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79 Cards in this Set

  • Front
  • Back
With what is the Optic nerve associated and how might test?
Visual fields
Test = Snellen chart
Skin Assessment
* Skin, hair, nails
* Inspection and palpation
* Pallor - may be sign of inadequate circulation; decreased oxygen; decreased hematocrit
- brown skin people = yellowish
- black people = ashen gray
* Cyanosis - bluish; decreased oxygen. Blue around lips and fingernails.
- black people lips are pale (not red)
* Jaundice - Yellow. First noticeable in sclera of eyes
* Erythema - redness or rash
* Skin Lesions
List characteristics of effective communication.
* Rapport
* Specific objectives
* Comfortable environment
* Privacy
* Confidentiality
* Client focus
* Use of nursing observations
* Optimal pacing
* Providing personal space
With what is the Glossopharyngeal nerve associated and how test?
Swallowing ability
Test = Apply tastes on posterior tongue for identification. Ask patient to move tongue.
Differentiate between social and therapeutic communication.

Therapeutic communication techniques assist the flow of communication and always focus on the client.

Social Response focuses attention on the nurse instead of the client.
Deep Palpation
* Done with two hands
* Top hand applies pressure while the bottom hand relaxes to perceive the tactile sensations.
* Done with caution
* Not indicated in patients with abdominal pain

Be sensitive to verbal and facial expressions of pain.
List blocks to communication
1 - Giving Reassurance - "You'll be just fine"
2 - Approving - "I'm glad to see you're cheerful today"
3 - Disapproving - "Now don't be so glum"
4 - Agreeing - "That's right. You do need to look at the bright side"
5 - Disagreeing - "No, you're wrong about that"
6 - Rejecting - "Don't think about that. It's too depressing"
7 - Denying - Pt. "I'm not worth bothering with", Nurse "Of course you are"
8 - Belittling - Pt. "I don't want to live like this" Nurse "You'll feel different in the morning"
9 - Interpreting - Underneath you really feel..."
10 - Making a stereotyped comment - "Chin up"
11 - Introducing an unrelated topic/Changing the subject
12 - Challenging - "It isn't possible for that to happen"
13 - Demanding an explanation - "Why do you feel that way?"
14 - Defending - "This is a fine institution"
Components of Assessing the Peripheral Vascular System (PVS)
* - Measuring blood pressure
* - Palpating peripheral pulses
* - Inspecting, palpating, and auscultating the carotid pulse
* - Inspecting the jugular and peripheral veins
* Inspecting the skin and tissues to determine perfusion
List forms of Verbal Communication
1 - Vocabulary
2 - Denotative/connotative meaning
3 - Pacing
4 - Intonation
5 - Humor
6 - Clarity
7 - Timing and relevance
Percussion Sounds (p. 297 SDM)
* Normal lung areas produce a resonance sound.
* Liver sounds are dull.
* Flat sound over muscle
* Flatness = dense tissue, like bones
* Hollow sounds = lungs
* Hyperracone (sp?) "booming" as heard in emphysema
* Dullness (thud) = liver, spleen, heart
* Tympany = air in belly
List forms of Non-verbal communication
1 - Body language
2 - Tone
3 - Posture/Position
4 - Gestures
5 - Touch
6 - Vocal cues
7 - Physical appearance
8 - Facial expressions
9 - Distance or spatial territory
With what is the Auditory nerve associated and how test?
Test = assess with cerebellar functions
Give examples of how to facilitate active listening.
1 - Acknowledgment - ex. "yes, go on", I hear what you're saying"
2 - Clarification - ex. "I don't understand. Can you say that a different way?"
3 - Feedback - ex. "You did that well."
4 - Focus - focusing or re-focusing on a statement. Ex. "You were telling me how hard..."
5 - Incomplete sentences - ex. "Then your relationship is one of..."
6 - Listening
7 - Minimum verbal activity - let patient lead. Ex. "go on"
8 - Mutual fit or congruence - creating harmony of verbal and nonverbal messages.
9 - Nonverbval Encouragement - ex. Nodding
10 - Open-ended questions - ex. who, what, why, where, when, how questions
11 - Paraphrase
12 - Reflection
13 - Restatement
14 - Validation - ex. "Yes, it is confusing with people around."
Purpose of Head to Toe Assessment
* Obtain baseline data
* Supplement, confirm, or refute data
* Make clinical judgments on patient's health status
* Obtain data to help nurse establish NDx and patient care
* To evaluate outcomes of healthcare and patient progress
List Forms of Communication
* Interpersonal communication
* Public communication

With what is the Abducens nerve associated and how test?
EOM; moves eyeball laterally
Test = assess directions of gaze
Which system is done in different order than IPPA?


