Assessment - Test 1 Objectives

Front 1

Know what objective data is

Back 1

Observed

Front 2

Know what subjective data is.

Back 2

Reported

Front 3

What information does a nursing database contain

Back 3

objective and subjective

Front 4

What is the purpose of evaluation in the nursing process?

Back 4

To assure interventions are successful

Front 5

Know how a "novice nurse" without a background of skills and experience makes his or her decisions.

Back 5

Based on theoretical knowledge

Front 6

Know what a "first-level priority problem" is.

Back 6

Life threatening

Front 7

Know what a "second-level priority problem" is.

Back 7

Those which need to be addressed to forestall further deterioration

Front 8

Know the definition of "health" according to the traditional Western biomedical model.

Back 8

Absence of disease

Front 9

Know about the holistic model and what factors it includes when considering health.

Back 9

Mind, Body and Spirit functioning in harmony

Front 10

Know something about how the public's concept of health has changed since the 1950's.

Back 10

Scope of health has increased to include lifestyle, personal habits, exercise, nutrition, social and natural environment

Front 11

Know the difference between a nursing diagnosis and a medical diagnosis.

Back 11

Medical diagnosis = identification of disease
Nursing diagnosis = pt. response to disease

Front 12

Know the difference between an episodic database, an emergency database, a follow-up database, and a complete database (as well as when it would be appropriate to use each one).

Back 12

Episodic database = problem centered
Emergency Database = compiled concurrently with lifesaving measures
Follow-up Database – evaluated at regular intervals
Complete Database – full history which establishes a baseline

Front 13

Know about the age-specific charts for periodic health care.

Back 13

Lifetime schedule of healthcare for periodic health visits & preventative services focusing on major risk factors for each age group

Front 14

Know about “at risk” diagnoses.

Back 14

Statement about health problems that the client doesn’t yet have, but for which the client has a greater than normal risk of developing in the near future

Front 15

Know the advantages and disadvantages of note taking during an interview.

Back 15

Advantage: Accurate
Disadvantage : impedes flow of interview
- impedes reading of verbal clues

Front 16

Empathy

Back 16

recognizes feelings and puts them into words

Front 17

Clarification –

Back 17

summarizes and restates

Front 18

Confrontation

Back 18

– points out inconsistencies

Front 19

Facilitation –

Back 19

encourages pt to say more (umm-hmm)

Front 20

Reflection –

Back 20

repeating part of what was just said

Front 21

Know about the pitfalls of providing false assurance or reassurance to a patient:

Back 21

Relieve the nurse's anxiety and essentially trivialize the fears of the patient.

Front 22

Know about the technique of interpretation:

Back 22

You run the risk of making the wrong inference, but it may serve to link events, make associations, and help the person understand his or her own feelings. If your interpretation is wrong, the person will usually correct it, and even if the inference is corrected, interpretation helps to prompt further discussion of the topic.

Front 23

Know how to recognize a leading or biased question.

Back 23

Passes judgement and discourages honesty

Front 24

Know that a patient's comfort level with spatial distance varies from culture to culture

Back 24

Hispanic, East Indian, and Middle Eastern cultures as ones with a higher comfort level for less personal space)

Front 25

Know that some cultures consider direct eye contact impolite or aggressive.

Back 25

Native Americans often stare at the floor during the interview; which is a culturally appropriate behavior indicating that the listener is paying close attention to the speaker.

Front 26

Know that some cultures consider it disrespectful to touch someone on the head.

Back 26

Southeast Asians

Front 27

Know that using "authority" responses promote feelings of dependency and inferiority in the patient.

Back 27

Although the health care provider and the patient do not have equal professional knowledge, it is still best to take the approach that both have equally worthy roles in the health process.

Front 28

Know 3 communication-related nursing diagnoses.

Back 28

Expressive ability
Receptive ability
Information processing
Hearing deficit
Speech defiicit

Front 29

Know the purpose of the health history.

Back 29

To collect subjective data

Front 30

Know how to document "reason for seeking care."

Back 30

Direct quotes are noted and measured signs reported

Front 31

Know the eight critical characteristics you should investigate regarding any symptom.

Back 31

- Location
- character or quality
- quantity or severity
- timing
- setting
- aggrevation or relieving factors
- assosited factors
- pt perception

Front 32

Gravida

Back 32

Number of pregnancies

Front 33

Para –

Back 33

# of viable births

Front 34

Abortus -

Back 34

# of pregnancies that were lost for any reason

Front 35

Know what else to document when someone tells you they are allergic to something (such as penicillin).

