Assessment- Focused, Physical

how long do you wash your hands?

40-60 sec

what is ADPIE?

Assessment Diagnosis Planning Implementation Evaluation

a group of students attended a NSNA presentation. what does NSNA do?

this organization provides programs of current professional interest

why is health history completed?

to obtain a baseline, get rapport with the patient, identify health concerns, identify teaching points

The nurse is conducting a physical examination of a client who is in the lying position. Place in order the areas the nurse will assess when completing this examination. a. Shins and ankles b. Groin, hips, and knees c. Breasts d. Chest and thorax e. Cardiovascular

c, d, e, b, a

What is an expected assessment finding when caring for a client with a percutaneous feeding tube?

Dark pink stoma without drainage

A nurse is palpating a child's forehead for signs of fever. Which part of the hand should the nurse use?

Dorsal surface

What word means pertaining to the whole body?

Holistic

The student nurse is caring for a client with emphysema. What sound would the student nurse expect to hear when percussing the client's lungs?

Hyperresonant

order for abdomen?

Inspect, Auscultate, Percuss, Palpate

Which is the priority for the nurse conducting a physical examination of a client with generalized muscle weakness?

Limit position changes as much as possible

a client has been diagnosed with a recent myocardial infarction. what problem would be the priority for the nurse to address?

PC decreased cardiac output related to cardiac tissue damage

What is a focused assessment?

Performed to assess a specific problem

Which illustrates the nurse using the technique of inspection?

The nurse detects a fruity odor of the client's breath.

Which consideration is the most important when performing tracheotomy suctioning?

client should be hype oxygenated then suctioned for 10 to 15 sec

which activity best helps the nurse apply theory to practice?

evidence based research

a nurse is interviewing a hospitalized client which nurse client positioning facilities an easy exchange of information?

if the client is in the bed and the nurse sits in a chair placed at a 45 degree angle to the bed

during the preparatory phase of interviewing for the purpose of obtaining information for the nursing history the nurse should?

review as much information as possible

at the beginning of the exam the nurse performs a general survey. what would the nurse assess at this time?

safety

a client visits the health care facility with reports of mild hearing loss. the nurse prepares to perform which test to compare bone and air conduction?

Rinne

A nurse is caring for a client who has experienced an acute exacerbation of Crohn's disease. Which assessment best indicates that the disease is under control?

The client exhibits signs of adequate GI perfusion with normal bowel sounds.

The nurse is admitting a client to the surgical unit. The nurse should begin the general survey at which point in the admission process?

Upon meeting the client and family members

after assessing a client a nurse identifies the nursing diagnosis "ineffective airway clearance related to thick tracheobronchial secretions". the nurse would classify this as which type?

actual

which client situation most likely warrants a time lapse nursing assessment?

an older adult refuses of an extended care facility is being assessed by a nurse practitioner during scheduled monthly visit

a homeless client in the public health clinic has a strong body odor and is wearing clothes that are visibly dirty. what diagnosis would be the most appropriate for the nurse to identify?

bathing self care deficit related to lack of access to bathing facilities as evidenced by strong odor

what skills are needed for a health assessment?

cognitive, clinical decision making, problem solving, psychomotor skills, interpersonal, ethical skills

what is initial assessment?

collection of subjective data about patient perception of body, past history, family, and lifestyle while also getting objective data

What is the ongoing assessment?

consists of data gathered after the database is completed; during every nurse-patient encounter

to evaluate clients cerebellar function a nurse should ask

do you have any problems with balance

the family household comprises of two parents, three kids and one grandparent. this is seen as?

extended family

two body systems that may be logically integrated and assessed at the same time are?

eye exam and the cranial nerves 2 , 3, 4, and 6

why is COPD considered a chronic disease?

has a gradual onset and lasts for a long time

when administering immunizations the nurse is engaged in?

illness prevention

a nurse is assessing a client at the beginning of the shift. which signs of hypoxia would alert the nurse to take further action

increased pulse, oxygen of 88% and circumoral cyanosis

order for body parts other then the abdomen?

inspect, palpate, percuss, auscultate

what four techniques are with a assessment?

inspection, palpation, percussion, auscultation

a nurse is planning education about prescription medications for a client newly diagnosed with asthma. what nursing diagnosis would be most appropriate for the nurse to select?

knowledge deficit medications related to new medical diagnosis

the nurse recognizes that it is best to begin the objective data collection with which procedure?

measuring the clients vitals, height, and weight

what terms should you avoid in documentation?

normal, abnormal, good, fair, poor

which nursing assessment is recommended to confirm placement of a NG tube into the stomach?

obtain a x ray and measure the PH of the stomach contents

what are the 3 main topics for a health history?

past medical, social, current illness

when should you report?

potential problem, family interests, may lead to self harm

A nurse is caring for a client who has suffered a severe stroke. During routine assessment, the nurse notices Cheyne-Stokes respirations. Cheyne-Stokes respirations are

progressively deeper breaths followed by shallower breaths with apneic periods.