Types of Skin Lesions - (pg. 313 SDM)
- Macules - flat locales changes in color
- Papules, plaques, nodules - solid elevated varying in size
- Wheals - elevated, circumscribed, transient
- Vesicles and bullae - clear, fluid-filled pockets between skin layers
- Pustules - vesicles or bullae filled with exudate
List Means of Communication
* Touch
* Expression
* Gesture
* with symbols
* with words
* with silence
What is attributed to the DUPP S2 sound?
Closing of the Semi-Lunar valves.
What might CRACKLES indicate?
Air is moving through mucous or fluid.
Head to Toe Physical Assessment
* Begin with a general survey of the patient
* Vital Signs
* General Appearance - Body build, posture
* Behavior - Depressed, odd, calm, cooperative, combative...listen to speech
List two causes of poor communication
1 - Ambiguity
2 - Discrepancy in a message
With what is the Olfactory nerve associated and how might a nurse test.
Ask client to close eyes and identify odors.
Where are Bronchial Sounds heard?
Over the trachea, above the sternal notch

Zones of Touch
* Social Zone (permission not needed)
- Hands, arms, shoulders, back
* Consent Zone (permission needed)
- Mouth, wrists, feet
* Vulnerable Zone (special care needed)
- Face, neck, front of body
* Intimate Zone (great sensitivity needed)
- Genitalia
Elements of Communication
* Referent = motivates one person to communicate with another
* Sender = the person who delivers the message
* Message = info sent by the sender
* Channels = means of conveying the message
* Receiver = the person to whom the message is sent
* Environment = The physical and emotional atmosphere present at the time of interaction
* Feedback = indicates whether the meaning of the sender's message was received
Managed Care
* Cost containment system
* Largest provider for health care in the U.S.
* Focus on quality of care/cost of care
* Controversial with health care professionals and the public
* Use of health care providers who agree with payment for service
* Nurses function as case managers
What are some characteristics of bronchial sounds (i.e. pitch, amplitude, sound, is it longer during expiration or inspiration)?
High pitch
High amplitude
Harsh, loud, tubular quality
Expiration is longer than inspiration
Bases are at the top of the heart
Apices (apex) is at the bottom.
Relationships between verbal and non-verbal
* Repeating
* Contradicting
* Complementing
* Accenting
* Relating and regulating statements
* Substituting
What are characteristics of bronchovesicular sounds (i.e. pitch, amplitude, sound quality, is inspiration or expiration longer in duration)?
Moderate to high pitch
Moderate amplitude
Hollow, muffled quality
Inspiration and expiration are equal in duration
Charting for Potential Legal Problems
* Use facts
* Do not use pat phrases. Be specific.
* Be professional. Do not make interpretations. State what happened.
* Chart potentially serious situations
* Use correct language and medical terms.
* Report problems to appropriate authorities, such as suspected child abuse.
* Provide the best care you are capable of giving.
List the different breath sounds.
1 - Bronchial Sounds
2 - Adventitious Sounds
3 - Bronchovesicular Sounds
4 - Normal Sounds
Components of the termination phase
- ending relationship

Define Non-Verbal Communication
Exchange of information without the use of words; it is what is not said; "body language"
List purposes of documentation.
1 - Legal document
2 - Safety of patient/staff
3 - Progress (or lack of)/Response to care
4 - Evaluating that tasks are completed by assigned personnel
5 - Communication
6 - Provides continuity of care
7 - Changes in condition

(SDM, p. 46)
1 - Charting communicates info, such as facts, figures, and observations to other members of the healthcare team
2 - Charting assists supervisory personnel to evaluate the staff's performance on a day by day basis for specific patients.
3 - Charting provides a permanent record for future reference that may become a legal document in the event of litigation or prosecution.
What might RHONCHI indicate?
Constricted airway; louder and coarser than wheezes.

Gurgles, may clear with a cough.
List the 4 phases of Therapeutic Relationship
1 - Preinteraction
2 - Orientation (Introductory)
3 - Working
4 - Termination
List Psychological Barriers to Communication
* Psychological
- Depression
- Flight of ideas
- Word salads
- Use of the same word/phrases
Components of Neurological System Assessment
* Routine Screening Test
* Mental status including level of consciousness
* Cranial nerves
* Reflexes
* Motor function
* Sensory function
List 4 "zones" of personal space.
* - Public Zone = 12+ feet (strangers)
* - Social Zone - 4-12 feet
* - Personal Zone - 1.5 - 4 feet
* - Intimate Zone - Body - 1.5 feet
List purposes of the incidence report.
- help document quality of care
- identify areas where in-service education is needed
- record the details of an incident for possible legal reference
List Communication and factors that may influence it...
1 - Attitude
2 - Sociocultural or ethnic background
3 - Past experiences
4 - Knowledge of the subject matter
5 - Ability to relate to others
6 - Interpersonal perceptions
7 - Environmental factors
List characteristics of Admission Charting.
* What patient was like when admitted
* What medications patient is taking
* OTC medications
* Herbal meds
* Ask about pain/symptom - "What's wrong?"
What might PLEURAL FRICTION RUB indicate?
High-pitched; absence of pleural fluid.

