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Nursing School > NUR 220 - Quiz 1 > Flashcards

NUR 220 - Quiz 1 Flashcards

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1
Q

What is a health assessment?

A

systematic method of collecting + analyzing data

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2
Q

what is a health assessment used to create?

A

plan-of-care

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3
Q

5 primary components of a health assessment:

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

ANA 6 Standards of Practice:

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

Benefit of clustering data:

A

problems more clearly apparent

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6
Q

what is the body system format?

A

organizing data based on body system ex. cardiovascular

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7
Q

what is conceptual format?

A

organize based on concept ex. oxygen, perfusion, mmobility

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8
Q

difference between health promotion vs. protection?

A

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

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9
Q

what is primary health promotion?

A

preventing disease through healthy lifestyle

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10
Q

what is secondary health promotion?

A

screening for early detection

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11
Q

what is tertiary health promotion?

A

already have illness but prevent further diabilities

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12
Q

what areas are assessed in lateral recumbant position?

A

heart, rectum, vagina

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13
Q

what areas are assessed in prone position?

A

musculoskeletal system

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14
Q

what areas are assessed in dorsal recumbant position?

A

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

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15
Q

what areas are assessed in supine position?

A

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

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16
Q

what areas are assessed in sitting?

A

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

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17
Q

what is included in the palpation part of assessment?

A

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

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18
Q

what is palmar used to feel?

A

vibrations

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19
Q

what is dorsal hand used to feel?

A

temperature

20
Q

light palpation depth

A

1/2 inch

21
Q

deep palpation depth

A

2 inches

22
Q

what is assessed in percussion?

A

light tapping, sound is what is being observed

23
Q

how would you do percussion for obese patients?

A

stronger percussion

24
Q

how many times should you tap in one area?

A

2-3x before moving onto next area

25
Q

tymphany

A

lound, high pitched - abdomen

26
Q

resonance

A

normal lung sound

27
Q

hyperesonance

A

overinflated lungs - higher pitched

28
Q

dullness

A

liver

29
Q

flatness

A

bones + muscle

30
Q

what is auscultation?

A

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

31
Q

whats the most common type of stethoscope?

A

acoustin

32
Q

what are the binurals?

A

metal parts that connect stethoscope

33
Q

whats the diaphragm (stethoscope)?

A

big side - high pitched sounds

34
Q

whats the bell?

A

small side of stethoscope - low pitch or soft sounds

35
Q

term for blood pressure machine

A

sphygmanometer

36
Q

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

A

too high

37
Q

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

A

too low

38
Q

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

A

cannot asses quality or strength of brachial pulse

39
Q

what is the advantage of an automated blood pressure machine?

A

can take blood pressure in time intervals

40
Q

chart used in dr. office to test vision

A

snellen chart

41
Q

what is the top number of a snellen chart reading?

A

distance away from chart (20)

42
Q

who is the E snellen chart used for?

A

kids + non-english speakers

43
Q

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

A

penlight

44
Q

what do nurses use a ruler or tape measure for?

A

to measure wounds or to take circumfrance of infants heads

45
Q

purpose of physical exam

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

Nursing School (16 decks)

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