Back 35

Document allergens and response to allergen

Front 36

Know what to ask for when you are collecting a patient's family history.

Back 36

Age, health or cause of death of blood relatives
(parents, grandparents siblings)

Front 37

Know the purpose of the "review of systems" (ROS), and know what sort of information it is supposed to contain. (A common mistake of many beginners is to think the ROS is the same as the physical examination. This is NOT true).

Back 37

- Evaluate past and present state of each body system
- double check for omission of info in present illness section
- evaluate health promotion practices

Front 38

Know that the impact of a disease on his or her daily activities and overall quality of life (called the disease burden) is often more important to older people than the actual disease diagnosis or pathology (Bernstein, 1992). Therefore, it is always important to assess the effect of any event (e.g. a stroke) on the person's ADL's (activities of daily living).

Back 38

...

Front 39

Should culturally -based beliefs be a part of a health history

Back 39

Yes, always

Front 40

Know about the content and purpose of a functional
assessment.

Back 40

- ADL
- Self esteem
- Activity
- Sleep
- Nutrition
- Relationshipd
- Spirituality

Front 41

Know which assessment technique is always first when performing a physical assessment on any body system.

Back 41

Inspection

Front 42

Know what technique is best when assessing skin temperature (what part of your hand would you use?)

Back 42

dorsa

Front 43

Know about palpation (e.g. when to use light palpation, when bimanual palpation is useful).

Back 43

Light palpation – surface characteristics
Bimanual Palpation – Precise organ deliniation

Front 44

Know about the stethoscope and its use (when to use the diaphragm and when to use the bell, etc.)

Back 44

Diaphram – High pitched – breath, bowel, heart

Bell – Deep Sounds – extra heart sounds

Front 45

Opthalmoscope

Back 45

interior of the eye

Front 46

Otoscope –

Back 46

interior of the ear

Front 47

Which areas should be assessed last

Back 47

painful areas

Front 48

Best index of a child's general health.

Back 48

Physical Growth

Front 49

What is the normal head circumference relationship to chest circumference in a newborn and how does it change?

Back 49

Head 2 cm > chest at birth

Head = chest between 6mo and 2 years

Front 50

Know when to avoid taking rectal temperatures (in what type of patient).

Back 50

Heart condition
Hemorroids
Rectal surgery
diarrhea

Front 51

What is the effect of the diurnal cycle and menstrual cycle on body temperature?

Back 51

Diurnal cycle – rise in temp every afternoon
Menstral cycle – rise in temp at time of ovulation

Front 52

How is a rectal temperature taken in an adult?

Back 52

Insert lubricated probe 2-3 cm towards umbilicus

Front 53

What happens to the temperature regulation in older adults?

Back 53

Decreased ability to perspire
Decreased subcutaneoud fat

Front 54

Know what the "tripod" position is and when you might observe a patient using it.

Back 54

Used by pts with advanced lung disease

Front 55

Know how to assess the radial pulse of a patient and what characteristics you should note in the process.

Back 55

Volume : strength of pulse
Rhythm: Regularity of beats
Condition of arterial Wall (It should feel elestic and soft

Front 56

What is sinus arrhythmia? When is it a normal finding?

Back 56

The normal increase in heart rate that occurs during inspiration is more response in children than in adults

Front 57

The force and strength of the pulse is a reflection of what?

Back 57

Stroke Volume

Front 58

Know how to explain "what the numbers mean" when discussing blood pressure with a patient.

Back 58

Systolic – left ventricle contraction
Diasolic – pressure at rest

Front 59

What five factors determine blood pressure?

Back 59

Cardiac output
- Peripheral Vascular resistance
- Volume of circulation
- Viscosity
- Elasticy of vessel walls

Front 60

Know about the increased incidence of hypertension among blacks in the United States.

Back 60

...

Front 61

Know what happens if you measure blood pressure with a cuff that is too small for the patient.

Back 61

- False high as cuff precludes brachial artery

Front 62

What is the reason for performing a palpatory pressure prior to auscultating blood pressure?

Back 62

- To assure pressure is higher than ausculatory gap

Front 63

What is pulse pressure and what does it reflect?

Back 63

Pulse pressure – the difference between systolic and diastolic pressure reflecs the stroke volume (blood which is ejected during each contraction

Front 64

Know how to check for orthostatic hypotension and when one would wish to do this.

