question

What are the most important roles of the nurse (5)

answer

Caregiver Advocate Educator Researcher Leader

question

What are the 5 steps in the nursing process?

answer

(1) Assessment (2) Nursing Diagnosis (3) Planning (4) Implementation (5) Evaluation *** All of the above require critical thinking!

question

Define Assessment

answer

Collects comprehensive data pertinent to the patient's health and/or situation. - info medical personnel can look at - begins the moment you walk through the door

question

Can the RN provide subjective information about patient?

answer

NO! Only the patient can give subjective info. OBJECTIVE info is what the RN sees, hears, or smells

question

What is the Diagnosis phase?

answer

Analyze the assessment and make a clinical judgement related to an ACTUAL or POTENTIAL health problem. ** Nurses have to be aware of potential risks based on health problems. ** Also collaborate with other specialists to manage the problem(s)

question

What are the three phases of a Nursing Diagnosis?

answer

First info ? Related to ? as evidence by WHAT is the problem? WHY is it a problem? WHAT is the evidence of that problem? Ex: "Acute pain ? related to surgical incision ? as evidence by patient report (or as evidence by crying)"

question

What are the OUTCOMES IDENTIFICATION?

answer

This is the statement of how a patient's status will change once interventions have been successfully instituted Identify the expected outcomes when planning for the patient's individual situation. Interventions must be measurable criterion indicating that objectives have been met.

question

Define the PLANNING stage of the nursing process

answer

Develops a plan that prescribes strategies and alternatives to attain expected outcomes. - Prioritize strategies - Goals (statement that describes the aim if the nursing care) should be short term and long term

question

Describe IMPLEMENTATION of the nursing process

answer

The actions to facilitate positive patient outcomes

question

What three skills are needed in order to implement goals?

answer

Cognitive Personal Psychomotor

question

Describe the EVALUATION phase of the nursing process

answer

This describes how well the patients needs were met (or not met). Done through reassessment

question

What percentage of all communication is nonverbal?

answer

90%

question

What two characteristics should nurses always exude?

answer

CARING COMPETENCE

question

How is communication used in the Assessment phase of the nursing process?

answer

Verbal interviewing and history taking Visual and intuitive observation of nonverbal behavior Visual, tactile, and auditory data gathering during physical examination. Written medical records, diagnostic tests, and literature review.

question

Define REFERENT

answer

The referent motivates one person to communicate with another. Examples of referents: sights, sounds, odors, time schedules, messages, objects, emotions, sensations, perceptions, ideas, etc.

question

Define SENDER in communication

answer

The person who encodes and delivers the message. Sender puts ideas or feelings into form that is transmitted and is responsible for accuracy and emotional tone of message content

question

What is the RECEIVER in the communication process?

answer

The person who receives and decodes the message ** senders message acts as a referent for the receiver, who is responsible for attending to, translating, and responding to the message.

question

MESSAGE in communication process

answer

Content of communication.... verbal, nonverbal ; symbolic language.

question

CHANNELS in communication process

answer

These are the means of conveying the message through visual, auditory, and tactile senses. Facial expression = visual message Spoken word = auditory Touch = tactile

question

FEEDBACK in communication process

answer

The message that the receiver returns. This indicates if receiver understood meaning of message. Sender can evaluate effectiveness of communication.

question

Explain the communication process briefly

answer

The source has a message and encodes the message. Message is sent through a channel Receiver must first decode the message Before message can be fully received

question

What are the 5 levels of communication in nursing?

answer

Interpersonal Interpersonal Small group Public Transpersonal

question

Define Intrapersonal

answer

a.k.a. SELF-TALK

question

Define Intrerpersonal

answer

Occurs between two people or groups - usually one on one conversation

question

Define Small Group Communication

answer

Committee or a conference

question

Public Communication

answer

Interaction of one person with a group of people

question

Transpersonal Communication

answer

Within a person's spiritual domain

question

Forms of Communication

answer

Messages conveyed verbally and nonverbally, concretely and symbolically. Expression through: Words, movements, voice inflection, facial expression, and use of space Elements can work in harmony to enhance a message OR conflict with one another to confuse it.

question

Example Forms of Communication VOCABULARY What is the role of the nurse?

answer

Nurse often the interpreter of medical terminology

question

Example Forms of Communication DENOTATIVE AND CONNOTATIVE What is the role of the nurse?

answer

Denotative is the exact meaning Connotative is shades of the meaning Be selective in word choice and avoid easily misinterpreted words.

