Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
50 Cards in this Set
- Front
- Back
How often should a pt. be assessed?
|
once a shift
|
|
name the four techniques to assess a pt.
|
inspection, palpation, percussion and auscultation
|
|
What two techniques are performed during an assessment by using fingers and hands?
|
Palpation and percussion
|
|
Why is palpation and percussion used to assess a pt.
|
Abnormalities of sound
|
|
What types of abnormalities could be found during palpation and percussion?
|
Vocal fremitus
|
|
What assessment technique is accomplished with a stethoscope?
|
Auscultation
|
|
During auscultation what is being assessed?
|
breath sounds
|
|
A total client assessment begins with?
|
a nursing health history
|
|
a complete health history includes what elements?
|
Biographic information
|
|
age, sex, educational level are considered what type of information?
|
biographic
|
|
the condition that brought the client to health care facility is
|
Chief Complaint
|
|
onset of problem, clinical manifestations, including severity of symptoms:pain is considered?
|
Present health status
|
|
hospitalizations,allergies,otc,herbal supplements and general habits are considered?
|
Health history
|
|
age and health status of parents,siblings is considered
|
family history
|
|
cultural beliefs, spiritual beliefs that influence health mgmt. is?
|
psychosocial factors
|
|
dietary habits preferences or restrictions are
|
nutrition
|
|
domestic violence
|
a JCAHO requirement
|
|
during inspection observe?
|
skin color and texture
|
|
While performing palpation determine?
|
position of the organs,size and consistency.
|
|
Percussion produces_____ by using the finger as a hammer.
|
sound waves
|
|
sound or tone of the vibration curing percussion is determined by?
|
body area or organ percussed
|
|
A normal lung sound is called?
|
resonance
|
|
Liver sounds are?
|
dull
|
|
Muscle sound is?
|
flat
|
|
the bell of a stethoscope during auscultation detect____ pitched sounds?
|
low
|
|
the diaphragm of the stethoscope detects ____ pitches sounds during auscultation
|
high
|
|
a focus assessment is also called a
|
shift assessment
|
|
Level of consciousness LOC
|
responds to questions of time,place,person,purpose
|
|
sign of abnormal LOC
|
Drowsy
|
|
motor responses
|
eyes open
|
|
pupil assessment
|
size
|
|
choreiform
|
jerky and quick
|
|
flaccid posturing
|
no motor response
|
|
athetoid
|
twisting and slow
|
|
tremors
|
'the shakes'
|
|
Seizures are seen in
|
brain injury
|
|
Asterixis is seen in
|
metabolic encephalopathy due to kidney or liver failure
|
|
opiate effect on pupils is
|
pinpoint and fixed
|
|
a sign that the parasympathic and sympathetic nervous systems are not in synchronization(pupils)
|
unequal
|
|
The light reflex is the most important sign for what problem
|
diabetic coma
|
|
client close eyes and can hold arms for 20 to 30 seconds he has good ____ _____
|
muscle strength
|
|
legs extended,feet extended with plantar flexion,arms internally roatated and flexed on chest may be due to lesion of corticospinal tract near cerebral hemisphere
|
decorticate posturing
|
|
arms stiffly extended and hands turned outward and flexed,legs extended with plantar flexion. may be due to lesion in diencephalon,pons or midbrain
|
decerebrate posturing
|
|
Glasgow coma scale consist of three phases, what are they?
|
motor response
|
|
motor responses glasgow coma scale responses are?
|
obeys a simple command6
|
|
verbal responses glasgow coma scale response are?
|
Oriented5
|
|
Eye opening glasgow coma scale response are?
|
Spontaneous when a person approaches4
|
|
the score of 3 on the Glasgow Coma Scale indicates
|
deep coma
|
|
if a catheter is in place check urine for:
|
color,odor,consistency and amount
|
|
ability of lens to adjust to objects at varying distances
|
accommodation
|