 33

big side - high pitched sounds

Question 34

whats the bell?

Answer 34

small side of stethoscope - low pitch or soft sounds

Question 35

term for blood pressure machine

Answer 35

sphygmanometer

Question 36

if the cuff size is too small what will happen to the blood pressure?

Answer 36

too high

Question 37

if the cuff size is too large what will happen to the blood pressure?

Answer 37

too low

Question 38

what is a limitation of using an automated blood pressure machine?

Answer 38

cannot asses quality or strength of brachial pulse

Question 39

what is the advantage of an automated blood pressure machine?

Answer 39

can take blood pressure in time intervals

Question 40

chart used in dr. office to test vision

Answer 40

snellen chart

Question 41

what is the top number of a snellen chart reading?

Answer 41

distance away from chart (20)

Question 42

who is the E snellen chart used for?

Answer 42

kids + non-english speakers

Question 43

common tool for nurses that is used during inspection of skin or eyes of a patient

Answer 43

penlight

Question 44

what do nurses use a ruler or tape measure for?

Answer 44

to measure wounds or to take circumfrance of infants heads

Question 45

purpose of physical exam

Answer 45

- gather baseline data - confirm or refute subjective data - identift + confirm nursing diagnosis - make clinical decisions - evaluate outcomes