Unit 2 (assessment) exam

You suspect child abuse and the parent of the child becomes angry asking why you reported it. What should you say back?

"I am required by law to report child abuse"

If a patient tells you that you are the worst nurse what should you say back?

"Tell me more"

What steps should you take to create a therapeutic environment?

-Make sure the client is comfortable (room temperature and chair). -Reduce noises (TV, Radio, Visitors Talking) to enhance communication. -Provide Privacy

normal pulse range for newborn

107-180bpm

Normal deep tendon reflex

2+

normal range for 3-5 y/o respirations

20-25 bpm

Normal range for newborn respirations

30-60 bpm

normal pulse range for 10 y/o to adolescence

50-90bpm

The apical pulse is located

5th intercostal space at midclavicular line

What is an older adults temperature range?

95.9-99.5

normal temperature range for children under 5

97.7-99.5

What is the second step when assessing the abdomen?

Auscultation

When assessing an older adult who have sensory aide's, you need to have them _______ for use.

Available

A nurse is performing a screening for scoliosis on a school-age child. What instructions should the nurse provide?

Bend forward with your knees straight and arms dangling

cranial nerve XII

Hypoglossal (tongue movement)

In what order should you assess the abdomen?

Inspect, Auscultate, Percuss, Palpate

What is the first step when assessing the abdomen?

Inspection

Why should you auscultate the abdomen before percussing/palpating?

It can activate the bowels.

If someone is making a cup of coffee when they are anxious, are they stress managing?

NO

When someone is performing SBE (self breast exam) should they lift their hand off the breast at anytime during the exam?

NO. leave hand on breast the whole time to make sure you do not skip over a lump

Cranial nerve I

Olfactory (smell)- tested by asking the patient to identify odors on cotton ball

Cranial nerve II

Optic- tested using the Snellen chart, or to test the visual fields have the patient cover one eye while moving your finger to all 4 visual quadrants.

open drainage system

Passes through an open-ended tube into a receptacle or out onto the dressing.

extra heart sound before S1

S4 sound

when someone has a low literacy level you should plan to include _____ teaching sessions.

Short

What would you need to think about when planning to assess children or older adults?

They may have lower levels of knowledge

cranial nerve VIII

Vestibulocochlear - hearing, balance Sensory

Is it pretty normal for the skin of an older adult to be thin?

Yes

When assessing a 10 y/o child is it appropriate to ask the child if they want their parent out of the room?

Yes it is appropriate.

a nurse is performing a cardiovascular assessment on a client. what finding should the nurse expect?

a brief thump felt near the fourth or fifth intercostal space near the left midclavicular line

if you hear turbulence between S1 and S2, you should document it as

abnormal sound

when teaching someone with low literacy level you should

ask patient to demonstrate

A nurse is performing an abdominal examination on a preschooler. what action should the nurse take during the assessment?

ask the child to "help" with the exam by placing their hand on top of the nurse's hand

ABCDE of skin cancer- focus "A"

asymmetry of shape

the peripheral pulse tibial is located?

at the inner ankle

the romberg test is used to assess

balance

Inflammatory phase of wound healing

begins once the skin is injured and continues for about 24 hours in partial-thickness wound healing.

popiteal pulse site

behind the knee

ABCDE of skin cancer- focus "B"

border irregularity

Normal Assessment Findings of the lymph nodes

chains of ______ ______ extend from the lower half of the head down into the neck. Not tender or visible.

wound irrigation step 2 (after waterproof padding)

clean gloves

wound irrigation step 3 (after clean gloves)

clean wound in circular motion

ABCDE of skin cancer- focus "C"

color variation within one lesion

nonverbal communication

communication using body movements, gestures, and facial expressions rather than speech

maturation phase of wound healing

completed the wound healing process and may take more than 1 year.

Wet, popping sounds during the inspiratory phase of each respiratory cycle are identified as what?

crackles

When you are removing sutures you should

cut as close to the skin as possible

When adults grow older their bladder capacity ________

decreases

What type of info is included in the general survey/health history?

demographic info, source of history, history of present illness, past health history and current health, family history.

a nurse is preparing to perform a comprehensive assessment on a client. what action should the nurse plan to take first?

develop a plan of care

Angiogenesis

development of new blood vessels within the wound

ABCDE of skin cancer - focus "D"

diameter greater than 6mm

Snellen chart measures

distant vision

when the nurse places the fingertips on the top of the client's foot, between tendons of the great toe and those next to it, what pulse is the nurse checking?

dorsalis pedis

How should the liver sound

dull

when should you document a patient's allergies?

during the initial assessment

completing an abdominal assessment. what is an abnormal finding?

