Unit 2

Question 1

Cephalocaudal

Answer 1

from head to toe

Question 2

Directive interview

Answer 2

highly structured

closed questions elicit specific information

Question 3

Subjective Data

Answer 3

• Obtained from client (primary source)
• recorded in “OWN WORDS”
• verified only by client
• symptoms/ covert data

Question 4

Objective Data

Answer 4

• detected by an observer
• measured/ tested against acceptable standards
• signs/ overt data

Question 5

Components of the Nursing Health History

Answer 5

Being Complete Makes For Proper Assessment

• Biographic Data
• Chief Complaint & HPI (hx of present illness)
• PMH
• Family Health Hx
• Pscyhosocial- Lifestyle & Health Practice Profile
• Assessment - ADL’s

Question 6

Discoloration of the skin (subject or objective)

Answer 6

objective

Question 7

Four Types Of Assessment

Answer 7

1. Initial
2. Problem-Focused
3. Emergency
4. Time-lapsed Reassessment

Question 8

Time-lapsed Reassessment

Answer 8

• several months after initial assessment

- compare to baseline data previously obtained

Question 9

Inspection

Answer 9

• visual examination; also uses senses (hearing & smell)

- deliberate, purposeful, systematic

Question 10

Pallor

Answer 10

• result inadequate circulating blood/ hemoglobin & subsequent reduction in tissue oxygenation

Question 11

Database

Answer 11

subject and objective data that provides baseline for comparing clients responses to medical/ nursing interventions

Question 12

Initial Assessment

Answer 12

performed within a specific time after admission

Question 13

Percussion

Answer 13

• tapping/ striking body surface to –> sound/ vibrations

- reveals location, size, and density of underlying structures (air/ fluid - filled, solid)

Question 14

Direct Percussion

Answer 14

directly on skin

Question 15

Indirect Percussion

Answer 15

non-dominate hand between subject and striking

Question 16

Blunt

Answer 16

Ulnar surface of fist against skin surface

Question 17

Tympany

Answer 17

• gas/ bowels (air-filled stomach)
• musical
• high-pitched, drum-like
• least dense tissues

Question 18

Dullness

Answer 18

– thudlike; organs→ liver, heart, spleen

Question 19

Hyper-resonance

Answer 19

• booming → emphysematous lung

- not anticipated

Question 20

Resonance

Answer 20

– hallow; lungs filled with air

Question 21

Stethoscope

Answer 21

• Diaphragm - S1/S2; high pitched

- Bell - S3/S4; Bruits, mummurs, low pitched

Question 22

PERRLA

Answer 22

Pupils 
Equal 
Round
Respond to Light
Accommodation

Question 23

Normal Pupil Size

Answer 23

3-5mm

Question 24

Normal Breath Sounds

Answer 24

• heard over Entire Lung
• inspiratory and expiration
• PRIMARY source is turbulent flow of air in larger airways

Question 25

Tracheal

Answer 25

• pause between I & E

- tubular quality

Question 26

Bronchial

Answer 26

• 1:2 ratio
• anteriorly over trachea
• Short Inspiratory, Loud Expiratory

Question 27

Bronchovesicular

Answer 27

• 1:1 ration

- Between scapulae posterior 1&2 ICS Anteriorly

Question 28

5-P’s

Answer 28

Pain, Pulse, Pallor, Paresthesia, Paralysis

Question 29

5th Vital Sign (Pain Assessment)

Answer 29

P,Q,R,S,T

• Provocative
• Quality/ Quantity
• Region/ Radiation
• Severity
• Timing

Question 30

Celsius

Answer 30

(F-32)*(5/9)

Question 31

F=

Answer 31

(C*9/5)+32

Question 32

Normal SaO2

Answer 32

95-100