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21,6,12
Concepts 3
| Question | Answer |
|---|---|
| What is the purpose of a Physical Assessment? | To establish a baseline against future changes. |
| When do you perform a Physical Assessment? | On admission, at the beginning of each shift, patient condition changes, evaluating the effectiveness of nursing care, anytime things do not feel right |
| What is the definition of a Comprehensive Assessment (complete assessment)? | in depth-assessment of the whole person that includes physical, mental, emotional, cultural, and spiritual aspect of a patients health. |
| What is the definition of a Focused Assessment? | involves a specific body system |
| Head to toe assessment in order is | Neurological, Cardiovascular, Respiratory, Integumentary, Gastrointestinal and Genitourinary |
| What is Subjective Data? | is what a patient says; when evidence of illness or injury is verbalized by the patient, findings are subjective not directly measurable; these will be your symptoms |
| What is Objective Data? | is what the nurse observes; when use of four senses produces evidence of illness or injury the findings are objective and measurable; these will be your signs |
| When interviewing a patient what questions are asked? | personal identity/demographics, current condition, medical history, social history, food/drug allergies, height/normal weight, expectations/hospitalization |
| the visual observation of anything about the body that you can see with the naked eye or with assistance of other equipment is known as | Inspection |
| What is used for assessment of pupil constriction of the eyes and examination of the areal and nasal mucous membranes? | Penlight |
| What is an Otoscope used for? | to inspect the lining of the nose, tympanic membranes and ear canals |
| What instrument is used to assess or examine the internal structures of the eyes? | Ophthalmoscope |
| What does the abbreviation "LOC" stand for? | Level Of Consciousness |
| What is Level Of Consciousness used for? | to assess if the patient is alert |
| What questions would be asked to assess patient level of consciousness? | Person: what is your name or Who is the president of the US |
| What questions would be asked to assess patient level of consciousness? | Place: Can you tell me where you are? |
| What questions would be asked to assess patient level of consciousness? | Time: What is today's date or What day is it? |
| What questions would be asked to assess patient level of consciousness? | Situation: What problem brought you to the hospital or Do you know why you are here? |
| Repeating the process for the opposite eye is known as | Consensual Reflex (consensual response) |
| What does the term Ptosis mean? | observe the eyelids for dropping |
| Term meaning yellowish orange color of the sclera is known as | Jaundice |
| What does the term Accommodation Response mean | to measure the eye muscles ability to focus on an image up close and in the distance |
| When you hold your finger in front of the patient's face and ask to focus on your finger ask it moves is known as | Accommodation Response |
| The term Cheilitis if referred to what? | inflammation of the lips, as well as excessive dryness and crackling |
| dried mucus or food caked on the lips and teeth is known as | Sordes |
| An individual who has difficulty coordination and organizing the words correctly in a sentence may be suffering form an impairment is known as what? | Dysphasia |
| When the veins in the neck are distended this indicates fluid overload of the cardiovascular system is known as what? | Jugular Vein Distended (JVD) |
| Equal chest expansion is known as | Excursion |
| What does the term Atelectasis mean | lack of or decreased excursion on one side of the chest and can be caused by severe pneumonia or lung (alveoli) |
| normal breathing is known as what ? | Eupnea |
| Tachypnea is defined as what? | increased respiratory rate more than 20 |
| When will you see Tachypnea? | fevers, anxiety, stress, fear, pain, exercise and hypoxia |
| Abnormally slow respiratory rate; less than 16 is known as | Bradypnea |
| When will you see Bradypnea? | opioid medications, sedatives, brain damage, metabolic alkalosis |
| what is a condition that causes abnormal breathing during sleep; begins very shallow; then each respiration gradually increases in depth until reaching peak? | Cheyne Stokes |
| When will you see Cheyne Stokes? | increased intracranial pressure, brain damage, impending death |
| What does the term Apnea mean? | temporary or periodic absence of breathing |
| When will you see Apnea? | Cheyne Stokes respirations, sleep Apnea, sudden infant death syndrome |
| What does the term Biot's mean? | a sequence of several breaths of equal depth that alternate with periods of apnea |
| When will you see Biot's? | brain damage |
| What is usually heard during inspiration and expiration? | Crackles |
| Crackles can be what? | fine or course |
| What can be caused by movement of air over secretion in the lung or sudden opening of alveoli that have been closed? | Crackles |
| Can Crackles be cleared by coughing? | No, Crackles can not be cleared by coughing |
| What can be cleared by having the patient cough? | Rhonchi |
| Rhonchi is caused by what? | secretions or partial occlusion of the airway, tumors |
| What is deeper and has more rumbling sounds than crackles? | Rhonchi |
| Rhonchi is usually heard during when? | Expiration |
| Sounds of snoring, rattling, gurgling, squeaking and low pitched wheezes are known as what | Rhonchi |
| Can Stridor be heard only with a stethoscope? | Usually can be heard with or without a stethoscope |
| What is Stridor a sign of? | life threatening upper airway obstruction caused by a foreign body, tumor, swelling or bronchial spasms |