question

Example Forms of Communication PACING What is the role of the nurse?

answer

Speak slowly and enunciate clearly! Too fast = unintended messages Too slow = impression of hiding the truth

question

Example Forms of Communication INTONATION What is the role of the nurse?

answer

Tone of voice... be careful

question

Example Forms of Communication CLARITY & BREVITY What is the role of the nurse?

answer

Simple - short - to the point & possible repeated

question

Example Forms of Communication TIMING & RELEVANCE What is the role of the nurse?

answer

When it is appropriate to discuss issues & what is most important at that time.

question

What are forms of Nonverbal Communication?

answer

Personal Appearance Posture and gait Facial Expression Eye Contact Gestures Sounds - sighs, moans, groans... Territoriality & Space

question

What are the four phases of the Helping (Nurse-Patient) Relationship?

answer

Pre-interaction Orientation Working Termination

question

Describe the PRE-INTERACTION phase of the Helping Relationship.

answer

This takes place before meeting the patient: - Review available data, history - Talk to other caregivers who have info about patient - Anticipate health concerns or issues that arise - Identify a location or setting that fosters comfortable, private interaction - Plan enough time for initial interaction

question

Describe the ORIENTATION phase of the Helping Relationship.

answer

When nurse and patient first meet and get to know one another: - Set the tone for the relationship by adopting a warm, empathetic, caring manner - Recognize relationship is tentative - Expect patient to test your competence and commitment - Closely observe - Begin to make inference and form judgements about messages and behaviors - ASSESS PATIENT HEALTH STATUS

question

Describe the WORKING phase of the Helping Relationship.

answer

When nurse and patient work together to solve problems and accomplish goals. TEACHING occurs. - Encourage pt. to express feelings about health - encourage pt. w/ self exploration - Provide information - Help pt. set goals - Take action to meet said goals - Use therapeutic comm - Use appropriate self-disclosure & confrontation

question

Describe the TERMINATION phase of the Helping Relationship.

answer

Ending of the relationship - Remind pt. that termination is near - Evaluate goal achievement with pt. - Reminisce about relationship with pt. - Separate from the pt. by relinquishing responsibility for care - Achieve a smooth transition for pt. to other caregivers

question

Acronym used for successful communication in the workplace to promote teamwork and safety.

answer

S - situation B - background A - assessment R - Recommendation

question

Characteristics of communication within Caring/Working Relationships:

answer

Professionalism - appearance, demeanor, behavior Courtesy - hello, good-bye, knock on doors, please, thank you... Use of Names - Always introduce yourself Confidentiality - HIPPA Trust - always honest! Acceptance & Respect - Non-judgmental attitudes Availability - "Anything else I can get you? Socializing - don't socialize with pt. and don't socialize with colleagues where pt's can hear

question

What is therapeutic communication techniques?

answer

Specific responses that encourage the expression of feeling and ideas and convey acceptance and respect.

question

Define the therapeutic communication technique of: Active Listening

answer

Being attentive to what patient is saying both verbally and nonverbally. ** Use SOLER to facilitate attentive listening

question

Define acronym SOLER

answer

S - Sit facing the patient O - Open posture L - Lean toward the patient E - Establish ; maintain eye contact R - Relax

question

Define the therapeutic communication technique of: Sharing Observations

answer

Observations/perceptions can help start a conversation, but need to be careful not to anger patient or make assumptions.

question

Define the therapeutic communication technique of: Sharing Humor

answer

Important but often underused resource in nursing interactions. It is a coping strategy that adds perspective and helps adjust to stress.

question

Define the therapeutic communication technique of: Using Silence

answer

Allow patient to break the silence, particularly when he/she has initiated it. Particularly useful when people are confronted with decisions that require thought.

question

Define the therapeutic communication technique of: Providing Information

answer

To help patient understand, but do not preach

question

Define the therapeutic communication technique of: Clarifying

answer

Check that understanding is accurate Restate an unclear message Rephrase to clarify

question

Define the therapeutic communication technique of: Focusing

answer

Centers on key elements of concepts of message Helpful when patient is vague or rambles

question

Define the therapeutic communication technique of: Restating

answer

or Paraphrasing this sends feedback that lets the patient know nurse is actively involved

question

Define the therapeutic communication technique of: Open-ended Questions

answer

Asking relevant questions allows patient to fully respond

question

Define the therapeutic communication technique of: Reflection

answer

Summarizing a concise review of key aspects of interaction. Especially helpful in termination phase

question

Other techniques of therapeutic communication are:

answer

Sharing empathy Sharing hope Use of Touch Sharing feelings Self-Disclosure Confrontation (with sensitivity after trust is established)

question

What physical and emotional factors must a nurse assess through communication?

