Exam 1

Question 1

What does ADPIE stand for?

Answer 1

Assessment, diagnosis, planning, implementation, evaluation

Question 2

What does SMART stand for?

Answer 2

single specific action, measurable, attainable, relevant, time limited

Question 3

What is the normal pulse and range for an adult?

Answer 3

80, 60-100

Question 4

How do you measure pulse?

Answer 4

4 point scale to measure force, equality (compare from side to side, noting any differences between arms), rhythm (irregularity could indicate heart arrhythmia), pulse deficit (when the apical pulse is faster than pulses in other areas)

Question 5

How do rectal, tympanic, and axillary temperature readings differ from oral temperature readings?

Answer 5

rectal and tympanic are 0.5C/0.9F higher while axillary is 0.5C/0.9F lower

Question 6

What are the lifespan considerations when checking the temperature of someone who has a suspected fever?

Answer 6

oral is for adults and older children (+2), method of choice for most hospital pts

rectal for infants and young children; do not use on pts with cardiac issues as it may stimulate the vagal response

Question 7

What are the considerations when taking a routine temperature check?

Answer 7

Axillary: only accurate with proper placement
Tympanic (ear): quick, non-invasive, done incorrectly about 90% of the time, should straighten ear canal and point toward inner ear, pain if inserted too far, ear wax can impact results… not a method of choice
Temporal: very quick, non-invasive, technique can vary; environment can change results (come in from cold weather, sweating etc)

Question 8

How do you calculate BMI?

Answer 8

weight (lbs)/height (in) X 703

Question 9

What is a focused health assessment?

Answer 9

short, used if an injury occurs or if with a long term PCP with no health changes

Question 10

What are head-to-toe assessments?

Answer 10

done upon assessment to review biographical data, source of history, reason for seeking care, present health or history of present illness, past health, family history, review of systems, ADLs, perception of health

Question 11

What does the history and physical tell the nurse? Why are they done?

Answer 11

Patient history and a physical can indicate the current baseline for the patient and if there are dysfunctions to any of their current baseline it could be attributed to the patient history and not a new disorder causing it.

Question 12

When is an appropriate use of an interpreter?

Answer 12

An interpreter can be used for patients whose primary language is not the same as the health care worker’s. The interpreter can be brought in for any conversations done between the health care worker and the patient. A family member should never be an interpreter.

Question 13

What is important to keep in mind during patient centered interviewing?

Answer 13

therapeutic communication, conscious and unconscious communication

Question 14

What are the advantages and disadvantages of clinical information systems?

Answer 14

Advantages: the ability to store, retrieve, and share information about each patient. It can support other care-related activities directly or indirectly through various interfaces, including evidence-based decision support, quality management, and outcomes reporting
Disadvantages: privacy and security of highly sensitive personal data

Question 15

What is the nursing responsibilities for clinical information systems?

Answer 15

ANA (American nursing association) states that all nurses should be able to practice safely in a technology-intensive health care environment.

Question 16

What are the sciences involved in clinical information systems?

Answer 16

Information science: applied math and electrical engineering
Computer science: theoretical foundations of information and computation and how these techniques relate to implementation and application of computer systems
Cognitive science: interprofessional study of mind, intelligence, and behavior from an information processing perspective
Organizational science: emerging field that focuses on behavior of organizations that includes a variety of topics: individual, group and organizational decision making; management of human resources; design of organizations and interorganizational networks

Question 17

What is the decision support system?

Answer 17

Computer software applications that match patient characteristics with a knowledge base to generate specific recommendations.
Apply evidence-based recommendations at the point of care, they are termed evidence-adaptive.
Ex/ Branden scale, fall risk, allergies

Question 18

What is the order of a MSK assessment?

Answer 18

Posture, movement and general body symmetry
(Symmetry of the skeletal framework; noticing any joints that look asymmetrical or cause pain with palpation)
Temporomandibular Joint (TMJ)
(Fluidity and ease of joint movement; noticing and clicking or popping, decreased ROM)
Cervical Spine
Shoulders
Elbows
Wrists
Hands & Fingers
Hips
Knees
Ankles & Feet
Gait

Question 19

What are the signs and symptoms of altered mobility?

Answer 19

Pain
Reduced joint movement
Reduced sensation or loss of sensation
Falls
Fatigue
Altered gait or imbalance
Reduced functional ability

Question 20

What is flexion and extension?

Answer 20

flexion is the bending of a limb at a joint while extension is the straightening of a limb at a joint

Question 21

What is abduction and adduction?

Answer 21

abduction is the moving of a limb away from the midline of the body while adduction is moving a limb towards the midline of the body

Question 22

What is pronation and supination?

Answer 22

turning the forearm so the palm is down and turning the forearm so the palm is up

Question 23

What is circumduction and rotation?

Answer 23

moving the arm in a circle around the shoulder and moving the head around a central axis

Question 24

What is inversion and eversion?

Answer 24

moving the sole of the foot inward at the ankle and moving the sole of the foot outward at the ankle

Question 25

What is protraction?

Answer 25

moving a body part forward and parallel to the ground