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Ms. Jackson Assessme
Ms. Jackson Assessment Exam
| Question | Answer |
|---|---|
| What role does the LVN have in the nursing process | Ongoing assessment of the patient after the inital RN assessment. |
| Where is the Pulmonic point found? | Left 2nd intercostal space |
| What term refers to a structure that is closer to the median plane than another structure in the body? | Medial |
| What is the Homan sign and what does it check for? | This is an examination procedure for determining if someone might have a thrombosis. |
| Are auxillary temperatures normally one degree higher or lower than oral temperatures? | Lower |
| What is a focus assessment? | An assessment where attention is concentrated or focused on a particular part of the body, where signs and symptoms are localized or most active, in order to determine their significance. |
| What are the bases of accurate charting? | Document complete and consistent, objective and factual, in accordance with health standards, spelling and structure correct and only chart what you have done, witnessed or implemented. Never chart for anyone else. |
| What is the normal range for the pH of Human blood? | Between 7.35 and 7.45 is considered normal blood pH. |
| When does discharge planning begin for the patient? | Upon admission |
| What term is used only in reference to the limbs and refers to the structure being further away from the median plane or root of the limb than the other structure? | Distal |
| Why is a procedure explained to the patient before it is performed? | To get informed consent |
| What is a chief complaint? | Why the patient sought care. |
| What is a craterlike lesion of the skin that usually extends at least into the dermis? | An ulcer |
| When doing percussion over a hollow organ such as the stomach what type of sound is produced? | A high-pitched, drumlike sound called tympany. |
| What are the techniques of assessment? | Head to Toe, Focus and System to System. |
| What are the components of the nursing process? | Assess, diagnose, plan and identify outcomes, implement and evaluate |
| Where is Erb's Point found? | At the left 3rd intercostal space. |
| How should a pen light be used when assessing the pupils? | Shine the light from the side of the eye; and across the eye w/the patient looking at a focal point. Look for both the direct (same) and consensual (other) eye reactions. Record pupil size and any symmetry or irregularity. |
| What is the difference between normal breath sounds and adventitious breath sounds? | Normal breath sounds are quiet. Adventitious breath sounds are abnormal sounds classified as either crackles or wheezes |
| What is the normal blood glucose fasting value? | 70-110 |
| What is the number called in the blood pressure that represents the pressure within the artery between beats? | Diastolic |
| How can muscle strength be determined in the extremities? | Equal bilaterally and able to maintain flexion against resistance and without tenderness |
| What is the best way to prevent infection? | Washing of hands |
| Where is the apical pulse located? | At the 5th intercostal midclavicular point |
| What are normal cardiac sounds? | Lubb Dubb S1 S2 |
| What is the pH of Human blood? | 7.35 - 7.45 |
| What is a small, discolored spot or patch on the skin, i.e freckle | Macule |
| What is a small, fluid-filled blister that's usually 1 cm or less in diameter, i.e., chx pox? | Vesicle |
| How can pain be measured? | By a pain rating scale. The most commonly used numerical scale is 0 to 10. The pt is asked to rate pain from 0 (no pain) to 10 (worst pain). For children, happy and sad faces are used to make the pain rating. Some agencies may use a scale of 0 to 5. |
| What are the correct techniques and order used to assess the abdomen? | Inspection, auscultation, percussion and palpation. |
| Which term refers to a structure that is further away from the median plane than any other structure in the body? | Lateral |
| What mnuemonic can be used to recall the 5 areas for listening to the heart? | All People Enjoy Time Magazine. Aortic, Pulmonic, Erb's Point, Tricuspid and Mitral |
| Where is the Aortic point found? | Right 2nd intercostal space. |
| What is a system to system assessment? | The review of systems (ROS) is a systematic method for collecting data on all body systems. During the ROS, the nurse asks the patient about normal functioning of each system and any noted changes. |
| Why is questioning the patient so important? | To determine whether the patient has any pressing questions before beginning the interview. By answering these questions, the nurse can meet some of the patient's immediate needs, and the patient may feel more comfortable answering questions. |
| Where is the Tricuspid Point found? | Lower left sternal border, 4th intercostal space. |
