Week 1

Question 1

Nursing process steps

Answer 1

Assessment
Analysis/Diagnosis
Planning
Implementation
Evaluation

Question 2

Primary survey includes checking:

Answer 2

ABCs= Airway, Breathing, Circulation
Disability
Exposure

Question 3

Level of consciousness

Answer 3

Alert and oriented
Confused and disoriented
lethargic
obtunded
unconscious

Question 4

What is first level priorities

Answer 4

life threatening, requires urgent action

Question 5

what is second level priorities

Answer 5

may lead to clinical deterioration, needs prompt action

Question 6

what is third level priorities

Answer 6

non urgent, but needs addressing (ex:educating clients)

Question 7

Intervention types

Answer 7

effective
ineffective
unrelated
contraindicated

Question 8

what is focused assessment

Answer 8

Specific to a health concern, reason for seeking care

Question 9

Complete health assessment

Answer 9

Full overview of client’s health status

Question 9

What is head to toe assessment

Answer 9

Cephalocaudal “head to toe” approach, provides overview of client’s current health status

Question 10

what type of level of consciousness: altered in consiousness

Answer 10

confused and disoriented

Question 11

what type of level of consciousness:slow and sluggish

Answer 11

lethargic

Question 11

what type of level of consciousness: significant impairment without stimuli they will return back to sleep

Answer 11

obtunded

Question 11

Diff types of health promotion

Answer 11

behavioural = focus on lifestyle

relational = focus on the person’s relationships (things around the patient)

structural = focus on policies

Question 12

locations of pulses

Answer 12

radial
brachial
carotid
apical pulse

Question 13

where is brachial pulse found?

Answer 13

Look for the pulse in the brachial artery in the antecubital fossa

Question 14

where is apical pulse found?

Answer 14

Auscultate the apical pulse at the 2nd-5th intercostal space, midclavicular line.

Question 15

when describing pulse what do you have to mention

Answer 15

Rate
Rhythm
Force
Equality (bilateral)

Question 16

when describing pulse rhythm you use either

Answer 16

Regular = even tempo with equal intervals

Irregular
- regularly irregular
- irregularly irregular

Question 17

when describing pulse force you use

Answer 17

3+ Full, bounding
2+ Normal/strong
1+ Weak, diminished, thready
0 Absent/non-palpable

Question 18

three regular pulse beats and one missed and this is repeated. what type of Irregular is it?
- regularly irregular
- irregularly irregular

Answer 18

regularly irregular

Question 19

there is no rhythm to the irregularity. what type of Irregular is it?
- regularly irregular
- irregularly irregular

Answer 19

• irregularly irregular

Question 20

normal pulse range

Answer 20

60-100 BPM = adults
+15 = in pregnant women

100-175 BPM = newborn/children

Question 21

what is bradycardia

Answer 21

slow BPM, below 60 bpm

Question 22

tachycardia is

Answer 22

elevated heart rte, above 100bpm

Question 23

what is sinus arrhythmia

Answer 23

Irregular heart rhythm = pulse fluctuates with breathing Higher during inspiration lower during expiration

Question 24

what is Atrial fibrillation (Arrhythmia)

Answer 24

when atria quivers (beat irregularly)

Question 25

what is auscultatory gap

Answer 25

brief period during blood pressure measurement when Korotkoff sounds disappear and then reappear

Question 26

orthostatic hypotension is

Answer 26

a person's BP decrease when moving

Question 27

orthostatic tachycardia

Answer 27

increased BPM of a person when they move

Question 28

Hypertension is

Answer 28

elevated BP (140/90 or higher)

Question 29

Hypotension is

Answer 29

decreased BP (less than 95/60)

Question 30

Aneurysm

Answer 30

blood vessels ballon bec of weak walls