Wellness Exam 1
When is a pulse weak and thready?
1+
What is a normal respiratory rate?
10-20 breaths per minute
As per the assigned chapter reading you know that the normal respiratory rate (breathing) of an adult patient is:
16 (12-20!)
Normal rectal temp
37.5°C, 99.5°F
Normal tympanic temp
37.5ºC, 99.5°F
What is considered a normal pulse rate?
60-100 bpm
You are listening to nurses give report on a cardiac patient. You hear the nurse say "Mr. Smith has had bradycardia all shift". After reading the assigned chapters you know the term "bradycardia" refers to:
A heart rate less than 50 beats per minute
You are conducting assessment of your patient's ear via the otoscope. Upon visualization of the tympanic membrane you know it is normal when you observe the following:
A pearly gray color with a transparent intact flat membrane
What is PQRSTU?
Another pain assessment
A 19 y/o female presents with right flank pain. You suspect a kidney infection. To assess for this condition you perform the following nursing assessment:
Blunt percussion of the right kidney
This is the most widely used method for calculating obesity risk and is endorsed by the Center for Disease Control (CDC) as the preferred method for evaluating obesity in both adult and pediatric patients:
Body mass index (BMI)
You are reviewing the assessment of a patient's peripheral pulses and notice that the documentation by the medical resident states that the radial pulses are "+4". You would interpret this reading as which of the following?
Bounding
Which type of assessment and database is most appropriate for a person being admitted to a new long-term care nursing facility?
Complete
What are the four different types of assessments?
Comprehensive, problem-focused, follow-up, and emergency
What does the E stand for in CAGE?
EVIDENCE of dependence or tolerance
You are the nurse caring for Mrs. Jones, a 65 y/o female admitted for hip surgery. At 0200 you administer pain medication to Mrs. Jones. At 0300, you enter her room to ask her about her pain level. What step of the nursing process are you performing?
Evaluation.
A nurse assesses a non-English speaking patient who grimaces and points to the right knee following a motor vehicle accidient. Which pain scale would be most appropriate for the nurse to use to assess the client's pain?
FACES scale
Your patient complains of gaining 25 pounds over the past nine months. To obtain more information regarding dietary habits and nutritional well-being on this patient you recommend the following intervention:
Have the patient complete a 72 hour dietary recall then return to review
What is the question associated with the A in CAGE?
Have you ever become ANNOYED by criticisms of your drinking?
When would you perform an emergency assessment?
Identify Life Threatening problems ABCS (Airway, Breathing, Circulation)
What are the four nursing techniques?
Inspection Palpation Percussion Auscultation
What does OLDCARTS stand for?
Onset Location Duration Character Aggravating and Alleviating Factors Radiation Timing Severity
The nurse just interviewed her patient to obtain information related to complaints of a skin problem. Which of the following documentation in the nurses notes represents subjective data? -Patient states she is not having any itching, redness, or rashes. -Large lesion noted lateral aspect R anterior arm, intact, no bleeding. -Skin is warm, dry, and intact. -No lesions or rashes are noted.
Patient states she is not having any itching, redness, or rashes.
As you are preparing for a clinical day in the operating room your nursing faculty reminds you to be sure to practice standard precautions. You know that the term "Standard Precautions" is based on the principle:
Precautions apply to all patients, whether you know if they are infected or not
What is the CAGE screening?
Screening for alcoholism
What happens during the planning stage of the nursing process?
Set your goals to solve the problem
The nurse is observing the chest / lung auscultation technique of the student nurse. The correct method to use when assessing the lungs of a patient is the _____________ comparison.
Side to Side
What is bradycardia?
Slow heart rate. < 50bpm
What are different examples of nonverbal communication?
Sounds (laughing, etc), ways of talking, posture, appearance, head movements, hand movements, eye movements, facial expression, body contact, and closeness
What can light palpation tell you?
Surface characteristics
An example of an open-ended question or statement is:
Tell me more about your pain
You are educating a group of young women about self breast awareness and performing Breast Self Exams (BSEs). Which of the following statements by the nurse is most appropriate? The best time to perform monthly self breast examinations are 2 - 3 days prior to the onset of the menstrual cycle. The best time to perform Self-breast examinations (SBEs) are when showering or when laying supine in bed. Women with a family history of breast cancer should initiate self breast examination (SBE) monthly beginning at age 50 As long as the patient is seeing her doctor annualyl for a clinical breast examination (CBE) she does not need to perform self breast examinations.