answer

Developmental - age, physiological status (pain, hunger, weakness) Socioculture Language Gender

question

How can you communicate with non-english speaking patient?

answer

Translator or translator phone

question

What are some non-theraputic communication characteristics?

answer

Inattentive listening use of medical jargon Sympathy Arguing Being defensive

question

How does the nurse demonstrate caring in communication?

answer

Become sensitive to self ; others Promote and accept expression of pos ; neg feelings Develop helping trust relationships Instill faith ; hope Promote interpersonal teaching ; learning Provide supportive environment Assist with gratification of human needs Allow for spiritual expression

question

What are the Zones of Touch?

answer

Social zone Consent zone Vulnerable zone Intimate zone

question

Social zone of touch is

answer

Hands, arms, shoulders, back Permission not needed

question

Consent zone of touch is

answer

Mouth, wrists, feet Permission needed

question

Vulnerable zone of touch is

answer

Face, neck, front of body Special care needed

question

Intimate zone of touch is

answer

Genitalia, rectum Great sensitivity needed

question

Zones of Personal Space

answer

Intimate - 0-18" Personal - 18" - 4' Social - 4 -12 ft Public - > 12 ft

question

What is Intimate zone of personal space?

answer

Holding crying infant Performing physical assessment Bathing, grooming, dressing, feeding, and toileting a patient Changing patient dressing

question

What is Personal Zone of personal space?

answer

Sitting at a patient's bedside Taking patient history Teaching patient Exchanging info at shift change

question

What is Social Zone of personal space?

answer

Making rounds with physician Sitting at the head of a conference table Teaching a class for patients with diabetes Conducting family support

question

What is public zone of personal space?

answer

Speaking at a community forum Testifying at a legislative hearing Lecturing to a class of students

question

INFECTION PHYSIOLOGY.......

answer

SEE NOTECARDS FOR MED-SURG EXAM, PART ONE to review vocabulary and basic understanding. THEN... proceed in this set of flashcards for the Nursing Care of Infections

question

Nursing process for Infection: Assessment

answer

Assess all risk factors: age, nutrition, diagnostic procedures (IV, catheters), occupation, high-risk behaviors, travel history, trauma, stress Nutritional Status - reduction in protein impairs healing Lab Data - WBC count (5000-10000 norm) - Cultures - ESR (up to 15 for men and 20 for women) - Iron level 60-90g/100mL - Differentials Chronic or serious infections/diseases/disorders - COPD ? pneumonia - heart failure ? skin breakdown - diabetes ? venous stasis ulcers * diabetes patients at risk for chronic infections

question

Nursing process of Infection: Diagnosis

answer

? Disturbed body image = look bad, smell bad, etc ? Risk for fall ? Risk for infection = lab results (WBC 5,000-10,000/mm³), review current meds ? Identify potential sites of infection = IV, catheter ? Imbalanced nutrition = protein needed for healing ? Acute pain ? Impaired skin integrity or tissue integrity ? Social isolation

question

Nursing process of Infection: Planning

answer

Goals ; Outcomes Setting priorities ? Treatment is always a priority Collaborative care

question

Nursing process of Infection: Implementation

answer

Health promotion - break chain of infection Nutrition Hygiene Immunization Adequate rest and regular exercise

question

Nursing process for Infection: Evaluation

answer

Measure the success of infection prevention Measure the patient and family adherence to discharge plans Wound status and healing ** did your patient get better or worse? Did your patient get an infection at hospital?

question

Standard precautions taken with ALL patients protect health care workers from:

answer

Blood Body fluids (except sweat) Excretions Non-intact skin ** These precautions began in the 80's as a result of HIV/AIDS

question

It is required to wash hands with water and soap when:

answer

Hands are visibly dirty When soiled with blood or other body fluids Before eating After toileting Exposure to spore-forming organisms (c-diff, bacillus anthracis)

question

Use of alcohol-based waterless antiseptic agent for routinely decontaminating hands for following situations:

answer

Hands NOT visibly soiled Before/after/between direct patient contact After contact with body fluids or excretions, mucous membranes, nonintact skin, or wound dressing When moving from contaminated to a clean body site during patient care After contact with inanimate surfaces or objects in the patients room Before caring for patients with sever neutropenia or other forms of immunosuppression Before putting on sterile gloves to insert invasive devices After removing sterile gloves

question

Nursing process for Infection: Implementation in Acute Care Settings

answer

Use standard precautions Control or eliminate infectious agents Cleaning Disinfection/Sterilization Control or eliminate reservoirs Control of portals of exit Control of transmission hand hygiene Isolation & barrier protection Protective equipment Proper removal of PPE Role of infection prevent & control Prep for sterile procedures Restorative/long-term care

question

What is order of preparing to enter room on isolation?