Back 64

- Known hypertension
- Antihypertension
- Pt. fainting

Front 65

stages of hypertension

Back 65

- Prehypertension – 120-139/80-89
- Stage 1 – 140-159/90-99
- Stage 2 – 160+/100+

Front 66

acute pain."

Back 66

Short term
Self limiting
Dissipates after healing

Front 67

Know about the pain experience of the elderly.

Back 67

Pain is not a natural consequence of aging
Common causes arthritis, constipation, PVD, angina, cancer

Front 68

pain scales

Back 68

Indicates baseline
Track intensity of pain

Front 69

reflexive sympathetic dystrophy

Back 69

- Complex regional pain syndrome
- Progressive neurological condition usually develops in an injured limb
- affects skin, muscle, joints and bones

Front 70

most reliable indication of pain.

Back 70

Subjective reports

Front 71

chronic pain.

Back 71

> 6 months

Front 72

neuropathic pain.

Back 72

Abnormal progression of pain message

Front 73

visceral pain.

Back 73

Organ

Front 74

nociception."

Back 74

- Noxious stimulus perceived as pain
- transmit pain sensations from periphery to CNS
- located in skin, connective tissue, muscle, thoracic, pelvic and abdominal viscera

Front 75

vertebra prominens? Where is it?

Back 75

C-7

Front 76

normal costal angle

Back 76

90 degrees

Front 77

Know how many lobes the left and right lung have

Back 77

Right – 3 lobes
Left – 2 lobes

Front 78

Know where the apices of the lungs are (in terms of anatomical landmarks).

Back 78

2.5-4 cm above the sternal end of the first rib

Front 79

normal lung findings include:

Back 79

symmetric chest expansion
resonant percussion tones
vesicular breath sounds over the peripheral lung fields
no adventitious sounds
and muffled voice sounds.

Front 80

primary muscle of respiration.

Back 80

Diaphram and external intercostals

Front 81

paroxysmal nocturnal dyspnea.

Back 81

Difficult painful breathing at night

Front 82

Where would you expect to feel tactile fremitus most intensely?

Back 82

On the chest wall

Front 83

What is tactile fremitus produced by?

Back 83

Vibrations on the chest wall when vibrations from the larynx to chest surface is impeded bu COPD, obrstruction, pleural effusion or pneumothoroax

Front 84

What would a dull percussion note indicate (if it were over the lung)?

Back 84

Dull sounds = pleural effusion or lobar pneumonia
Hyperresonant = emphysema or pneumothorax

Front 85

Remember that side-to-side comparison is most important when auscultating the chest.

Back 85

...

Front 86

Would you use the bell or diaphragm of the stethoscope when auscultating the chest in an adult?

Back 86

Diaphram

Front 87

Know when decreased or absent breath sounds occur.

Back 87

ARDS
Asthma
Emphysema
Pleural Effusion
Pneumothorax

Front 88

Know that in the elderly, the costal cartilages become calcified resulting in a less mobile thorax.

Back 88

...

Front 89

Know that the anterior chest is inspected for:

Back 89

the shape and configuration of the chest wall, level of consciousness, skin color and condition, quality of respirations, retraction and bulging of the intercostal spaces, and use of accessory muscles.

Front 90

Why would fine crackles be a normal finding in the immediate newborn period

Back 90

due to the opening of the airways and clearing of fluid.

Front 91

When does unequal chest expansion occur?

Back 91

Empysema

Front 92

What is broncophony associated with?

Back 92

Pneumonia

Front 93

Where do you expect to hear bronchovesicular breath sounds?

Back 93

Between 1st and 2nd intercostal anteriorly and between scapula osteriorly

Front 94

What causes wheezes?

Back 94

Inflammation and constriction of the airways

Front 95

What shape would a person's chest be if s/he has COPD?

Back 95

Barrel chest

Front 96

Know about pneumothorax.

Back 96

Air in the pleural cavity

Front 97

symptoms you are likely to see with an acute exacerbation of asthma.

Back 97

SOB
Wheezing
Chest tightness

Front 98

What changes might you expect to see in the respiratory system of an older adult?

Back 98

Lungs become stiffer
Respiratory muscle strength and endurance diminishes
Vital capacity decreases
Residual volume increases
Alveoli collapse
# cilia decline

Front 99

Know the symptoms of Tb.