The best time to perform Self-breast examinations (SBEs) are when showering or when laying supine in bed.
You are assessing Mrs. James, an 87 year old patient admitted to your unit from a skilled nursing facility. As part of her admission assessment you complete a Braden Scale for which Mrs. James received a total score of 9. Based on this finding you know Mrs. James has the following risk for loss of skin integrity:
Very high risk
What is a sign?
What the nurse can detect
Your patient presents with a chief complaint of "headache". Which of the following is a critical assessment question you should ask to elicit more information relating to the chief complaint of "headache"? "On a scale 1-10, how bad is your headache pain right now?" "Did you have headaches as a child?" "Do you have a family history of headaches?" "Have you had any recent changes in your diet?"
"On a scale 1-10, how bad is your headache pain right now?"
When is a pulse normal?
2+
When is a pulse bounding?
3+ full
Normal forehead temp
34.4°C, 94.0°F
Normal axillary temp
36.5°C, 97.7°F
Normal oral temp
37.0°C, 98.6°F
You are taking care of Mr. Jones, a 75 y/o male admitted for prostate surgery. During your morning assessment you palpate the radial pulse of Mr. Jones. Which pulse rate would you, as his nurse document as bradycardia? 115 bpm 62 bpm 105 bpm 57 bpm
57 bpm
What is bradypnea?
< 10 breaths per minute
What is tachypnea?
> 20 breaths per minute
You are caring for four patients on your nursing unit. Based on the following vital signs which patient would cause you the greatest concern? A 15 y/o female with a B/P of 90/60 A 67 y/o female with a resting pulse of 60 bpm A 29 y/o male with respirations of 9 a 89 y/o male with an axillary temperature of 97.0 F
A 29 y/o male with respirations of 9
You are providing education to your patient on risk factors for breast cancer. All of the following patients have increased risk factors for breast cancer EXCEPT:
A 35 y/o female whose diet is exclusively soy and plant based
Which of the following patient situations would you interpret as requiring an emergency assessment? -A patient with sunburn who enters the the clinic in a wheelchair. -A patient who is unresponsive to voice commands and is suspected of a drug overdose. -A patient who missed her last period and is concerned that she may be pregnant. -A patient in need of an employment physical who is due to start work this week.
A patient who is unresponsive to voice commands and is suspected of a drug overdose.
What does the A stand for in CAGE?
APPARENT to others that there is a problem
You are performing an eye exam on your patient. You determine, by way of the Snellen Chart that your patient's eye acuity is 20/50 in both eyes. What does this indicate?
Abnormal vision, he can see at 50 feet what an normal eye can see at 20 feet
When would you perform an initial complete comprehensive assessment?
Admission to Hospital or New Patient to a Primary Care Practice
You are preparing to assess your patient's abdomen. Which of the following is the proper way to perform this assessment?
Always auscultate the abdomen BEFORE palpating it
As you prepare to perform a physical assessment on your patient you consider your assigned readings. Based on your readings which statement below reflects the most correct action when performing patient examinations? -Follow the same examination sequence, regardless of the patient's age or condition -Always begin your assesment from the right side of the patient's bed -Always organize the assessment to ensure the patient does not need to change positions too frequently -Always examine painful or tender areas first
Always organize the assessment to ensure the patient does not need to change positions too frequently
As the nurse initiates the general survey examination, you know data collection for this portion of the review of systems (ROS) begins:
As soon as the nurse sees the patient.
You are preparing to perform a rectal temperature assessment. You know that all of the following are TRUE regarding rectal temperatures EXCEPT: It is the best method of temperature assessment in a comatose or confused patient The probe should be lubricated and inserted 2 to 3 cm into the rectum (adult) It is the most accurate route as it is closest to the body's core Because it is the most accurate it is the preferred method of temperature assessment in all patients.
Because it is the most accurate it is the preferred method of temperature assessment in all patients.