answer

Gown Mask or Respirator Eye wear Gloves

question

What is order of removal of protective equipment for isolation?

answer

Gloves Goggles Gown Mask

question

Sterile field must have what size border?

answer

1 inch

question

What are the vital signs?

answer

Pulse Pain Temp BP Respiration Pulse Ox

question

When do you take vitals?

answer

When they first enter Appropriate intervals during stay Just before they leave

question

Why must you know the baseline vitals for a patient?

answer

Any changes in vital signs can help the nurse immensely

question

What are guidelines to measuring vital signs?

answer

Must get baseline by taking when first enter Measure correctly Understood & interpreted Communicated

question

Body Temp normal range

answer

96.4-100.1

question

Body temp is affected by heat loss, what causes this?

answer

Radiation Conduction Evaporation Convection

question

What produces heat in the body?

answer

Cellular Respiration

question

What is considered a fever?

answer

Adult 102.2 ? Child 104

question

What is pyrexia?

answer

FEVER

question

What is an Antipyretic?

answer

Medication that brings down fever Ex: Tylenol, NSAIDS

question

How is temp measured?

answer

At the core or the surface by: Electronic Infrared Digital Disposable Chem Dot

question

What is pulse?

answer

Palpable bounding of the blood flow in a peripheral artery

question

What are the locations for pulse?

answer

Temporal Carotid Apical Brachial Radial Ulnar Femoral Popliteal Posterior tibia Dorsalis pedis

question

What is Tachycardia

answer

Pulse faster than 100 bpm

question

What is Bradycardia

answer

Pulse slower than 60 bpm

question

What is Blood Pressure

answer

Ability of the peripheral blood vessels to constrict and dilate that depends on cardiac output, PV resistance, blood volume, blood viscosity, and artery elasticity

question

What are the blood pressure variations?

answer

Hypertension Hypotension Orthostatic hypotension

question

Orthostatic Hypotension

answer

Looking for a drop in blood pressure during a rise in heart rate when person changes from lying to sitting to standing.

question

What is the Systolic Pressure?

answer

Ventricular contraction that forces the blood into the aorta

question

What is the Diastolic Pressure

answer

Minimal pressure exerted against the arterial wall * Pulse pressure is the difference between systolic and diastolic pressures

question

Korotkoff sounds of BP

answer

There are 5 phases, we listen for phase 1 (systolic) and then for phase 4 into phase 5 (diastolic) phase 1 - sharp thump phase 2 - blowing or whooshing sounds phase 3 - crisp intense tapping phase 4 - softer blowing sound that fades phase 5 - silence

question

What is respiration?

answer

the mechanism the body uses to exchange gases among the atmosphere, blood and cells

question

What is normal respiration rate?

answer

12-20 per minute

question

Define Eupnea

answer

Normal breathing

question

What is ventilation?

answer

Physical act of breathing in and breathing out

question

What is Pulse Oximetry

answer

Looking at hemoglobin molecule to determine how saturated it is with oxygen.

question

What is a weakness of Pulse Ox measure?

answer

CO can fake out the pulse oximeter because blood will be saturated with CO, not O?, but oximeter thinks that it is O?

question

What is apnea?

answer

Absence of breathing

question

How do we naturally release CO??

answer

Sign or yawn up to 15 times an hour

question

What is Chain-Stokes Respiration?

answer

Rhythm of acceleration of respirations followed by deceleration then followed by apnea.

question

Why can pulse ox be an indicator of iron deficiency anemia?

answer

Patient doesn't have enough red blood cells to carry enough O? to meet metabolic needs

question

What is a seizure?

answer

Uncontrolled electrical neuronal discharges from the brain that interrupts normal brain function.

question

What causes seizures?

answer

Brain tumor Brain trauma concussion Infection Metabolic disorders Withdraw from alcohol Idiopathic (no known cause)

question

How do you assess a seizure?