| What are crackles? | Crackles are produced by fluid in the bronchioles and alveoli and are mostly heard on inspiration. |
| What are wheezes? | Wheezes are sounds produced by the movement of air through narrowed passages in the tracheobronchial tree and are mostly heard on expiration. |
| What are the 2 classes of wheezes? | Sibilant or sonorous. |
| What are the normal cardiac sounds? | Lubb Dubb or S1 S2, is caused by the closure of the atrioventricular and semilunar valves, respectively. |
| What is the nursing process? | Assess, diagnose, plan and identify outcomes, implement and evaluate. |
| What term refers to a stucture being more in front than another structure in the body? | Anterior or ventral |
| What is a closed sac in or under the skin that contains fluid or semisolid material. | A cyst |
| What term is used only in reference to the limbs and refers to the structure being closer to the median plane or root of the limb than the other structure in the limb? | Proximal |
| What is used as a quick and standardized system to assess the degree of consciousness impairment in the critically ill, particularly with head injuries and contains 3 catories, eye opening response, verbal response and motor response? | The Glasgow scale |
| What are the normal levels for sodium? | The normal blood level is 134 to 142 mEq/L. |
| How do you rate a weak radial pulse? | 1+ |
| What does PQRST stand for? | Provocative, quality/quantity, region/radiation, severity and timing |
| What is the normal blood level of calcium? | The normal blood level of calcium is approximately 4.5 mEq/L. |
| What is the normal WBC? | 5,000 - 10,000 |
| What is a normal body temperature? | 97-99.6 F |
| How do you assess a core temperature? | Using a thermometer |
| How do you assess surface termperature? | By touching the skin |
| Are rectal temperatures normally one degree higher or lower than oral temperatures? | Higher |
| What is the normal blood serum level of Potassium? | 3.5 to 5 mEq/L |
| What is a sphygmomanometer? | Blood pressure cuff and gauge |
| What is dysarthria? | Difficulty forming words |
| How do you rate a normal radial pulse? | 2+ |
| What is Cephalocudal? | Head to toe |
| What is a raised, reddish area that is commonly itchy and usually lasts less than 24 hours., ie., insect bite, allergic reaction | A wheal lesion |
| What do you observe for on a suspicious lesion? | ABCDE - Asymmetrical lesion, Border irregular, color varies w/shades of tan, brown or black and sometimes blue or white, Diameter greater than 6 mm and Elevated or enlarging |
| How many cranial nerves are there? | 12 |
| What is a small, pus-filled lesion called? | Postule (i.e., acne) |
| What are we testing for when we have the patient bend forward and touch toes, posterior ribs should be symmetric? | Scoliosis |
| What terms refer to a structure being closer to the feet or the lower part of the body than another structure in the body? | Caudal or inferior |
| What terms refer to a structure being more in the back than another structure in the body? | Posterior or dorsal |
| How often should a SBE (self breast exam) be performed? | Monthly |
| When assessing the radial pulse how would we document a pulse that is bounding? | 4+ |
| What is the other name for the pedal pulse? | Dorsalis pedis pulse |
| What is it called when the nail beds feel spongy and the angle straightens out to 180 degrees and can be caused by heart disease,emphysema or chronic bronchitis? | Clubbing |
| What are the 3 types of nursing diagnosis? | Actual, Risk and Wellness |
| What is a process of discovering and making decisions about the nature of the client's problems or needs? | Assessment |
| Name the two types of assessments? | Medical assessment and Nursing assessment |
| What helps maintain a balance between heat lost and heat produced by the body? | The hypothalamus |
| Which peripheral pulse sites are easily palpated? | Radial and carotid |
| Which pulse sites are the most common for pulse rate assessment? | Radial and apical |
| What is the number called in the blood pressure that represents the ventricles contracting? | Systolic |
| What type of assessment begins with a neurological assessment, then assesses the skin, hair, head, and neck, including the eyes, ears, nose, and mouth. The chest, back, arms, abdomen, perineal area, legs, and feet are examined in that order? | Head to Toe |
| What are the sounds called when assessing a blood pressure? | Korotokoff |
| The point at which the last korotokoff sound is heard is called what? | The diastolic pressure |
| When doing percussion over a dense organ such as the liver what type of sound is produced? | A low-pitched, thudlike sound called dullness. |
Created by:
bsmymicareo
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