You are working in the Emergency Department and are preparing to assess a patient who presents with complaints of severe chest pain. Which of the following represents the best way for you to begin your assessment of this patient? -First, obtain a thorough medical, surgical, and family history from the patient or a family member -Have the patient lay down so you can perform a detailed assessment of the heart, lungs, and neurological systems -The order of the assessment does not really matter as long as all areas and systems are assessed -Begin your assessment of the problem area first so important data can be collected and communicated to other members of the healthcare team -Immediately begin your head to toe assessment examining all body areas
Begin your assessment of the problem area first so important data can be collected and communicated to other members of the healthcare team
What does the C stand for in CAGE?
CONCERN by the person that there is a problem
Which of the following is an example of a symptom? -Potassium level of 4.3 mEq/l -Chest pain -Increased respirations -Sweating
Chest pain
You are the nurse caring for Judy, a 67 y/o female admitted 2 days ago for pneumonia. As part of your assessment on Judy you auscultate her bilateral lungs. Based on her diagnosis of pnuemonia, you expect your auscultation of Judy's lung to reveal:
Crackles
What happens during the evaluation stage of the nursing process?
Determine outcome of goals and what, if anything, needs to be changed.
You are observing a patient in acute respiratory distress and note his difficulty in breathing. This observation is best described as:
Dyspnea
What does the G stand for in CAGE?
GRAVE consequences
You are the student nurse caring for Mr. Jones on the cardiac acute unit. You are ready to auscultate Mr. Jones heart sounds, which of the following is the best practice for auscultating the heart? Have Mr. Jones pull his gown tight to his skin to prevent "artifact" Have Mr. Jones shave his chest prior to auscultaton to prevent artifact Place the stethoscope under cool water before placing on Mr. Jones chest Have Mr. Jones remove his gown and place the stethoscope directly on his skin
Have Mr. Jones remove his gown and place the stethoscope directly on his skin
You are assessing the thyroid gland of your patient. Which of the following is an appropriate assessment technique when examining the thyroid gland? Auscultate the gland with your stethoscope but only if there are no masses or nodules palpated Have the patient swallow a sip of water while palpating the gland Have the patient turn their head side to side and observe for limitations Percuss the thyroid gland after inspection
Have the patient swallow a sip of water while palpating the gland
What is the question associated with the G in CAGE?
Have you ever felt GUILTY about your drinking?
What is the question associated with the C in CAGE?
Have you ever felt that you should CUT down on your drinking?
What is the question associated with the E in CAGE?
Have you ever had a morning EYE OPENER to get rid of a hangover?
What happens during the diagnosis stage of the nursing process?
Identify the problem through a nursing diagnosis
Which of the following would be most important for the nurse to do when assessing a client's blood pressure? Inflate the cuff 30 mm Hg above where the radial pulse disappears Palpate the pulsations of the radial artery Hold the client's arm slightly flexed with palm Deflate the cuff about 5 mm Hg per second.
Inflate the cuff 30 mm Hg above where the radial pulse disappears
You enter your patient's room to perform their physical assessment examination. To perform a proper examination you know the first technique you will utilize is:
Inspection
Your nursing faculty instructor instructs you to obtain objective data from your laboratory partner. Which of the following indicates the best way from which you can obtain objective data?
Inspection
Your patient complains of abdominal pain. You are preparing to perform your physical assessment patient and remember the proper sequence in performing an abdominal assessment is:
Inspection, Auscultation, Percussion, Palpation
The nurse is caring for an elderly patient and he suspects elder abuse. Which of the following actions is most appropriate? -Confront the caretakers about the suspicions of abuse -Notify the authorities of the suspected abuse -Ask the patient if it is ok to call the authorities -Collect proof of the abuse before alerting the authorities
Notify the authorities of the suspected abuse
What happens during the assess stage of the nursing process?
Nurse gathers information and reviews
As you prepare to auscultate your patient's heart sounds you note the two different sides of the stethoscope. You remember reading in your text that stethoscopes have a larger side and a smaller side because:
One side is best for higher pitched sounds, while the other side is best for low-pitched sounds
What can deep palpation tell you?
Organs, masses, tenderness
You are conducting an annual physical examination on a 32 y/o female. She denies any problems but states she is "scared to death to get breast cancer". She continues on with "I know so many people getting breast cancer younger and younger. What can I do to make sure I don't get it?" Which of the following information would be appropriate to share with this woman concerning risk factors for breast cancer? The majority of women who get breast cancer do not have apparent risk factors The majority of women who get breast cancer can be prevented if they were tested for the breast cancer gene One out of every 25 women in the United States will get breast cancer in her lifetime regardless of family history Over 50% of woman who get breast cancer have a first degree relative who has also had breast cancer
Over 50% of woman who get breast cancer have a first degree relative who has also had breast cancer
When would you perform a problem focused assessment?
