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
you will hear the S3 sound at the apex in about ____% of children
30
Normal range for newborn respirations
30-60 bpm
Lordosis (swayback) is normal before age ____
5
normal pulse range for 10 y/o to adolescence
50-90bpm
The apical pulse is located
5th intercostal space at midclavicular line
distance vision for children does not reach 20/20 until _____ years old
6 or 7
when assessing balance, infants should be able to sit alone by ___ months of age
8
would a Braden scale rating of 8 or 16 be at higher risk?
8- the lower the number the higher the risk
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
how should you asses dark skinned patients temperature?
Back of hand
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
in older adults it is easier to palpate arterial pulses. T/F
False- it is sometimes harder to palpate because of the decreased arterial perfusion.
older adults have a slightly faster gag reflex. T/F
False- slower gag reflex
cranial nerve XII
Hypoglossal (tongue movement)
RICE (healing) "I"
Ice - 24 hours
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 slough or eschar is present on the heels, should you take it off?
NO
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.
an ordered system of beliefs regarding the cause, nature, and purpose of the universe, especially the beliefs related to the worship of a God or Gods
Religion
extra heart sound before S1
S4 sound
when someone has a low literacy level you should plan to include _____ teaching sessions.
Short
injury with full thickness, MUSCLE, BONE, TENDON SHOWING, palpable
Stage 4 Pressure Injury
Hand hygeine is an important infection control measure Select one: True False
TRUE
how to document level of orientation
The client is awake, alert, and oriented to time, place, and person
What would you need to think about when planning to assess children or older adults?
They may have lower levels of knowledge
In infants, the AP is equal to the lateral diameter. T/F
True
You have to see bone or tendon to classify a injury as stage 4. T/F?
True
adolescents should be examined w/o parents or siblings present unless they request otherwise. T/F
True
newborns have very thin nails. T/F
True
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
inflammation that lasts 2-3 weeks
acute inflammation
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.
inflammation that lasts weeks, months, years
chronic inflammation
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.
RICE (healing) "C"
compression- reduce edema and stabilize
on dark skinned clients, look for color changes in the _______
conjunctiva
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
separation of wound edges
dehiscence
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
A patient with anemia is at risk for developing pressure injuries as a result of which of the following?
diminished oxygen
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
older adults skin can be ___ and flaky
dry
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
RICE (healing) "E"
elevation- reduce edema and pain
intestines exposed
evisceration
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.
triggers killing microorganisms, +phagocytosis, +T cells, +interferon activity
fever
cranial nerves IX and X
glossopharyngeal and vagus nerves- gag reflex
final stage of inflammation
healing
fever comes from the
hypothalamus
how to document memory
immediate, recent, and remote memory are intact.
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
redness, heat, swelling, pain, loss of function
inflammatory response
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
excessive scarring/ tumor like
keloid scarring
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
the presence of granulation in a wound signifies
movement towards wound healing
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
in older adults it is ____ to have drier mucosa than in young adults because of decreased salivary gland activity
normal
protuberant abdomen is ____ for infants and toddlers
normal
The patient with a nasogastric (NG) tube in place may experience skin breakdown:
nose
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
other places to look for color changes in dark skinned clients
oral mucosa, tongue, lips, nail beds, palms of the hands, and soles of the feet
dullness is heard over
organs and solid masses such as the heart or liver
older adults may have a higher _____ threshold, so they may not react to palpation even if there is an abnormality in the abdomen.
pain
tapping on skin to hear elicit sound: feel texture and consistency with palms and fingertips
palpation
tapping on the skin to elicit sound, dullness/tympany
percussion
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
edges appointed w/ suture
primary intention
fine scarring in 3-5 days
primary intention
incision with blood clot or blood fills the incision area
primary intention
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
no scar and didn't fully heal
regeneration
RICE (healing) - "R"
rest- nutrients for repair and wound healing
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
leaves a big scar and granulates from edges in and bottom up
secondary intention
A client underwent abdominal surgery for a ruptured appendix. The surgeon did not surgically close the wound. The wound healing process described in this situation is:
secondary intention healing
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.
how to document normal communication abilities
speech flows easily, and patient enunciates clearly. Vocal is consistent with the client's age, education, and language fluency
Cranial Nerve XI:
spinal accessory- tested by asking the patient to raise their shoulders against resistance.
A "journey" that takes place over time and involves the accumulation of life experiences and understanding. An attempt to find meaning, value, and purpose in life.
spirituality
injury with INTACT SKIN, NONBLANCHABLE REDNESS, localized area over body prominence
stage 1 pressure injury
injury with partial thickness, shallow, open wound
stage 2 pressure injury
injury into subcutaneous tissue, SLOUGH PRESENT, full thickness, UNDERMINING OR TUNNELING
stage 3 pressure injury
Tympany is heard over
stomach, bladder, and bowels
Is the general Survey (health history) subjective or objective data?
subjective
localized area of discolored intact skin or a blood filled blister (not a bruise)
suspected deep tissue injury
Normal Assessment Findings of the face
symmetric facial features, symmetry of expressions, no involuntary movements, proportionate facial features.
increased WBC count, malaise, nausea, and anorexia
systemic
open wound
tertiary intention
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
how to document behavior
the client is well groomed, with an erect posture, pleasant facial expression, and appropriate affect.
documenting normal findings for the weber test
the patient hears the sounds equally in both ears
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)
abdominal breathing is common in infants and children T/F
true
older adults may have dry ear wax. T/F
true
older adults sense of smell diminishes over time. T/F
true
plan of care for a stage 3 pressure ulcer
turn patient every 2 hours
If slough or eschar is covering the wound/injury it is _________
unstageable
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
in infants and children, peristaltic waves are often ______
visible
how to document normal general knowledge findings
vocabulary and general knowledge are intact
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
