Exam 1

What is bpm force?

- 0 (absent) - 1 (weak, hard to find, decreased SV) - 2 (easily felt) - 3 (full bounding, increased SV)

When should a nurse measure a patient's height?

- Adults (preferred, word of mouth okay in emergencies) - Children (required to measure growth) - Infants (required to measure growth)

When should a nurse measure a patient's weight?

- Adults (record in both pounds and kilograms, 2.2lbs per kg) - Children (required to measure growth) - Infants (required to measure growth)

What should a nurse check for when assessing physical appearance?

- Age (look their age?) - Sex (stage of development?) - Skin Color (appropriate for genetic background?) - Facial Features (symmetrical with movement?) - Level of Consciousness

What are the ABCDEs?

- Airway - Breathing - Circulation - Disability - Exposure

What is ALOSC when assessing consciousness?

- Alert (notices your precense) - Lethargic (sleepy or tired) - Obtunded (responds to physical stimulus) - Semi Coma (in and out of consciousness) - Coma (totally incoherent)

What is ABCT when assessing a patient?

- Appearance (what the patient looks like) - Behavior (how the patient is acting) - Cognition (does the patient seem mentally competent?) - Thought Process (is the patient behaving rationally?)

What is AAPIE?

- Assessment - Analysis - Plan - Implement - Evaluate

What are the components of health history?

- Biographical Data (name, contact info, birthday, gender, marital status, race, ethnicity, occupation) - Reason for Seeking Care (primary chief of complaint in patient's own words, no diagnosis) - History of Present Illness (when did you last feel well? OPQRSTU) - Past Medical History (medications, illnesses, hospitalizations, surgeries, immunizations, allergies) - Family History (any diseases that run in the family) - Review of Symptoms (health promotion activities for each body system, oral and skin care routines) - Functional Assessment (ADLs, activities of daily living, personal habits, diet, sleep routine)

What should a nurse check for during a physical exam for signs of abuse?

- Bruises - Bites - Swelling - Cuts - Burns

What symptoms should a nurse expect from a patient who is withdrawing from opioid use?

- Cognitively Intact (patient will remember everything) - SEVERE Flu Like Symptoms - Pain (every cell in the body is withdrawing, resulting in extreme aches and pain) - Agitation (patients will be very upset and sometimes cry and scream from the pain) - Mental Agony (brain is completely deficient of dopamine and serotonin resulting in extreme depression, anxiety, and schizophrenia) - Increased Vital Signs (body is panicking) - Dilated Pupils (flight or fight system is engaged)

What symptoms should a nurse expect from a patient who is withdrawing from alcohol use?

- Cognitively NOT Intact (will not remember anything) - Hallucinations (patients will sometimes see things due to withdrawal) - Increased Vital Signs - Headaches - Body Aches

What are the 4 types of databases?

- Complete (complete health history and physical exam) - Focused (limited or short term problems) - Follow Up (current status, follow up visits) - Emergency (rapid collection of life saving info)

What are the 6 types of speech disorders?

- Dysphonia (disorders of the voice) - Dysarthria (weak speech muscles, slurred speech) - Aphasia (general term for trouble with speech) - Global (patient has trouble understanding and expressing speech) - Broca (patient understands speech but cannot get the words out) - Wernicke (patient can talk normally but speaks fluent gibberish, doesn't comprehend language)

What should a nurse check for when assessing behavior?

- Facial Expression - Eye Contact - Mood and Effect - Speech - Dress - Hygiene

What should a nurse check for when assessing mobility?

- Gait (balanced, smooth, no use of assistive devices) - Range of Motion (symmetrical, no involuntary movements, no paralysis)

What are the 3 components of interviewing?

- Gather Data (observe, ask, document) - Critical Think (takes time to be mindful) - Prioritize (help based on severity)

What is IPPA?

- Inspection (visual exam) - Palpation (use of hands to feel) - Percussion (using sounds to examine) - Auscultation (listening to sounds)

What are the 4 levels of space?

- Intimate (0 - 1.5 feet) - Personal (1.5 - 4 feet) - Social (4 - 12 feet, where a nurse would talk to the patient) - Public (12+ feet)

What might result in an error when measuring BP?

- Legs Crossed - Cuff Too Small - Cuff Too Big - Patient Supporting Their Body

What are the 4 components of holistic health?

- Mind (mental health) - Body (physical health) - Spirit (spiritual health) - Community (poverty)

What should a nurse document if signs of abuse are detected?

- No Biased Notes - No Opinions - Photographic Documentation in Health Record All documentation may be useful in court proceedings.

What is OPQRSTU?

