Rn Test 2

Front 1

Purpose of physical exam

Back 1

a) Provides indication of the person’s overall health status
b) Can provide additional information about the clinical significance of reported symptoms
c) Can provide indication of how person is responding to treatment already given

Front 2

2) Assessment Data

Back 2

b) Subjective
c) Objective

Front 3

3) Nursing Assessment takes a __ approach with client and family

Back 3

b) Holistic
i) physical
ii) psychosocial
iii) spiritual

Front 4

4) Types of Assessment

Back 4

comprehensive
ongoing partial
focused
emergency

Front 5

comprehensive examination

Back 5

i) A comprehensive assessment is performed with a health history and complete physical examination.
ii) This type of examination is done on admission to a hospital or when first meeting a client at home or in an office or clinic setting if appropriate.

Front 6

b) Ongoing Partial Assessment

Back 6

i) This is conducted at regular intervals such as the beginning of each shift or at each home visit, and may be repeated as needed

Front 7

c) Focused Assessment

Back 7

i) A focused assessment is conducted to address one specific problem.

Front 8

d) Emergency Assessment

Back 8

i) A rapid assessment used to detect life threatening situations
ii) Airway, breathing, circulation come first

Front 9

5) Physical Assessment i) Gathering equipment

Back 9

(1) Stethoscope
(2) BP cuff
(3) Thermometer
(4) Scale
(5) Measuring Tape
(6) Reflex hammer
(7) Otoscope
(8) Snellen Chart
(9) Vaginal spectulum
(10) Gloves
(11) Mask
(12) Gown
(13) Goggles
(14) Lubricant

Front 10

c) Positioning During Exams

Back 10

i) Supine
ii) Semi-fowlers
iii) Supine
iv) Dorsal recumbant
v) Side lying
vi) Lithotomy
vii) Knee chest
viii) Sims

Front 11

6) Inspection

Back 11

a) The process of deliberate, purposeful observations performed in a systematic manner.
b) One area at a time.
c) Compare one side to the other.

Front 12

7) Palpation

Back 12

a) Uses sense of touch to gather information that cannot be obtained through inspection alone.

Front 13

light vs deep palpation

Back 13

i) Light
(1) Dorsal Surface of Hand
(a) Light Palpation
ii) Deep
(1) Palmar Surface of Hand

Front 14

8) Percussion

Back 14

i) Act of tapping a person’s skin in order to set up a vibration that can be interpreted by you the health professional.

Front 15

Pleximeter vs Plexor? When used?

Back 15

pleximeter (non-dominant hand middle finger)
plexor (dominant hand middle finger)

Used for indirect percussion

Front 16

c) Percussion Tones

Back 16

1) Flatness, Soft, Thigh
2) Dullness, Medium, Liver
3) Resonance, Loud, Normal Lung
4) Hyperresonance, Very Loud, Emphysema
5) Tympany, Loud, Air in Abdomen (drum like)

Front 17

9) Auscultation

Back 17

a) Use of stethoscope to listen to body sounds.
b) Listen for:
i) pitch
ii) loudness
iii) quality
iv) duration

Front 18

1) General Survey

Back 18

i) First Component of any exam
iv) Uses inspection technique including sight, smell, and, hearing
v) Includes observation of appearance and behavior, taking vital signs, and measuring height and weight

Front 19

b) Level of Consciousness

Back 19

i) awake and alert, or lethargic, or stuporous, or comatose

Front 20

General survey observations

Back 20

i) Body build, posture, gait
ii) Hygiene, grooming
iii) Signs of Illness
iv) Affect, attitude, mood
v) Cognitive process

Front 21

2) Skin, Hair, Nails a) Inspect

Back 21

i) overall condition, color, vascularity, lesions,
ii) body odors

Front 22

2) Skin, Hair, Nailsb) Palpate

Back 22

i) temperature,
ii) moisture,
iii) turgor,
iv) texture
v) nails-capillary refill,

Front 23

Abnormalities in Skin Color

Back 23

(1) Erythema
(a) redness,flushed
(2) Cyanosis
(a) gray or blue
(3) Jaundice
(a) yellow: light to dark
(4) Pallor
(a) pale, ashen