answer

Was seizure seen Precipitating factors Where did it start How did it progress Type of movement in extremities Gaze deviation Incontinence? Mental status How long did seizure last? Mental status after seizure? Motor weakness after seizure Any injury from seizure

question

Another term for a seizure?

answer

Irritable focus -or- Foci

question

What is Postictal Phase?

answer

Altered state of consciousness that a person enters after experiencing a seizure. It usually lasts between 5 and 30 min, and is characterized by drowsiness, confusion, nausea, hypertension, headache or migraine and other disorienting symptoms.

question

Nursing Diagnosis for Seizures

answer

? Risk for injury ? Risk for aspiration - breathing fluid into lungs ? Ineffective airway clearance related to relaxation of tongue and gag reflex secondary to muscle innervation ? Anxiety ? High risk of ineffective therapeutic regimen related to insufficient knowledge

question

Nursing plan for Seizures

answer

Assess and detect signs of seizure Implement seizure precautions Medications as ordered Assess history, serum drug levels, compliance with drug regimen

question

Nursing Interventions Before Seizures

answer

How to call for help Place pads on side rails Bed in low position Access to O? ; suction

question

Nursing Interventions during a seizure

answer

Attempt to turn patient on side Maintain airway Place O? on patient Suction mouth as needed Do not attempt to insert anything into mouth Do not restrain Monitor pulse ox Assess type ; length of seizure Administer meds as ordered

question

Nursing Evaluation for seizures

answer

Identify criteria and standards Collect data interpret findings document ; notify Revise plan, if needed - are the taking any meds? - if so, is the dosage correct?

question

What are the different roles during a CODE?

answer

Compressor/ventilator Recorder/ time keeper Medication Administrator Defibrillator Traffic Controller

question

Code Blue

answer

Check for responsiveness Assess for breathing 5-10 sec Activate code blue check pulse for 5-10 sec If not pulse, begin CPR

question

What does CAB represent?

answer

Compressions: - compress at least 2 inches - 100 per min - complete chest recoil - correct hand placement Airway - head tilt, chin lift Breathing - 2 breaths every 10 seconds

question

What is ACLS?

answer

Advanced Cardiac Life Support - manual defib - cardiac drugs - advanced airway - lab values

question

When assessing skin, what alterations in condition are you looking?

answer

Color Thickness Texture Turgor Temperature Hydration

question

Examples of color changes in the skin are:

answer

Cyanotic - blueish color indicating poor O? circulation. Smurf blue - methhemoglobinemia yellow-gray - Dusky (blueish-gray) - Jaundice - accumulation of billirubin Mottled (blotchy - pale/red/blue) - poor perfusion Flush - normal color but face becomes red Pale - lack of blood circulation Ruddy (Erythema) - Redness of the skin. Eschar - Black, necrotic tissue. Petichiae - A small purplish spot on a body surface, such as the skin or a mucous membrane, caused by a minute hemorrhage

question

What can thickness changes in skin imply?

answer

Keloids - Hypertrophic scarring that extends beyond the borders of the initial injury. Langerhans Cells - Attach themselves to antigens that invade damaged skin. Lichenification - Thickening and roughening of the skin with increased visibility of skin furrows from chronic rubbing. Precursor - A substance, cell, or cellular component from which another substance, cell, or cellular component is formed especially by natural processes. Stratum germinativum - Inner cellular keratin layer of the epidermis, that contains melanocytes. Stratum corneum - Outer horny layer of dead keratinized cells ** ONLY THE HEELS ; PALMS SHOULD BE THICK

question

What does skin Texture imply during assessment?

answer

Lumpy Smooth Rough Moles, lesions, etc

question

How is Turgor assessed and why?

answer

Grasping the skin on the sternum, forehead, or top of the hand and gently pulling up. After letting go of the skin, the skin should "snap" back into place within three seconds. Skin that remains elevated or "tented" may be due to age related changes, dehydration, or a combination of both

question

What is venous thrombosis

answer

WARM body temperature

question

What is arterial thrombosis

answer

COLD body temperature

question

Hydration concerns for the skin

answer

Normally, your patient's skin should be dry with only a slight amount of moisture. Overly moist skin may be due to environmental conditions, anxiety, obesity, hyperthyroidism, fever, or diaphoresis

question

What is Dependent Rubor?

answer

A redness or purple color of a leg when it is in the dependent or lowered position. If the leg blanches on elevation it may be a sign of lower leg ischemia

question

Why is it important to assess the Nails?

