Nurse 252

Question 1

what does the nursing process include?

Answer 1

Assessment, Diagnosis, outcome identification, planning, implementaiton, and evalution

Question 2

what is a first level priority

Answer 2

those that are emergencies, life-threatening, and immediate, such as establishing airway or support breathing

Question 3

What is a second level priority?

Answer 3

Those that are next in urgency; necessitating prompt intervention to prevent further deterioration, such as a mental status change, acute pain, untreated medicate problem, abnormal labs, risk to safety and security

Question 4

what is a third level priority?

Answer 4

problems that those that are important to the patient’s health that can be addressed after more urgent health problems are addressed

Question 5

what is evidence-informed practice?

Answer 5

” gold standard” - systematic approach to practice that emphasizes the use of best evidence in combination with the clinician’s experience, as well as the patient preferences and values, to make decisions about care and treatment

Question 6

what does the world health organization identify the prerequisites to health as?

Answer 6

peace, shelter, education, food, income, a stable ecosystem, sustainable resources, social justice and equity

Question 7

definition of health promotion?

Answer 7

a comprehensive social and political process of enabling people to increase control over the determinants of health and thereby improve their health

Question 8

what are some examples of health promotion from the public health agency of Canada?

Answer 8

• Canadas food guide
• Community Action for Children Edmonton
• Physical activity tips for seniors
• injury prevention programs

Question 9

what does a complete health database include?

Answer 9

complete health history and results of a full physical examination

Question 10

what is inspection?

Answer 10

• begins the moment you meet your patient, starts the assessment of each body system with inspection
• learn to use each pt by comparing left to right of their body

Question 11

what is palpation

Answer 11

• follows inspection
• Assess texture, temp, moisture, and organ location as well as any swelling, virbration, ridigity, or spasticity, crepitation, presense of lumps or masses, and presense of tendernes or pain

Question 12

what are the fingertips of ones hand used to determine in palpation?

Answer 12

Skin texture, swelling, pulsation, and determining the presence of lumps

Question 13

what is the dorsa (back of hands) used to determine in palpation?

Answer 13

for determining temp because the skin is thinner

Question 14

what should a nurse be catious about when palpating?

Answer 14

to avoid deep palpation in situations in which it could cause internal injury or pain

Question 15

what is precussion and what is it used for?

Answer 15

is it the tapping on the pts skin with short, strokes to assess undelying structures
-the strokes yeild a palpable vibration that depicts the location, size, and density of the underlying organ

Question 16

what is ausculation?

Answer 16

listening to sounds produced by parts of the body, such as the heart and blood vesseles, lungs and the abdomen

Question 17

can a nurse listen through a pts gown?

Answer 17

no

Question 18

what kind of sounds is the disaphram used to listen to?

Answer 18

high pitched sounds, such as breath, bowel and normal heart sounds

Question 19

what kind of sounds is the dell used to listen to?

Answer 19

low pitched sounds such as extra heart sounds or murmurs

Question 20

what is a general survey?

Answer 20

a study of a whole person, covering the general health state and any obvious physical charactristic
Consider: physical apperance, body structure, mobility and behaviour

Question 21

what should a nurse observe when it comes to physical apperance

Answer 21

age (do they appear thier stated age?)
Sex; (sexual development appropriate for gender and age)
Level of consciousness; alert and oreinted, reponding appropraitely
skin colour: even tone, intact skin with no odvious lesions
facial features: symmetrical with movement
-No sign acute distress

Question 22

what should a nurse observe about body structure?

Answer 22

Stature: height within normal range for age
Nutrition: weight within normal ranch for height and body build
Symmetry: Body parts equal bilaterally and in relative proportion to eachother
Posture: sitting comfortably in a chair, on bed or exam table
Body build, Contour: Normal proportions

Question 23

what should a nurse assess with mobiltiy of a pt?

Answer 23

Gait: normally, base width equal to shoulder width, well balanced walk
Range of motion: full mobility in each joint

Question 24

what should a nurse assess with a pts behaviour?

Answer 24

Facial expression: maintanining eye contact with examiner
Mood and Affect: Comfertable and cooperative with the examiner and interacting pleasently
Speech: clear and understandable articulation
dress: clothing appropriate for climate, looks clean and fits the body
Personal hygiene: Clean and groomed approparitely for pts age, occupation and socioeconomic group