| What sound does Stridor make? | a shrill, high pitches, harsh, crowing sound |
| Can Stridor be delayed? | Stridor requires immediate intervention |
| What sounds are heard on inspiration? | Stridor |
| What is SI? | the lubb of the rhythmic lubb dubb sound of the heartbeat |
| Should you take an Apical Pulse for 5 minutes? | No, 1 full minutes is the standard practice |
| What sound does a murmur make? | swishing, rumbling, or blowing sound or it may be soft loud or booming |
| What does the term Peristalsis mean? | wavelike muscular contractions of the intestines that move intestinal contents through the alimentary canal, where absorption of nutrients and water takes place |
| What term means numbness or decreased sensation or tingling? | Paresthesia |
| If Paresthesia is present it can indicate what? | some type of nerve impairment |
| When is Paresthesia commonly seen? | complication of diabetes and as a result of a stroke or traumatic event |
| What are Solar Lentigines? | spot of yellowish brown discoloration caused by years of sun exposure |
| Pale skin color description? | a lighter color, more white than usual; indicates poor circulation, anemia |
| Erythematous skin color description? | redness of a designated site; usually a sign of inflammation due to increased circulation to the inflamed site |
| Flushed skin color description? | widespread, diffuse red color of face; possibly includes body; usually caused by fever, embarrassment, exertion, or sunburn |
| what is ment by the term Jaundiced? | yellow or orange coloring of the skin and mucous membranes, easily detected in the sclera and palm of hands; caused by liver impairment |
| Cyanotic is termed by what? | bluish gray color of the skin and mucous membranes due to hypoxia and extreme vasoconstriction |
| Ecchymotic is caused by? | bruising of the skin (ecchymosis); fresh bruises are bluish purple, and older bruises turn greenish yellow as the being the resolve |
| What is Bronzing pigmentation? | Bronze pigmentation of the skin due to disorders of iron metabolism |
| Skin Turgor is an indicator of what? | Hydration level in all ages of patients except elders |
| How do you check skin turgor on an elderly payment? | gently pinch a fold of skin over the sternum or just below the clavicle between your index finger and thumb |
| How much urine should the kidneys produce per hour? | 30 mL |
| What is ment by Verbal Communication? | more than non-verbal; used to give specific information |
| Nonverbal communication is termed? | is less than conscious and more indirect than verbal, conveys more of what a person fells, thinks, and means than what is stated in words; requires observation and forming a valid or true interpretation of the language |
| What is termed Personal Space? | the distance or personal spaces, people place between themselves, and others is called proxemics, reflects feeling and attitudes and affects communication |
| What is the distance for Intimate space? | can range form physical contact to 18 inches |
| Causal space is termed? | 18 inches to 4 feet |
| Social Consultative space is termed as? | 4 feet to 12 feet |
| Public space is termed as what? | 12 feet if possible |
| A slumping body posture may indicate what? | disinterest or boredom |
| Folded arms may indicate what? | a resistance to hearing a massage |
| To demonstrate a willingness to communicate effectively with patient you need to do what? | communicate at eye level with the other person, lean slightly forward, and maintain and open body posture |
| When communicating with a person who speaks a language other English you may point to what? | object and picture board to communicate the idea |
| what is termed Connotative? | refers to the emotional associations that can be attached to the word |
| Denotative is termed as? | is the literal meaning, absent of any interpretation |
| what does it mean to practice active listening? | demonstrate to your patients that you are interested in their feelings, concerns, and needs |
| As an active listener how would the nurse respond? | by confirming that he or she understood what was stated and what was ment |
| what is ment by Assertive communication style? | characterized by standing up for oneself without violating the basic rights of others |
| what learning style shows respect for other? | Assertive |
| What communication style is the most effective communication for nurses to practice? | Assertive |
| what communication style express their own feelings in an honest and direct way is ? | Assertive |
| Passive or Avoidant communication style is termed as | a desire to avoid confrontation and the inability to share feelings or needs with others |
| Individuals with this style have trouble asking for help and allow others to take advantage of them, resulting in feelings of anger, emotional pain and anxiety is known as what | Passive or Avoidant |
| Communication style characterized by putting ones owns needs, rights, and feelings before those of others is known as | Aggressive |
| Aggressive Communication Style | exhibit superior attitude |
| Aggressive Communication Style humiliates | others and communicate in any angry hostile way that does not acknowledge the feelings of others |
| DESC Method does what | helps promotes assertive communication |
| D in DESC Method describes what | the behavior, focus on what is observed or heard without a personal attack; Discuss behavior no the person |
| E in DESC Method explains what | the impact of the behavior; does not minimize the impact of behavior |
| S in DESC Method states what? | the desired outcome |
| C in DESC Method stand for what? | Consequences should grab the person's attention |
Created by:
Valadiece
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