Back 99

Cough > 3 weeks
Chest pain
Coughing blood or rust sputum
Night sweats

Front 100

Know that heart failure often presents with

Back 100

increased respiratory rate, shortness of breath on exertion, orthopnea, paroxysmal nocturnal dyspnea, ankle edema, and pallor in light-skinned people.

Front 101

pericardium

Back 101

Area on the anterior chest overlying the heart and the great vessels

Mediastinum - Middle third of the thoracic cage

Front 102

Know which valve closures can BEST be heard at the base of the heart.

Back 102

S2 – closing of semilunar valves heard at base
S1 – closing of AV valve hear at apex

Front 103

what component of the conduction system is known as the "pacemaker" of the heart.

Back 103

SA Node

Front 104

the sequence of the electrical stimulus of the heart.

Back 104

SA Node

Across Atria
AV Node
Bundel of His
Bundle Branches
Ventricles

Front 105

Know why we check for distended jugular veins, what findings are normal, and what would be considered abnormal.

Back 105

Jugular veins reflect volume and pressure changes in right side of heart

Carotid Arteries – coincide with ventricular systole

Front 106

What is the foramen ovale and when does it close?

Back 106

Atrial Septal opening – closes one within one hour after birth

Front 107

Why does BP drop in pregancy despite increased cardiac output

Back 107

due to peripheral vasodilatation. The blood pressure drops to its lowest point in the second trimester, then rises after that.

Front 108

Know about paroxysmal nocturnal dyspnea and what condition you would be likely to have in order to get this symptom.

Back 108

Paroxysmal nocturnal dyspnea (PND) is a sensation of shortness of breath that awakens the patient, often after 1 or 2 hours of sleep, and is usually relieved in the upright position.

Congestive heart failue, pulmonary congestion

Front 109

What would you ask about in order to assess a patient's MAJOR risk factors for heart disease?

Back 109

Chest pain
Dyspnea
Orthopnea
Cough
Fatigue
Cyanosis or pallor
Edema
Nocturia
Cardiac History
Family Cardiac history
Personal Habits

Front 110

Know that to screen for heart disease in an infant, focus on feeding.

Back 110

Infants with congestive heart failure take fewer ounces each feeding; become dyspnic with sucking; may be diaphoretic, then fall into exhausted sleep; awakening after a short time hungry again.

Front 111

Know how to auscultate the carotid artery for bruits.

Back 111

Have patient hold their breath
Place the diahram lightly on the carotid artery listening for swooshing sound

Listen again with the bell

Front 112

If you find a bruit what does it mean? Is it a normal or abnormal finding?

Back 112

Turbulent blood flow due to local vascular cause. Usually abnormal, indicating a blockage in the vessel, but can be a normal finding, particularly in young people

Front 113

If you see a heave or lift during your inspection of the precordium, what does that indicate?

Back 113

Enlarged ventricle – you may or may not see the apical impulse

Front 114

In a normal healthy adult where would you expect to palpate the apical impulse?

Back 114

5th costal space 7-9 cm from the midsternal line

Front 115

Know what sequence to use for auscultation of heart sounds.

Back 115

"all patients take meds." (Aortic, pulmonic, tricuspid, mitral).

Front 116

Remember that sinus rhythm can speed up and slow down with inspiration and expiration in young adults and children, and this is a normal finding.

Back 116

...

Front 117

Know that S1 is louder than S2 at the apex; S2 is louder than S1 at the base. S1 coincides with carotid artery pulse. Feel the carotid gently as you auscultate at the apex; the sound you hear as you feel each pulse is S1.

Back 117

S1 – Louder at Apex
S1 – coincides with carotid artery pulse
S1 – coincides with R wave on elctrocardiogram

Front 118

Know about split S2 sounds and whether this is a normal or abnormal finding.

Back 118

Caused when the semilunar valves close at different times. Can be normal or pathological (ASD or VSD)

Front 119

Know what they mean when they talk about "innocent murmurs," and where you would be likely to find one.

Back 119

Common in healthy children and teenagers – due to increased blood flow in heart.

Front 120

Know about S3 sounds.

Back 120

Occurs at the beginning of systole and is caused by the oscilltation of blood back and forth between the walls of the ventricle.

Can be benign in youth, trained athletes and in preganacy, but later in life is indicative of CHF

Sounds like Ken- tuc-ky

Front 121

How does pregnancy change the location of the apical pulse?

Back 121

higher and more lateral as the enlarging uterus elevates the diaphragm and displaces the heart up and to the left and rotates it on its long axis.

