Week one Head to Toe

Question 1

1. What 4 items must be done upon the beginning of assessment EVERY TIME? Failure to do these will cause you to fail.
2. What should be done prior to going in room?
3. What are the other 2 items that need to be performed in the initial part of the assessment?

Answer 1

1. Provide patient privacy (curtain), Introduce self, Identify patient (verbal and arm band), and Perform Hand Hygiene
2. gather all equipment (steth, scissors, black pen, and pen light).
3. Explain your procedure, and demonstrate four caring behaviors.

Question 2

1.-9. What questions should be asked in the subjective data assessment?

Answer 2

1. Ask about general health
2. Ask about past medical history and surgeries.
3. Current medications?
4. Smoking, alcohol, drug use?
5. Ask about occupation (for risk assessment).
6. Any new or acute symptoms?
7. Diet and activity level
8. Vaccinations up to date?
9. Any allergies?

Question 3

1. • 7. What 7 items must be assessed in the general survey and vital signs?

Answer 3

1. chief complaint (diagnosis), age, and gender
2. Assess for orientation x4
3. Assess physical development and build compared with age
4. Assess posture
5. Get vitals (BP, HR, RR, T, SpO2, and Pain)
6. Assess speech
7. Assess for pain (if present, use COLDSPA).

Question 4

1. What are the 5 vitals?
2. What is normal BP?
3. What is normal HR?
4. What is a normal RR?
5. What is a normal temp (in C)?
6. What is a normal SpO2?
7. How do we rate pain?

Answer 4

1. BP, HR, RR, T, SpO2, and pain
2. 120/80
3. 60 - 100 bpm
4. 12 - 16 breaths per min.
5. 36.1 - 37.2 C
6. min 95%
7. scale of 1-10

Question 5

1. When do we use COLDSPA?

2. What does COLDSPA stand for?

Answer 5

1. When pain is present

2. Character (sharp, dull)
Onset (when began)
Duration
Location (where is it? Radiates?)
Severity (1-10)
Pattern: what makes better or worse?
Associated Factors (worse when lying down or after eating etc.)

Question 6

1. What are the 4 tools of physical assessment?
2. What types of sounds are the stethoscope’s diaphragm used to hear?
3. What types of sounds are the stethoscope’s bell used to hear?

Answer 6

1. Inspection, auscultation, percussion, and palpation
2. High sounds like S1 and S2 heart sounds
3. Low sounds like S3 and S4 heart sounds