Front 24

ii) Abnormalities in Skin Turgor

Back 24

(c) In elderly client
(i) decreased turgor MAY be normal finding
(d) Dehydration
(i) turgor delayed
(e) Edema
(i) difficulty in lifting skin fold

Front 25

d) Age Variations ii) Older Adult

Back 25

(1) Wrinkles, dryness, scaling, decreased turgor
(2) Raised dark areas (senile keratosis)
(3) Small flat age spots (senile lentigines)
(4) Small round red spots (cherry angioma

Front 26

4) Eyes c) use of light source to check for

Back 26

i) reaction to light
ii) consensual reflex
iii) accomodation
iv) convergence
v) extraocular movements
vi) peripheral vision

Front 27

5) Ears

Back 27

i) Whisper Test
ii) Weber’s Test
iii) Rinne’s Test
(1) Both tests with tuning fork for hearing acuity
(a) compare air conduction of sound to bone conduction
(2) Normal finding is that air conduction is better than bone conduction

Front 28

6) Nose and Mouth is

Back 28

is the beginning of the respiratory and the GI systems

Front 29

g) Neck Inspection

Back 29

i) Chains of lymph nodes extend into face under chin and down the lateral neck and on the posterior neck.
ii) Thyroid Gland is assessed for
(1) size, shape, masses, nodules, tenderness, and symmetry.
iii) Assess vascular system
(1) JVD?, Carotids
iv) Auscultate the carotids

Front 30

7) Thorax and Lungs

Back 30

c) Best if patient is sitting, make adjustments for bed ridden patient.

Front 31

d) General Inspection of Chest

Back 31

i) Observe color, shape, contour, and breathing patterns.
(1) Color should be the same as the face.
(2) Shape should be transverse is greater than the anterior/posterior diameter.
(3) Breathing pattern should be even and 12-20 breaths/minute

Front 32

ii) Palpation of chest checking for

Back 32

tenderness, temperature, muscle development, and fremitus.

Front 33

Palpation of chest normal findings and abnormal findings

Back 33

(2) Normal findings would be warm skin, well developed muscles, no tenderness, and equal voice vibrations throughout.
(3) Abnormal would be cool or excessively dry or moist skin, muscle assymetry, tenderness, unequal fremitus, abnormal breathing patterns or expansion.

Front 34

percussion of chest

Back 34

(a) Flat
(b) Hyperresonance
(c) Dullness
(d) Hollow, loud, low pitch, and long duration (normal)
(e) Heard over bone (normal)
(f) Emphysematous lung (abnormal)
(g) Heard over solid mass or fluid (abnormal)

Front 35

i) Bronchial sounds

Back 35

(1) Blowing hollow sounds normally heard over the trachea.

Front 36

ii) Bronchovesicular sounds

Back 36

(1) Medium pitched, medium intensity blowing sounds normally heard over upper chest posteriorly and anteriorly.

Front 37

iii) Vesicular

Back 37

Soft low pitched sounds heard over remainder of lung fields.

Front 38

v) Adventitious Breath Sounds

Back 38

(1) Crackles (or rales)
(a) fine or coarse
(2) Wheezes
(3) Gurgles (rhonchi)

Front 39

9) Cardiovascular Inspection and Palpation

Back 39

(1) for peripheral pulses and perfusion noting strength of pulse and color of extremity.

Front 40

pulse grading

Back 40

0 through 4: absent through bounding

Front 41

v) Auscultation of Heart

Back 41

(1) Aortic
(2) Pulmonic
(3) Tricuspid
(4) Mitral

Front 42

(6) Normal Heart Sounds(7) Abnormal Heart Sounds

Back 42

(a) S1
(b) S2

(a) S3
(b) S4
(c) Murmurs

Front 43

b) Normal Age Related Variations for heart

Back 43

i) Newborns/Children (3) Presence of S3

ii) Older Adult
(2) Increased SBP and DBP

Front 44

10) Abdomen assesment order

Back 44

i) inspection
ii) auscultation
iii) percussion
iv) palpation

Front 45

Normal assesment order

Back 45

Inspection
palpation
percussion
auscultation

Front 46

11) Musculoskeletal System

Back 46

a) Use inspection and palpation only
e) Muscle Strength
d) Palpate and inspect joints for tenderness, symmetry, and swelling