Front 122

Know about S4. Would it best be heard with the bell or diaphragm of the stethoscope? What position should you put the patient in if you wish to check for S4?

Back 122

Sound of blood being forced into a stiff ventricle

Always pathologic

Best heard at the Apex, with pt lying on left side and holding breathe

Sounds like Tenn-es-see

Front 123

friction rub.

Back 123

The sound is high-pitched and scratchy, like sandpaper being rubbed. You can hear it anywhere on the precordium, but usually it is best heard at the apex and left lower sternal border. You might hear it after someone has recently had an MI—if there is still inflammation of the precordium.

Front 124

What is a "thrill" (in cardiovascular assessment, of course!)

Back 124

A tremor or vibration felt on palpatation

Front 125

Know if the arterial system is a high or low pressure system.

Back 125

Arteries are high pressure
Veins are low pressure

Front 126

What is the major artery supplying the arm?

Back 126

Briachial

Front 127

What is ischemia? Did you know that ischemia may only be apparent at exercise when oxygen needs increase?

Back 127

A restriction in blood supply due to factors in the vessels with resultant damage or dysfunction of the tissue

Front 128

By what mechanism does venous blood return to the heart?

Back 128

1. Pressure (albeit low pressure)
2. Valves
3. muscle contractions

Front 129

Who is probably at most risk for venous disease?

Back 129

Family History
Obesity
Pregnancy
Prolonged standing
Prior episodes of clot formation

Front 130

Is the flow of lymph fast or slow when compared to that of blood?

Back 130

Slow – 3L/day (blood 5L/minute)

Front 131

Where would you expect to find the epitrochlear lymph node on a person?

Back 131

Proximal to the elbow crease on the medial side
- usually not swollen except for cat scratch disease

Front 132

If a person had a foot infection, which lymph nodes might be swollen and tender?

Back 132

Femoral or inguinal node in groin

Front 133

Know that superficial nodes are relatively large in children and may often be palpable even when the child is healthy.

Back 133

...

Front 134

What causes the predicted increase in systolic pressure with age

Back 134

the growing rigidity of blood vessels

Front 135

Know about intermittent claudication.

Back 135

Pain in the legs caused by Peripheral Artery Disease

Front 136

Know about night leg pain in aging adults.

Back 136

- 70% older adults experience benign nocturnal leg cramps.
- Cause unknown, but dehydration may playa role

Front 137

What is the profile sign and how is it used?

Back 137

- the angle at the meeting of the proximal nail fold and nail plate ( should be 180 degrees)

- indicitive of clubbing

Front 138

What is normal capillary refill time and what are some of the factors that might slow it down.

Back 138

<2 seconds
Slower time = dehydration and /or peripheral perfusion

Front 139

scale for documenting pulse.

Back 139

3++ =bounding
2++ = normal
1+ = weak, thready
0= absent

Front 140

What kind of pulse would you expect in a patient who has untreated hyperthyroidism?

Back 140

Extremely fast

Front 141

Why would one perform an Allen's test?

Back 141

Test the blood supply to the hand to test if it is appropriate to cannulate or prink the radial artery

- by compressing the Radial and Ulnar arteries with hand in upright fist.

- open fist, palm should appeared blanched.

- When ulnar artery is released, color should return in 7 seconds

Front 142

Know what a positive Homan's sign might mean.

Back 142

DVT

+ sign is present if there is pain in the calf or politeal reagion with dorsiflexion of footwith knees flexed to 90 degrees.

Front 143

What symptoms are you likely to observe in a patient who has venous stasis?

Back 143

- Edema
- aching tired legs
- varicosed veins
- reddish-brown discoloration as RBC stain the skin from the inside
- leg ulcers

Front 144

What would be the significance of a bruit in a femoral artery?

Back 144

Indicitive of life or limb threatening peripheral vascular disease.

Front 145

scale for documenting edema.

Back 145

1- slight pitting, no visible distortion
2- disappears within 10-15 seconds
3- may last more than a minute
4. lasts as long as 2-5 minutes

Front 146

If you noticed your bedridden patient had a positive Homan's sign and that one leg had increased warmth, tenderness, swelling, and redness, you would alert the doctor immediately. Why would you do that—what would you suspect?

Back 146

DVT and possible Pulmonary Embolus

Front 147

How do you perform the Trendelenberg test and what would be considered a normal finding?

Back 147

- determines competency of superficial and deep veins of the leg
- tournequet is place on upper theigh
- return of normal color 20 seconds after tournequet is removed