- Onset / Origin (where did the pain start?) - Provoking (what makes the pain worse?) - Quality (what does it feel like?) - Radiating (does it hurt anywhere else?) - Severity (how bad does it hurt?) - Treatment (have you tried to treat anything?) - Understanding (why do you think it hurts?)

What are the 5 types of temperature measurements?

- Oral (mouth, very accurate) - Tympanic (ear, pretty accurate) - Axillary (arm, not that accurate) - Rectal (butt, most accurate, used on babies) - Temporal (forehead, least accurate)

What are the different body positions?

- Prone (lying on stomach) - Fowlers (sitting 90 degrees) - Supine (lying on back) - Sims (lying on side) - Lateral (lying on side)

What are the 8 types of mental tests?

- Repitition (repeat "no ifs, ands, or buts" back to me) - Orientation (do you know where you are?) - Judgement (what would you do if a car was speeding at you?) - Math (what is 2+2?) - New Learning (repeat tree, purple, and baseball back to me in 5 minutes) - Remote Learning (what high school did you attend?) - Recent Memory (what did you eat for breakfast?) - Abstract (what is the meaning of "a bird in the hand is worth two in the bush"?)

What order should vitals be performed on an infant?

- Respirations - Pulse - Temperature Least invasive to most invasive.

What should a nurse check for when assessing respirations?

- Rhythm - Depth - Effort

What are the 4 stages of language development?

- Sensorimotor Stage (0-2 years, understanding the difference between themselves and others) - Preoperational Stage (2-7 years, able to use structured grammar and language to communicate) - Concrete Operational Stage (7-11 years, using numbers and logic to solve problems) - Formal Operational Stage (11-15 years, thought becomes abstract, complex sentences)

What should a nurse check for when assessing body structure?

- Stature (height appropriate for age?) - Nutrition (weight appropriate for age and sex?) - Symmetry (body parts equal?) - Posture (standing or sitting comfortably?) - Position (relaxed?) - Body Build (arm span and height?)

What is TPR?

- Temperature - Pulse - Respiration

What are the different types of sound?

- Tympany (stomach, bowels, drum like sound) - Resonance (respiratory, clear and hollow sound) - Hyperresonance (child respiratory, booming sound) - Dullness (heart, liver, muffled thud sound) - Flatness (muscle, bones, dead stop, no sound)

What is the body mass index?

- Underweight (less than 18.5) - Normal (18.5 - 24.9) - Overweight (25 - 29.9) - Obese (30 - 39.9) - Extreme (more than 40)

A patient comes in to the clinic requesting information on how to use his inhalers, is having trouble breathing, and has a skin laceration. What order should the concerns be prioritized?

1. Trouble Breathing 2. Skin Laceration 3. Education

What is the normal range for respirations per minute?

12-20

What is the normal range for blood pressure?

120/80

What is the high range for blood pressure?

140/90

How far should a nurse stand when assessing the posture of a patient?

2 feet

What is the normal range for pulse?

50-100bpm

Up until what age should adults be able to do the 3 item recall test at 5, 10, and 30 minutes?

65

What are the temperature conversions between F and C?

95 F = 35 C 98.6 F = 37 C 104 F = 40 C

What is the normal range for oxygen saturation?

95-100%. 100% is almost impossible to reach in Colorado. Always record the method that oxygen is being delivered (oxygen tube, face mask, room oxygen).

What is the normal range for temperature?

96.4 - 99.1 F (35.8 - 37.3 C)

What is cyanosis?

A bluish discoloration of the skin resulting from poor circulation or inadequate oxygenation of the blood.

What is pallor?

A paleness of skin color resulting from anemia (not having enough red blood cells).

What might a patient do when under the influence of hallucinogenic drugs?

A patient might say that they have super human strength.

What are some symptoms of morphine, methadone, and heroin?

A patient might show slow and slurred speech, impaired coordination, and impaired motor skills. Very similar symptoms to alcohol.

What might a patient suffering from depression do?

A patient might take long pauses between sentences or have poor posture.

What is erythematous?

A redness of the skin resulting from inflammation.

What is jaundice?

A yellowing of the skin and eyes due to a build-up of bilirubin in the blood. Usually from liver failure.

What should you do while interviewing?

Address patients by last name and introduce yourself, use open ended questions and don't give false reassurance.

What kind of interpreters should be used?

Always use a medically trained interpreter when available, family members will alter sentences and change wording. Use words that you know in the patient's language.

What is cultural assessment?

Ask primary and preferred language, dietary needs, and person in charge. Ask neutral questions.

What is the healthy range for blood pressure?

Below 120/80.

What is the fetal position?

Curled over and typically holding abdomen due to stomach pain.