Lower anterior; "creaking"
Components of the orientation phase.
- establish rapport
- determine interventions and expectations
- gather info for patient database
- identify strengths and limitations
- formulate NDx
- set goals
- develop POC
- explore feelings of nurse and patient
List Physical Barriers to Communication
* Physical
- Respiratory
- Oral/nasal cavities
- Speech center
- Auditory system
With what is the Oculomotor nerve associated and how test?
Extraocular eye movement (EOM)
Test = Assess six ocular movements and pupil reaction.
What might WHEEZES indicate?
Constricted airways.

Wheezes will not clear with a cough.
List types of information to be recorded on a chart.
Educational Planning
Discharge Planning
Cheif complaint
Present Health Status
Health history
Family History
Nutrition - preferences/restrictions
What might STRIDOR indicate?
Inspiratory wheeze; heard in neck.
List major components of documentation.
1 - Nursing Process
2 - Precise measurement
3 - Pain scales
4 - Patient quotes
5 - Administration of meds/treatment
6 - Preparation for tests
7 - Signature and title
8 - NEVER document something like "patient fell"
9 - "Do not get even in the chart"
10 - Use only approved medical terminology and abbreviations
11 - Be specific, clear and concise
12 - Use correct spelling
13 - Leave no blank lines
List types of adventitious sounds.
Crackles (discontinuous)
Wheezes (continuous)
Rhonchi (continuous)
Pleural friction rub (continuous)
Stridor (continuous)
Components of the working phase.
- maintain trust and rapport
- promote client insight
- problem solve
- overcome patient resistance
- evaluate progress
Where are bronchovesicular breath sounds normally heard?
Over the mainstem bronchi below the clavicles and adjacent to the sternum between scapulae.
Components of Urinary Tract Assessment
* Look at external urethra
* Urine output
* Bladder distention
* Pain
What does IPPA stand for?
Components of the Preinteraction phase.
- Obtain available info about the client from chart, others, etc.
- Examine one's own feelings about working with the patient.
List three Charting Systems.
1 - Problem-oriented
2 - Source-oriented
3 - Computer-Assisted
* Frequency of the vibrations
* Low Pitch - abnormal to heart tones
* High Pitch - bronchial sounds; bowel sounds
Best Practice for Nursing Documentation.
1 - Write clearly and legibly
2 - Do not erase or "white-out"
3 - To correct an error, strikeout with one line
4 - Use approved abbreviations and symbols
5 - Document close to time when collected
6 - Transcribe accurately
7 - Do not leave blank spaces
8 - Time and date each entry
9 - Document like a reporter.
10 - Do not state that incident reports have been filed
11 - Follow facility polices for documentation
12 - Use carat to add words
13 - Label late entries appropriately.
14 - Make sure all information will be picked up by a copy machine.
* Subjective
* Whistling, gurgling, or snapping
What is attributed to the LUBB sound of S1?
Closing of the AV valves.
List Components of Head to Toe Assessment
Components of Head to Toe Assessment
* General Appearance
* Inspection = to look at
* Palpation
* Percussion = to listen
* Auscultation = to listen
List two types of interactions
1 - Social - occur daily; pleasantries, etc.
2 - Therapeutic - helping or encouraging the patient to communicate feelings of perceptions, fears, anxieties, frustration, expectations, and increased dependency needs.
List Techniques which promote effective communication
* Rapport
* Specific objectives
* Comfortable environment
* Privacy
* Confidentiality
* Client focus
* Use of nursing observations
* Optimal pacing
* Providing personal space
Where is the Peripheral Vascular System most often measured?
* measured most often using feet (farthest point from the heart)
List Characteristics of Inspection
* Visual Examination
* Deliberate, purposeful, and systematic
* Assess moisture, color, and texture
* Assess shape, position, size, color, and symmetry
List characteristics of Admission Protocol.
* Availibality of advanced directives
* The client's bill of rights is presented
* Admission assessment is completed by a RN within a specified time period
* All clients must be clearly identified by a legible identification band
Describe Percussion
* Act of striking the body surface to elicit sounds that can be heard or vibrations that can be felt
* Direct used for the sinuses...ASK PATIENT ABOUT PAIN
* Indirect - using the finger of one hand to tap the finger of the other
* Indirect used for abdomen and lungs
With what is the Trochlear nerve associated and how test?
EOM, specifically moves eyeball downward and laterally
Test = assess six ocular eye movements.
* Examination using touch
* Pads of the fingers
* Can assess texture, temperature, vibration, position, size, mobility of organs or masses, distension, pulsation, and pain upon pressure
List components of Discharge Charting.
* Summarize patient's stay
* Patient family education
* Referrals (ex. community referrals)
* Long or short
With what is the Facial nerve associated and how test?
Facial expression; taste
Test = ask patient to smile, raise the eyebrows, frown, puff out cheeks, close eyes tightly
* Loudness or softness
With what is the Trigemenal nerve associated and how test?
Sensation of cornea, skin of face, and nasal mucosal
Test = Seek blink reflex by touching sclera
Describe Auscultation
* Listening to sounds produced within the body
* Auscultated sounds are described according to their pitch, intensity, duration, and quality