What are important nursing responsibilities when a referral to other health team members has been made for a client?

sharing assessment information and information on the client's capability and level of participation in meeting activities of daily living

which piece of equipment is needed to establish a baseline BMI?

skinfold calipers

a nurse is conducting a physical exam and is percussing the gastric area of a client. what percussion tone is normally heard in this area?

tympany

The nurse is preparing the examination room before assessing a client. What is the purpose for a clean folded sheet on the examination table?

use as a drape

what is a emergency assessment?

very rapid assessment performed in life threatening situations

a client fell through ice and was submerged longer then one min, they are admitted to the ED with hypothermia and near drowning. When would the nurse best be able to determine the client

when the client is warmed

do extensions of a focused problem such as IV get included in a assessment?

yes

A nurse is preparing to perform intubation on a client. Which pieces of equipment are needed to prevent the transmission of infectious agents during this procedure? Select all that apply.

-gloves -gown -face shield

what are the four basic types of assessment?

-initial -ongoing -focused -emergency

what is the difference between a medical assessment and a nursing assessment?

-medical: looks at diagnosis and treatment -nursing: looks at patient as a person

A client with scabies visits the health care facility for a follow-up appointment. Which preparation by the nurse is of greatest priority for the physical examination of this client?

Adequate lighting

What is never your first response as a nurse?

Calling the HCP

A client who has been using a combination of drugs and alcohol is admitted to the emergency unit. Behavior has been combative and disoriented. The client has now become uncoordinated and incoherent. What is the priority action by the nurse?

Complete a thorough assessment, including a Glasgow Coma Scale, and place the client in a location for frequent monitoring.

What is secondary information?

Information from sources other then the patient EX: family, health care team

what vital sign is one of the first things to change when the body worsens?

RR

A nurse determines that a client has 20/40 vision. Which action by the nurse is most appropriate?

Refer the client to a healthcare provider for possible corrective lenses.

Which is an example of percussion? Select all that apply.

-The nurse notes dullness over the client's liver. -The nurse notes resonance over the client's thorax. -The nurse notes tympany over the client's lower abdomen.

Which assessments would provide the nurse with a determination of the level of jaundice in an infant receiving phototherapy? Select all that apply.

-assessment of capillary refill time -assessment of sclerae

What is good for environment during interview?

-proper lighting -noise control -proper temperature -limiting visitors and roommate

A client with Parkinson disease who is scheduled for physiotherapy is experiencing nausea and weakness. What is the most appropriate action by the nurse?

Assess the nausea and weakness, and call physiotherapy to cancel or reschedule the appointment.

at 8 am a nurse assesses a client who is scheduled for surgery at 10 am. in the assessment the nurse detects dyspnea, nonproductive cough, and back pain. What should the nurse do?

Immediately notify the HCP

What would be the expected tone elicited by percussion of a normal lung?

Resonance

A nurse is conducting a physical assessment on an adolescent who does not want her parents informed that she had an abortion in the past. Which statement best describes the information security measures the nurse would implement in this situation?

Respect the adolescent's wishes and maintain her confidentiality.

which client is at a increased risk for developing a wound infection

a client with a albumin level of 2.4 g/dl

a client has been experiencing abdominal cramps, diarrhea and concentrated urine for past two days. which signs would be included?

signs of dehydration including loss of weight, poor tissue turgor and dry cracked mucous membranes

communication is an example of which dimension of the individual?

sociocultural

which statement best describes a period of remission for a client with chronic illness?

symptoms are not experienced

a student nurse working with a RN is assessing a child with epiglottitis the student nurse tells the child that she must look into his/her throat. Which intervention by the RN is the most appropriate?

tell the student nurse that the anesthesiologist will visually exam the child throat

The nurse has identified a nursing diagnosis of "risk for impaired parenting" for a client who has recently learned of being pregnant. what assessment data would be appropriate to lead the nurse to this diagnosis?

the client states "i do not know how to take care of a baby"

which action by the nurse demonstrates the nurse's efforts to meet clients self actualization needs?

the nurse arranges for the client clergy to visit after visiting hours