Front 47

g) Inspecting Spinal Curves

Back 47

(1) Kyphosis: Increased thoracic curve, seen in elderly.
(2) Lordosis: Exaggerated lumbar curve seen in pregnancy, obesity, childhood
(3) Scolioisis: Lateral curvature that forms S shape to spine (often school screenings identify)

Front 48

h) Orthopedic Checks

Back 48

i) Also called extremity check, vascular check, splint check or neurovascular checks
ii) Checking an extremity that has been compromised
iii) Check temperature, swelling, pulse, sensation, discoloration, pain, drainage and record and if necessary report changes

Front 49

12) Neurological System

Back 49

c) We use inspection and touch for this exam.

Front 50

e) Twelve Cranial Nerves

Back 50

1 olfactory
2,3,4, and 6- eyes
5 Trigeminal face sensation
7 Facial facial muscles
8 acoustic
9 Glossopharyngeal swallowing
10 vagus speaking
11 spinal accessory shoulder
12 Hypoglossal tongue

Front 51

f) Reflex Grading Scale

Back 51

i) 0 no tone, +1 low tone, +2 normal,
ii) +3 brisker than average but may be normal
iii) +4 hyperactive often indicative of disease.

Front 52

g) Glasgow Coma Scale

Back 52

: Score of 0 to 15
i) Eye Opening,
ii) Motor Response,
iii) Verbal Response

Front 53

13) Diagnostic Testing

Back 53

c) Diagnostic test results confirm or repute physical assessment findings. Nurses obtain results for the chart

Front 54

13) Diagnostic Testing Nurses are responsible for

Back 54

assisting with obtaining consent, preparation, scheduling, and patient support following procedures.

Front 55

a) A total Health Assessment will include

Back 55

the Health History and the Physical Assessment.

Front 56

1) The History of the Nursing Process Defined by Hall in 1955

Back 56

to describe the work of nurses

Front 57

d) ANA Congress for Nursing Practice (1973) recognized

Back 57

the 6 step Nursing Process as the model for nursing practice.

Front 58

2) Steps of the Nursing Process

Back 58

a) Assessment
b) Diagnosis
c) Outcome Identification & Planning
d) Implementing
e) Evaluating

Front 59

3) Characteristics of the Nursing Process

Back 59

a) Systematic
b) Dynamic
c) Interpersonal
d) Outcome oriented
e) Universal

Front 60

4) Nursing Process - Purpose

Back 60

a) Helps the nurse manage each client’s care
i) Holistically
ii) Scientifically
iii) Creatively

Front 61

4) Nursing Process Focus

Back 61

i) on the unique human response

Front 62

5) Problem Solving and the Nursing Process

Back 62

c) Scientific
b) Trial and Error
d) Intuitive Thinking
e) Critical Thinking

Front 63

6) Critical Thinking

Back 63

b) A systematic way to form and shape one’s thinking.
c) Solves problems creatively
d) Thinking with a purpose

Front 64

The Four Blended Skills

Back 64

1) Cognitive
2) Technical
3) Interpersonal
4) Ethical/legal

Front 65

Cognitive Skills

Back 65

a) Use scientific rationale when planning patient care
b) Identify the purpose or goal of your thinking
c) Determine if the knowledge is accurate, complete or relevant

Front 66

Technical Skills

Back 66

a) Involves psycho motor skills
b) Includes the mastery of the manual skills essential to the nursing process

Front 67

Interpersonal Skills

Back 67

a) Caring behaviors are essential to nursing practice
b) Promote the dignity and the respect of patients
c) Communicate caring through patient interactions

Front 68

Ethical/Legal Skills

Back 68

a) Accept accountability for the care you delegate
b) Voice your concerns over the unmet needs of your patients
c) Document patient needs
d) Report incompetent, unethical, or illegal practice

