Assessment

Question 0

What are the two main areas of assessment?

Answer 0

Health history and physical assessment

Question 1

What begins the nursing process?

Answer 1

Assessment

Question 2

What are the four major assessment activities?

Answer 2

Collection
Organization
Validation
Documentation

Question 3

What is a collection or store of information?

Answer 3

Data base

Question 4

Clients description of the problem

Answer 4

Subjective Data

Question 5

Detectable by an observer. Something seen, heard, smelled, or felt.

Answer 5

Objective Data

Question 6

Who states Administer assessment done to determine each persons need for nursing care?

Answer 6

Joint Commission

Question 7

What is the purpose of assessment?

Answer 7

To enable the nurse to make a judgment or diagnosis about the patients health state.

Question 8

What is identified as the purpose of assessment?

Answer 8

1. The deviations from normal
2. The clients health beliefs and patterns of health illness
3. The presence of risk factors for physical and behavior health problems
4. The patients resources for support and adaption

Question 9

Is a continuous process carried out during all phases of the nursing process

Answer 9

Assessment

Question 10

What are the 5 components of the nursing process?

Answer 10

1. Assessment
2. Nursing Diagnosis
3. Planning
4. Implementation
5. Evaluation

Question 11

What is collected so problems are identified?

Answer 11

Initial data

Question 12

What are the 4 types of assessments?

Answer 12

1. Initial
2. Problem-focused
3. Emergency
4. Time-lapsed

Question 13

All the information about a client including past history and current problems

Answer 13

Baseline data or database

Question 14

What is the purpose of data collection?

Answer 14

To provide information or identify patient needs. It need to be continuous and symptomatic without omission.

Question 15

Who is the primary source of data?

Answer 15

Client and they are the best source

Question 16

Who is the secondary source of data?

Answer 16

Support people, medical charts, client records, diagnostic studies, record of therapies etc

Question 17

What is the pupils normal size?

Answer 17

3-5mm

Question 18

What does PERRLA stand for?

Answer 18

Pupils round reactive to light accommodation

Question 19

Skin springs back

Answer 19

Elastic

Question 20

Skin is slow to return

Answer 20

Tenting

Question 21

20 - 30 seconds of skin tenting indicates what?

Answer 21

Dehydration

Question 22

Decreased skin turgor is a late sign of what?

Answer 22

Dehydration

Question 23

What is anosmia?

Answer 23

Unable to smell

Question 24

Normal breath sounds are?

Answer 24

Soft and breezy

Question 25

What is the major breath sound?

Answer 25

Vesicular: best at the base of the lungs. Soft intensity. Low pitched.

Question 26

What are abnormal breath sounds?

Answer 26

Adventitous breath sounds

Question 27

Musical or constant pitch?

Answer 27

Continuous adventitous breath sounds

Question 28

Intermittent, cracking, bubbling

Answer 28

Discontinuous adventitous breath sounds

Question 29

Where does the heart lie?

Answer 29

Behind and to the left of the sternum

Question 30

PMI is found where?

Answer 30

At the apex of the heart

Question 31

Area of the chest above the heart is?

Answer 31

Precordial

Question 32

Aortic valve can hear?

Answer 32

S1

Question 33

Mitral valve can hear?

Answer 33

S2

Question 34

Which valves are responsible for LUB?

Answer 34

Atrioventricular (atrial, tricuspid)

Question 35

Which valves are responsible for DUB?

Answer 35

Semilunar (aortic and pulmonary)

Question 36

Systole

Answer 36

Ventricles contract

Question 37

Diastole

Answer 37

Ventricle relax

Question 38

What percentage is the atrial kick?

Answer 38

30% or more

Question 39

Bruit or thrill indicates what?

Answer 39

Turbulent blood flow

Question 40

You can ______ the bruit and ______ the thrill

Answer 40

Hear, feel

Question 41

Decrease or absent pulse and hair, pallor with elevation, nails thick, skin cool, shiny, and dry, ulcerations on bony points.

Answer 41

Arterial insufficiency

Question 42

Edema, ulcers, brownish color, warm, scaling eczema, pulse unaffected.

Answer 42

Venous insufficiency

Question 43

Inspect external jugular vein and interior jugular vein for JVD at what angle?

Answer 43

45 degree

Question 44

The abdomen is divided by:

Answer 44

A vertical line from Xiphoid process to Symphysis pubis and a horizontal line across the umbilicus

Question 45

High pitch and air-filled indicates

Answer 45

Tympany

Question 46

Dull and solid or fluid filled

Answer 46

Resonance

Question 47

Awake and responsive

Answer 47

Alert

Question 48

Sleepy but arousable

Answer 48

Lethargic

Question 49

Obtunded

Answer 49

Needs to be shaken

Question 50

Arouses with difficulty

Answer 50

Stuporous

Question 51

Not arousable

Answer 51

Comatose

Question 52

What is the babinski sign?

Answer 52

Toes bend = negative | Toes flair = positive (but is normal in a baby)

Question 53

What is validation of data?

Answer 53

Double checking

Question 54

SLIDE

Answer 54

Single line initial date error

Question 55

A head to toe assessment is called?

Answer 55

Cephalocaudal