Unit 2 (assessment) exam

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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


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