ecchymosis (bleeding underneath, typically caused by bruising)

a nurse is inspecting the skin of a toddler. what finding should the nurse report to the provider?

ecchymotic (bruised) area on the abdomen

ABCDE of skin cancer- focus "E"

evolving or change in color, elevation, shape, size or development of itching, crusting, or bleeding

verbal communication

expressed in words

cranial nerve VII

facial nerve- tested by looking at asymmetry in facial movements.

cranial nerves IX and X

glossopharyngeal and vagus nerves- gag reflux

When assessing an older adult you should be sensitive to conversations related to loss or possible loss of ________ as it might be difficult for the client to discuss.

independence

closed drainage systems reduce the risk of ____ and allow more accurate measurement of drainage

infection

In the orientation phase you should illicit ____ from the client

information

When assessing an older adult you should allow adequate time for more _____

information. They have lived longer so they may have more medical history etc.

In what order should you assess body parts EXCLUDING the abdomen?

inspect, palpate, percuss, auscultate

Active listening skills

intermittent eye contact

wound irrigation step 5 (after opening sterile package)

irrigate wound

a nurse is performing a physical examination of the spine for an older adult client. which is a common finding with aging?

kyphosis "hunchback"

age related changes to body

low muscle mass

the _____ phase of wound healing begins and overlaps with the proliferation phase, remodeling works to reorganize collagen within a scar to help increase strength and integrity

maturation

When assessing an older adult you should allow adequate time for ______ ______

mobility issues. -older adults take more time to change positions

Normal Assessment Findings of the neck

muscles of the _____ symmetrical, shoulders are equal in height and with average muscle mass, full range of motion, CN XI

pressure ulcer stage 3 shows what tissue?

necrotic subcutaneous tissue

Is the physical assessment data subjective or objective?

objective

cranial nerve III

oculomotor nerve, innervates all the rest: the superior, inferior, and medial rectus and the inferior oblique muscles

Cranial nerve III, IV, and VI

oculomotor, trochlear, abducens- tested by symmetry of movement, droop of eyelids, twitches or flutters. These are tested by asking the patient to follow a moving target (butterfly)

dorsalis pedis pulse is located

on top of the foot

wound irrigation step 4 (after cleaning wound in circular motion)

open sterile package

a nurse is taking the temperature on an 18 month old toddler. what actions should the nurse take?

place the thermometer tip in the center of the toddler's axilla against their skin

when should you auscultate bowel sounds?

prior to percussion

When assessing a child's ear you should

pull ear DOWN and back

When assessing an adults ear you should

pull ear UP and back

a nurse is palpating a tender area of a clients abdomen. the nurse slowly applies pressure over the area with their fingertips, then quickly releases it. the client reports increased pain on the release pressure. what should the nurse document?

rebound tenderness

Proliferative phase of wound healing

restores skin integrity by filling in the wound with new tissue.

a nurse is performing an abdominal assessment on a client. over which area should the nurse attempt to auscultate bowel sounds first?

right lower quadrant

lateral curvature of the spine

scoliosis

a nurse is taking BP on a school-ages child. what action should the nurse take?

select a cuff width that covers 40% of the upper arm

Normal Assessment Findings for the skull

size (normocephalic), no depressions, deformities, masses, or tenderness, overall contour and symmetrical

Normal aging effects on integumentary

skin thin, drier, tears. Thinning of pubic area, slow growth of nails, less oil, moisture, sweat, uneven pigmentation, slow wound healing.

Cranial Nerve XI:

spinal accessory- tested by asking the patient to raise their shoulders against resistance.

Is the general Survey (health history) subjective or objective data?

subjective

Normal Assessment Findings of the face

symmetric facial features, symmetry of expressions, no involuntary movements, proportionate facial features.

A nurse is performing an annual physical examination on an adolescent. What should the nurse include in the general survey?

the adolescent makes good eye contact

skin temp is best assessed with

the back of the hand

a nurse is assessing a clients cranial nerves. what indicates that cranial nerve 1 is intact?

the client can identify a minty scent

A BMI of 23 is

the client has a BMI within the expected reference range

cranial nerve V

trigeminal nerve- evaluated by using a pinprick to test facial sensation and brushing a wisp of cotton against the lower or lateral cornea to evaluate corneal reflex. (clench your teeth and tell me when you feel a touch)

plan of care for a stage 3 pressure ulcer

turn patient every 2 hours

closed drainage system

use compression and suction to remove drainage and collect it in a reservoir

when you hear the S3 sound this is

ventricular gallop

What are two types of communication?

verbal and nonverbal

wound irrigation step 1

waterproof padding

When is it somewhat normal to find blood ox down to 85%

when the patient has a lung disease