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Nurse Assessment > Chapter 1 > Flashcards

Chapter 1 Flashcards

(43 cards)

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1
Q

What is the purpose of assessment in the nursing process?

A

To gather comprehensive information for patient care

This is part of the ADPIE process: Assessment, Diagnosis, Planning, Implementation, Evaluation.

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2
Q

Name the types of assessments in nursing.

A
  • Comprehensive
  • Focused
  • Emergency
  • Ongoing/Shift
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3
Q

What are the phases of the interview in therapeutic communication?

A
  • Introduction
  • Working
  • Summary
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4
Q

Define cultural competence in the context of health assessment.

A

The ability to understand, communicate with, and effectively interact with people across cultures.

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5
Q

What is health literacy awareness?

A

The ability to obtain, process, and understand basic health information.

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6
Q

Differentiate between subjective and objective data.

A
  • Subjective data: information reported by the patient
  • Objective data: measurable or observable information
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7
Q

What does OLDCART stand for in health assessment?

A
  • Onset
  • Location
  • Duration
  • Characteristics
  • Aggravating factors
  • Relieving factors
  • Treatment
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8
Q

What is the difference between narrative documentation and charting by exception?

A

Narrative documentation is a detailed account, while charting by exception highlights only abnormal findings.

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9
Q

What are SOAP notes?

A
  • Subjective
  • Objective
  • Assessment
  • Plan
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10
Q

List the methods for measuring temperature.

A
  • Oral
  • Rectal
  • Axillary
  • Tympanic
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11
Q

What are the components of a pulse assessment?

A
  • Rate
  • Rhythm
  • Amplitude
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12
Q

What is assessed during a respiratory assessment?

A
  • Rate
  • Depth
  • Rhythm
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13
Q

What are the types of blood pressure measurement?

A
  • Manual
  • Automatic
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14
Q

What does SpO₂ measure?

A

Oxygen saturation in the blood.

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15
Q

Name two pain assessment tools.

A
  • 0–10 scale
  • Wong-Baker FACES
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16
Q

Define bradycardia.

A

A slower than normal heart rate.

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17
Q

What does hypotension mean?

A

Lower than normal blood pressure.

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18
Q

What is included in a general survey?

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A
  • Overall appearance
  • Hygiene
  • Body structure
  • Mobility
  • Behavior/affect
  • Level of consciousness (LOC)
19
Q

What are key terms related to level of consciousness?

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A
  • Alert
  • Lethargic
  • Obtunded
  • Stupor
  • Comatose
  • Orientation (person/place/time)
20
Q

What is inspection in assessment techniques?

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A

A visual examination of the patient.

21
Q

What is palpation used for?

Study These Flashcards
A

To assess texture, temperature, and tenderness using hands.

22
Q

What does percussion assess?

Study These Flashcards
A

Underlying structures by tapping on the body.

23
Q

What is auscultation?

Study These Flashcards
A

Using a stethoscope to listen to heart, lungs, and bowel sounds.

24
Q

What are key terms associated with lung assessment?

Study These Flashcards
A
  • Dyspnea
  • Orthopnea
  • Retractions
  • Accessory muscles
  • Adventitious sounds
25
What should be inspected in the abdomen assessment?
* Inspection * Auscultation * Percussion * Palpation
26
What is rebound tenderness?
Pain that occurs upon release of pressure on the abdomen.
27
Name the cranial nerves involved in neurological assessment.
Cranial nerves I–XII.
28
What does the Mini-Mental State Exam (MMSE) assess?
Cognitive function including orientation and memory.
29
What is the difference between delirium and dementia?
Delirium is a sudden change in mental status; dementia is a gradual decline in cognitive function.
30
What are considerations for pediatric assessments?
Adjusting for developmental stage or disabilities.
31
What should be considered during pregnancy assessments?
Physiological changes and the health of both mother and fetus.
32
33
34
What is the normal range for magnesium?
1.7–2.2 mg/dL
35
What are signs of hypomagnesemia?
Twitching, tremors, increased heart rate
36
What are signs of hypermagnesemia?
Lethargy, slow heart rate, weak muscles
37
What type of IV fluid is 0.9% NaCl?
Isotonic
38
What does a hypotonic IV solution do to cells?
It causes water to move into cells, making them swell.
39
When is a hypertonic IV fluid used?
To reduce cerebral edema or treat severe hyponatremia.
40
What is the function of calcium in the body?
Supports bone strength and nerve conduction.
41
What are signs of hypocalcemia?
Tetany, positive Chvostek and Trousseau signs
42
What are signs of hypercalcemia?
Muscle weakness, kidney stones
43
What is the normal range for bicarbonate (HCO3)?
22–26 mEq/L

Nurse Assessment (3 decks)

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