answer

The appearance of the patient's nails may provide information about systemic illnesses and yield information about their self care abilities or behaviors: •Clubbed nails may indicate chronic hypoxia. Bases are flat or rounded, not concave. ° Inadequate nutrition - lines (grooves) going across nails horizontally. •Cyanosis: May be present in the nail bed, indicating poor perfusion and possible underlying vascular insufficiency. Nicotine staining can be seen in the nails. Observe for infections of the nails or nail bed

question

Condition of what areas greatly impacts patient's ability for self-care?

answer

Feet - bear weight or ambulate Hands - dexterity Nails - infection

question

What are the purposes of a bath in the hospital?

answer

Cleanses the skin Acts as skin conditioner Relax the patient Promotes circulation Encourages musculoskeletal exercises Stimulates rate & depth of respirations Promotes comfort through muscle relaxation and skin stimulation Improves self-image Helps build stronger nurse-patient relationship

question

What are the types of baths

answer

Complete bed bath - nurse washes entire body. usually comatose or critical care patients Partial bath - only areas that cause discomfort or odor if left unwashed Sponge bath at sink - pt. sits in chair at sink and nurse helps with areas pt. can"t reach Bag bath - commercially prepared & disposable Shower - full self-care

question

Assessment for Hygiene

answer

Self-care ability * encourage self-care skin feet & nails Oral cavity hair & hair care Eyes, ears & nose

question

Nursing diagnosis for Hygiene

answer

Through assessment hygiene status and patient self-care ability has been identified and it must be determine if patient has an actual problem or is at risk for problem and in need of hygiene diagnosis.

question

Common NANDA International diagnostic Identification for patient situation:

answer

Activity intolerance Ineffective health maintenance Risk for infection Impaired physical mobility Bathing self-care deficit Dressing self-care deficit

question

Nursing process: Planning for Hygiene

answer

Develop individualized plan of care - Techs may be involved in planning Use concept map (may be helpful) Set realistic goals Collaborate with other health care providers -dentistry -podiatry

question

Nursing process for Hygiene: Implementation

answer

Health promotion - teaching patient Reinforce infection control * use a mirror to help patient see

question

How can you maintain comfort in patient room?

answer

Room temp (68°-74°) Clean equipment Water, phone, tissue, & other personal items within reach

question

Nursing process in Hygiene: Evaluation

answer

Observe patient reaction after hygiene measures - comfortable -relaxed Assess condition of skin, mouth, hair after interventions

question

What is the hallmark of the Nurse's role?

answer

Health Assessment ; Physical Examination ** CANNOT delegate assessment to anyone! Nurse should be very proficient in assessment skills

question

Reasons for physical examination are:

answer

- Triage for emergency care (making clinical judgements) ° Gather baseline data - routine screening to promote wellness ° Identify nursing diagnosis - determine eligibility for health insurance, military, new job ° evaluate the outcome of care - admit patient for long-term care

question

How can nurse show respect for cultural differences?

answer

Acknowledge health beliefs (what family can afford too) Use of alternative therapies Nutritional Habits Family relationships (who makes decisions in family) Use of personal space

question

What is most important about INSPECTION of a patient?

answer

PAYING ATTENTION TO DETAIL! - size, shape, color, symmetry, position, abnormalities Make sure lighting is adequate and low level of noises Expose areas you need to examine so that clearly visible while still respecting patient privacy

question

When palpating the skin, what should the nurse pay attention to?

answer

Temperature Moisture Texture Turgor Tenderness Thickness

question

When palpating the abdomen, what should nurse examine?

answer

Tenderness Distention Masses

question

Best way to palpate is?

answer

Lightly - for superficial Deeply - with two hands for deeper findings

question

What is percussion?

answer

Tapping the body with fingertips to produce vibration Nurses typically do not percuss

question

What is Auscultation?

answer

Listening to sounds produced by the body with the aid of a stethoscope. i.e: heart, lungs, GI

question

How can sense of Olfaction assist the nurse in assessment?

answer

Identify nature and source of body odors Help detect abnormalities Used in conjunction with other measurements

question

In case of a fire, always remember RACE:

answer

R = Rescue ? remove all patients from danger A = Activate Alarm C = Confine ? close doors to confine the fire E = Extinguish ? if possible

FUNdamentals of Nursing – Exam 1 – Flashcards

Unlock all answers in this set

Haven't found what you were looking for?

Search for samples, answers to your questions and flashcards