Performed in relation to a specific health concern Example: Sick visit to your PCP
The nurse is assessing the skin turgor of her 65 y/o patient. Which of the following techniques should the nurse use to properly assess skin turgor in this patient?
Pinch the skin over the clavicle and observe its return to the original shape
What does PQRSTU stand for?
Provoking or palliating factors quality region or radiation severity time and treatment understanding and impact
What happens during the implementation stage of the nursing process?
Reach the goals through nursing actions. IMPLEMENT the treatment
When would you perform a follow up assessment?
Reassessment of previous problems (deterioration or improvement). Wheezing Improve with Meds?
You are reviewing the vital signs of your 64 y/o male patient who was admitted for surgery. Which of the following vital signs would you identify as "abnormal"? Radial pulse of 78 bpm oral temperature 98.0 respirations 28 / minute Blood Pressure 136/88
Respirations 28/minute
Which action by the nurse demonstrates the proper sequence for auscultation of the lung fields? Starting posteriorly, listen to each site for one complete respiratory cycle, moving from side to side for comparison Use the bell of the stethoscope to auscultate all lung fields posteriorly Instruct the patient to breath in and out deeply and rapidly through the mouth Starting anteriorly, move from superior to inferior on one side before assessing the opposite side
Starting posteriorly, listen to each site for one complete respiratory cycle, moving from side to side for comparison
You are conducting an assessment of the head and neck lymph nodes.You would most likely palpate the posterior cervical chain of lymph nodes best by locating which of the following structures:
Sternomastoid muscle
You note your patient has a respiratory rate of 24. When documenting this finding in the patient's chart you referred to this as:
Tachypnea
What is ADPIE?
The nursing process: Assessment Diagnosis Planning Implementation Evaluation
During an assessment in the Emergency Department (ED) the nurse utilizes the CAGE assessment tool. The patient answers YES to two of the questions. What does this indicate?
The patient may have a problem with alcohol and should be assessed further for alcohol abuse
Do you write the reason for the patient's visit in their words or in your own words?
The patient's words
The goal of performing tactile fremitus during a respiratory assessment is:
The presence of mass or fluid in the lungs
You are examining a 14 y/o teen patient who complains of sore throat, difficulty swallowing, and low grade fever for 2 days. Upon visualization of this patient's tonsils you observe they are erythemic and edematous and both are touching the uvula. How would you document this assessment finding?
Tonsil Grade III
What is a symptom?
What the patient reports
You are performing a respiratory assessment on Jenny, a 24 y/o female who was admitted with severe asthma. Given Jenny's diagnosis of "severe asthma", you expect to hear adventitious sounds of air passing through narrow or constricted bronchioles on her physical assessment. These sounds are best described as:
Wheezing
When are the nursing techniques not in IPPA order?
When examining the abdomen, in which case the order is: inspection, auscultation, percussion, palpation
What information do you gather in a health history?
demographics, source of history (primary - patient, secondary - anything or anyone else), past history, CHIEF COMPLAINT, present health or history of present illness, past medical history, family history, ROS, functional assessment including activities of daily living.
What is tachycardia?
fast heart rate. > 100 bpm
What is reviewed in the review of systems?
general overall state of health, skin, head, hair, eyes, ears, nose and sinuses, mouth and throat, neck, breast, axilla, respiratory system, cardiovascular system, peripheral vascular, gastrointestinal, and urinary system
When should you use the diaphragm side of the stethoscope?
high-pitched sounds, such as normal heart sounds, breath sounds, bowel sounds
You are just entering the unit for your shift. The departing nurse tells you "the guy in room 320 has tachypnea". You know this term to mean:
increased respirations
When should you use the bell side of the stethoscope?
low-pitched sounds, abnormal heart sounds and bruits (abnormal loud, blowing, or murmuring sounds)
What is eupnea?
normal breathing rate and pattern
The nurse is having difficulty auscultating Korotkoff sounds. The nurse should:
reposition the stethoscope and ensure it has good contact directly on the skin