What should you do around special populations?

Don't assume everyone is kind, protect yourself. Close the door behind you, never turn your back to the patient.

How do you find stroke volume?

End diastolic volume - end systolic volume.

What is the MMSE (Mini Mental State Examination)?

Exam that assesses patient awareness by asking questions like who is the president and what year is it. A score of 24-30 would be no cognitive impairment.

What is the MoCA (Montreal Cognitive Assessment)?

Exam that assesses patient mental capacity or progess of mental disorders. A score of 26-30 would be normal.

What is obesity?

Extreme accumulation of body fat.

What is cachexia?

Extreme wasting and malnutrition.

How is pain measured for children?

Faces scale from 0-10.

What is tachypnea?

Fast breathing.

What is systolic blood pressure?

First number, max pressure exerted on arteries during pump.

What kind of data should be gathered?

Gather objective data like speech, appearance, breathing, don't assume anything.

What should you do when performing a mental health status exam?

Gethering objective data like meds, speech, appearance, behavior, stress levels, drug and alcohol use.

What a normal MAP?

Greater than 60. Less than 60 means that organs aren't getting enough blood and oxygen.

How do you measure cardiac output?

Heart rate x stroke volume.

What is kyphosis?

Humpback in the thoracic area of the spine.

Why should a nurse use the thigh to measure BP?

If arms are unavailable, typically 10-40mmHg higher than arm BP.

What are the symptoms of alcohol intoxication?

Incoordination, dysarthria, and impaired judgement.

What is the tripod position?

Leaning forward with arms braced against the knees, chair, or bed. Usually seen in patients with COPD.

What should a nurse measure when doing a physical exam on an infant?

Length, head and chest circumference. Measured at every check up until 2y. Infants should have a head circumference 2cm greater than their chest.

What is bradycardia?

Less than 50 bpm.

What is hypotention?

Low blood pressure.

How do you find mean arterial pressure (MAP)?

MAP = 2/3 (DBP) + 1/3 (SBP)

What is tachycardia?

More than 100 bpm.

How much alcohol does the CDC recommend to pregnant women?

None

What is a sinus arrythmia?

Normal jumping around of heart beat.

What is mandatory reporting?

Nurses are mandated to report any suspicion of abuse following facility policy. Child and elder abuse is required to be reported by Colorado Law.

What should you do when discussing adolescent sex talk?

Nurses should always ask parents to leave the room so you can communicate with the teen.

What questions should a nurse ask when performing OPQRSTU?

O - Where is the pain? When did it start? P - What makes it feel better or worse? Q - What does it feel like? R - Does it spread or shoot anywhere else? S - On a scale from 0-10 how does it feel? T - Have you ever tried to treat it? U - What do you think is causing the pain?

What is FLACC?

Objective data for infants. Face, legs, activity, cry, consolability.

What is the status of opioid use?

Opioids get a bad rap due to the opioid crisis, but are extremely helpful when treating pain in the hospital. Mild to moderate pain should be treated with over the counter medications.

What is non verbal communication?

Our bodies often say more than our words, be mindful of body language.

What is chronic pain?

Pain lasting longer than 6 months.

What is neuropathic pain?

Pain that arises from abnormal or damaged pain nerves.

What is nociceptive pain?

Pain that arises from stimulus detected by functioning nerve fibers.

What should you do with infants and toddlers?

Parents can hold them, it will help keep the children calm. Let child examine tools so they aren't so scared.

When should you perform a comprehensive mental status exam?

Perform if family members or client are concerned, brain lesions, history of substance abuse or violence.

What is the mini cog test?

Quick and easy screen for cognitive impairment that includes drawing a clock and doing a 3 item recall test after drawing the clock.

What is diastolic blood pressure?

Seond number, resting pressure.

What is acute pain?

Short term and self limiting. Usually confined to one area.

What is equal status sitting?

Sit at equal height with the patient, don't sit with a computer in the way or stand above the patient.

What is bradypnea?

Slow breathing.

What is lordosis?

Swayback in the lumbar region of the spine.

How do you find pulse pressure?

Systolic pressure - diastolic pressure.

What is the Denver II Screening Test?

Test that assesses infant and child behavior, cognition, and psychosocial development, as well as motor, language, and social skills.

What is cultural competence?

Understanding and attending the individual's total contect of the situation.

What are orthostatic vital signs?

Used to identify orthostatic hypotension. BP and HR are taken while the patient is lying, sitting, and standing. If BP drops 10-20mmHg then the test is positive.

What should you do with adolescents?

Work around street clothes because they are self-conscious, be mindful of privacy and open, let them know what you are doing and finding.