Week 1-2 lecture

Question 1

1.What are the five steps in hand rubbing *hand hygiene with alcohol based hand sanitizer 2.Duration? Flat Bed Pickups interweave through firetrucks

Answer 1

Flat Palms Back of hands interlaced Palms interlaced Interlocked hands *finger pads* Thumbs Fingertips 20 seconds until dry

Question 2

What 4 things should all assessments be? SAC-E

Answer 2

Safe, Accurate, Systematic, Efficient

Question 3

What are two main types of impaired cognitive status?

Answer 3

1 dementia 2. Brain injury or dysfunction

Question 4

How can the RN become more culturally aware?

Answer 4

Through Self-reflection and Elimination of personal biases

Question 5

Aprox. how many people die in hospitals each year due to medical errors that could have been prevented?

Answer 5

44,000 - 98,000

Question 6

The RN should always use what type of communication?

Answer 6

Therapeutic Communication

Question 7

What does MDS stand for and when is it utilized?

Answer 7

Minimum Data Set used in medicare

Question 8

What are the 5 methods of assessment? IPP-AO

Answer 8

1. Inspection 2. Palpation 3. percussion 4. Auscultation 5. Olfaction

Question 9

What are the 5 components of a basic complete physical exam. Ruby Has Visits Post Sex

Answer 9

1. Reason for Visit 2. Health history (subjective) 3. Vitals 4. Physical assessment 5. Systematic assessment

Question 10

Health assessment data is either ____ or ____

Answer 10

Healthy and within defined limits or not (equates to a health problem)

Question 11

What do continuous, ongoing, and follow-up assessments determine? How?

Answer 11

Determine the effects of time and/or nursing care by comparing the most recent assessments with previous ones

Question 12

The RN should do what action every-time they interact with the patient

Answer 12

1. Complete a quick assessment at minimum 2. Follow AIDET

Question 13

Describe lateral recumbent position

Answer 13

Patient lies on side with lower extremities moderately flexed

Question 14

What are the two main focuses of a physical assessment?

Answer 14

1.Subjective data 2. Objective data

Question 15

What are the 4 main types of developmental differences that the RN may need to accommodate for during physical assessments? AIR-I

Answer 15

1. Age (growth and development of children) 2. Impaired or delayed development 3. Regression-trauma 4 impaired cognitive status

Question 16

What are the 5 aspects of holistic patient centered care? PPDSS *for each aspect tell if it is subjective or objective*

Answer 16

1. Psychological-Sub 2. Physiological-Ob 3. Developmental-Ob 4. Sociocultural-Sub 5. Spiritual-Sub

Question 17

What is the purpose of a basic complete physical? 2

Answer 17

1. To obtain objective data and interpret it 2. To determine patients status

Question 18

What 3 things does the RN need to ensure they are respectful of during assessments? Carefully Recognize Emergency’s

Answer 18

1. Culture 2. Ethnicity 3. Religion

Question 19

Describe supine position

Answer 19

lying on the back with the face up.

Question 20

What is the nurses responsibility upon discovering any abnormal finding or change in patient status?

Answer 20

To immediately report change to MD or NP

Question 21

Describe Dorsal Recumbent position

Answer 21

patient lies on the back with the lower extremities moderately flexed and rotated outward.

Question 22

Describe lithotomy position

Answer 22

a supine position of the body with the legs separated, flexed, and supported in raised stirrups

Question 23

What must the RN do when faced with a patient that is expressing values from a different culture that affect the process of assessment?

Answer 23

Modify the plan of care and environment to accommodate the patients values and wishes.

Question 24

What are the possible outcomes of continuous, ongoing, and follow-up assessments

Answer 24

1. patient Condition is stable or stabilizing 2. patient condition is changing or changed

Question 25

What four things must a systematic assessment be? SAS-E

Answer 25

Safe, accurate, systematic and efficient

Question 26

Of the two main focuses of physical assessments, which one will be the focus of nurse 144?

Answer 26

Objective Data

Question 27

What is the main difference between a nursing assessment and a Medical Assessment?

Answer 27

Nursing assessments have a holistic approach

Question 28

Treat others religions with_____ and ____

Answer 28

dignity and respect

Question 29

What example did the joint commission used when discussing the importance of constant ongoing assessment?

Answer 29

Patients deteriorate 8-12 hours before a cardiac event in clinical settings. Interventions are possible if deterioration is recognized and reported

Question 30

What are the two outcomes if the continuous assessment shows a patients condition is changing or has changed?

Answer 30

1. patient is improving and progressing towards optimum health 2. Patient is worsening

Question 31

What is the number one consideration above all else in any assessment or procedure?

Answer 31

Safety

Question 32

Describe sims position

Answer 32

It is performed by having a patient lie on their left side, left hip and lower extremity straight, and right hip and knee bent. Can also be called lateral recumbent

Question 33

What are the 4 types of physical assessments? EPCF

Answer 33

1. Emergency ALWAYS NUMBER ONE 2. Pain or primary concern 3. Comprehensive 4. Focused or Targeted

Question 34

What is a baseline assessment. When is one taken.

Answer 34

A baseline assessment is taken upon the initial meeting with a patient. Whether a new patient at a doctors office or a patient in an emergency situation. The purpose of the baseline assessment is to obtain an initial record of patients status to be compared with later assessments to determine any change in status/condition.

Question 35

Describe Prone position

Answer 35

lying on the chest with the face down (“lying down” or “going prone”)