Front 69

9) Characteristics of Critical Thinkers

Back 69

a) Independent thinker
b) Fair minded
c) Intellectually courageous Intellectually humble
e) Demonstrates good faith and integrity
f) Possesses curiosity and perseverance
g) Creative
h) Disciplined
i) Confident

Front 70

11) Concept mapping

Back 70

a) A critical thinking approach to care planning
b) An instructional strategy that links key concepts
c) A visual map of why relationships exist among patient problems

Front 71

Nursing Assessment

Back 71

i) First step of the nursing process
iii) A patient data base is started or revised

Front 72

1) Unique Focus of Nursing Assessment

Back 72

a) Gathering information about the client
b) Does not duplicate medical assessments
c) Strives to determine the client’s RESPONSE to health problems or illness
d) No other health professional does this

Front 73

2) Types of Assessments

Back 73

a) Initial
b) Focused
c) Emergency
d) Time Lapsed

Front 74

i) Objective data

Back 74

(1) includes the Physical Assessment and what you observe
iii) Uses the senses

Front 75

ii) Subjective Data

Back 75

(1) the Nursing Health History and what the patient tells you
(2) Health history told by pt

Front 76

b) Data Sources primary vs secondary

Back 76

i) Primary
(1) most reliable
(2) Client/Patient
ii) Secondary
(1) Family, significant other
(2) Health record
(3) Lab results
(4) Diagnostic procedures
(5) Health team members
(6) Literature/Internet

Front 77

a) Data needs to be

Back 77

i) Complete
ii) Factual and accurate
iii) Relevant
iv) Purposeful

Front 78

Nursing History

Back 78

h) Focus should be getting to know the person
i) Should capture the uniqueness of the person
j) Information gained helps nurse identify patient strengths and weaknesses

Front 79

1) The Interview Purpose

Back 79

i) Obtain a health history that contains information about the client’s health status

Front 80

2) Phases of the Interview

Back 80

i) Preparatory
ii) Introduction
iii) Working
iv) Termination

Front 81

b) Preparatory Phase

Back 81

iv) Use a non-judgmental approach
v) Ensure privacy (family presence only if patient approves)
vi) Conduct interview at opportune time

Front 82

c) Introduction phase

Back 82

i) State purpose
iii) Introduce self
iv) Clarify roles

Front 83

d) Working Phase

Back 83

i) Focus on the patient
ii) Use therapeutic communication skills
iii) Gather information

Front 84

e) Termination

Back 84

i) Conclude carefully, not abruptly
ii) Encourage client/family to give nurse additional information in order to help nursing staff to plan care

Front 85

3) Problems Related to Data Collection

Back 85

a) Inappropriate organization of the data base
b) Omission of data
c) Inclusion of irrelevant data
d) Failure to establish rapport
e) Failure to observe appropriate behavior
f) Failure to update the data base
g) Failure to document accurately, clearly & timely

Front 86

a) Confirm or verify discrepancies

Back 86

i) Between objective and subjective data
ii) Between sources, client and family or record

Front 87

a) Cues

Back 87

i) pieces of information obtained through assessment;
(1) an indication that something may be wrong
(2) can be objective or subjective

Front 88

b) Inference

Back 88

i) assignment of a meaning to the cue
ii) is the Nursing DX
(1) do not use the medical problem as dx. Use it as a strength to help identify the response to form RN Dx.

Front 89

Complete Health Assessment
1) Two components

Back 89

a) Nursing history
b) Physical assessment

Front 90

ii) Biographical Data

Back 90

(1) Patient initials, age, sex, marital status, religion, occupation, education

Front 91

subjective data needed for health assesment

Back 91

ii) Biographical Data
iii) Reason for seeking healthcare
iv) Patients opinion of own general health
v) Activities of Daily Living
vi) Pattern of Nutrition
vii) Elimination
viii) Activity/exercise
ix) Rest/sleep
x) Safety
xi) Previous illnesses (major) & hospitalizations
xiii) ALLERGIES
xiv) Wellness Practices:
xv) Medications
xvi) Family History
xvii) Family Support:
xviii) Psychosocial History:

Front 92

b) Review of Systems

Back 92

a brief subjective account as reported by the patient of any recent signs or symptoms associated with any body system.

Front 93

i) Average Life expectancy

Back 93

(1) Women- 80.5
(2) Men- 75.4

Front 94

old age groupings

Back 94

ii) Young Old
(1) 60-74
iii) Middle Old
(1) 75-84
iv) Old-old
(1) The over 85 group
(2) Fastest growing segment
v) Elite old
(1) Over 100!

Front 95

1) Ageism

Back 95

a) Form of prejudice
b) Deep seated uneasiness on the part of the young and middle aged adults
c) Personal revulsion or distaste

Front 96

d) Consequences of Ageism

Back 96

i) People distance themselves from elders
ii) Don’t see elders as “like them”
iii) Elder is viewed as being less than human

Front 97

3) Examples of Negative Attitudes

Back 97

a) Raising the voice when speaking to an elder
b) Providing no or less privacy during care
c) Referring to elders as cute
d) Talking about elder in their presence

Front 98

a) Myths on older adults

Back 98

i) Most elders are in nursing homes
ii) Being elderly means being “senile”
iii) Older adults do not care how they look
iv) Most elderly have bladder problems

Front 99

Aging Changes General Status

Back 99

(1) Less efficiency of physiologic processes
(2) Fragile balance of homeostasis
(3) More vulnerable to stressors
(4) Decreased reserves

Front 100

Aging Changes Integumentary

Back 100

(1) Wrinkles- decreased elasticity
(2) Dryness
(3) Balding
(4) Skin pigmentation-moles
(5) Thickened nails

Front 101

iv) Neurologic age changes

Back 101

(1) CNS responds more slowly to multiple stimuli
(2) Cognitive/behavioral response is delayed
(3) Temp perception and pain regulation become less efficient
(4) Sense of balance declines, fine movements become more difficult
(5) Sleep at night shortens, naps more common

Front 102

v) Special Senses age changes

Back 102

(2) Diminished hearing acuity
(1) Diminished visual acuity

Front 103

vi) Musculoskeletal age changes

Back 103

(1) Muscle mass, strength decrease
(2) Bone demineralization
(3) Stiff joints
(a) Overall mobility slows.
(4) Height decreases
(5) Decrease in subcutaneous tissue and weight

Front 104

vii) Cardiopulmonary age changes

Back 104

(1) Blood vessels-
(a) Less elastic, rigid
(b) Fatty plaque deposits
(2) Lower extremity edema and cooling
(3) Body less able to increase HR and cardiac output with activity

Front 105

viii) Gastrointestinal age changes

Back 105

(1) Digestive juices diminish
(2) Nutrient absorption decrease
(a) Anemia
(3) Decreased peristalsis
(a) Constipation
(b) Indigestion

Front 106

ix) Genitourinary age changes

Back 106

(1) Blood flow to kidneys decrease with diminished cardiac output
(a) Waste products filtered more slowly
(b) Bladder capacity decreased
(2) Men
(3) Hypertrophy of the prostate

Front 107

7) Older Adult Health

Back 107

i) Chronic illness
ii) Accidents and injuries
iii) Dementia, Depression
iv) Elder Abuse

Front 108

e) Elder Abuse

Back 108

i) Neglect
ii) Abuse
(1) Physical
(2) Emotional
(3) Financial

Front 109

f) Dementia

Back 109

i) Various organic disorders that effect cognition
ii) Alzheimer’s disease
(a) Most common
iii) Affects brain cells
iv) Progressive

Front 110

8) Gerontologic Nursing

Back 110

a) Specialty of nursing concerned with assessment of health and functional status of older adults and planning, implementing health care and services to meet needs as well as evaluating the effectiveness of care

Front 111

b) Gerontology

Back 111

i) Scientific and behavioral study of all aspects of aging and its consequences
c) Meeting Healthcare Needs

Front 112

c) Meeting Healthcare Needs
i) Major goals:

Back 112

(1) Promote health
(2) Prevent illness/injury
ii) Areas of concern
iii) Nursing actions

Front 113

9) Care Settings

Back 113

a) Retirement communities
b) Continuing care retirement communities
c) CCRC
d) Acute care
e) Home care
f) Assisted living
g) Adult day care
h) Respite care
i) Long-term care