Health Assessment In Nursing

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Assessment
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Collection of subjective and objective data
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Diagnoses
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Analysis of subjective and objective data to make a professional nursing judgement
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Planning
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Developing a plan of nursing care and outcome criteria
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Implementation
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Carrying out the plan of care
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Evaluation
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Assessing whether outcome criteria have been met and revising the plan of care if necessary
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Nursing Diagnosis
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Clinical judgement about individual, family or community responses to actual or potential health problems and life processes
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Subjective Data
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Sensations or symptoms that can be verified only by the client (ex. pain)
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Objective Data
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Findings directly observed or indirectly observed through measurements (ex. body temperature)
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Collaborative Problem
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Physiologic complications that nurses monitor to detect their onset or changes in status
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Referral Problem
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Problem that requires the attention or assistance of other health care professionals
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A medical examination differs from a comprehensive nursing examination in that the medical examination focuses primarily on the client’s
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Physiologic status
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The result of a nursing assessment is the
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Formulation of nursing diagnoses
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Although the assessment phase of the nursing process precedes the other phases, the assessment phase is
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Continuous
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When a client first enters the hospital for an elective surgical procedure, the nurse should perform an assessment termed
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Comprehensive
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An ongoing or partial assessment of a client
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Includes a brief reassessment of the client’s normal body system
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The purpose of the comprehensive health assessment is to
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Arrive at conclusions about the client’s health
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The use of this type of question can keep a client interview from going off track
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Closed-ended
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A nurse can clarify a client’s statements by
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Rephrasing the client’s statements
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During what phase of the interview between a nurse and client do you collaborate to identify problems and goals
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Working phase
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When dealing with a manipulative client it is important for the nurse to
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Provide structure and set limits
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The primary purpose of the health history is to
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Identify risk factors to the client and his or her significant others
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Define the “COLDSPAA” accronym
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Character, Onset, Location, Duration, Severity, Pattern, Associated factors, how it Affects the client
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Sim’s position
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Side-lying position used during the rectal examination
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Sitting Position
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Position used during much of the physical examination including examination of the head, neck, lungs, chest, back, breast, axilla, heart, vital signs, and upper extremities
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Supine Position
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Back-lying position used for examination of the abdomen (with one small pillow under the head and another under the knees); this position also allows easy access for palpation of peripheral pulses
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Standing Position
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Position used to examine male genitalia and to assess gait, posture, and balance
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Prone Position
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Client lies on abdomen with head turned to the side; may be used to assess back and mobility of hip joint
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Lithotomy Position
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Back-lying position with hips at edge of examining table and feet supported in stirrups; used for examination of female genitalia, reproductive tract, and rectum
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What part of the examiner’s hand is used to feel for fine discriminations: pulses, texture, size, consistency, shape, and crepitus
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Fingerpads
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Part of the examiner’s hand used to feel for vibration, thrills, or fremitus
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Ulnar surface or palm of hand
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Part of the examiner’s hand used to feel for temperature
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Dorsal surface of hand
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Smaller end of stethoscope used to detect low-pitched sounds (abnormal heart sounds and bruits)
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Bell of stethoscope
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Larger end of stethoscope used to detect breath sounds, normal heart sounds, and bowel sounds
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Diaphragm of stethoscope
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Name the four basic techniques used for physical assessment
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Inspection, palpation, percussion, auscultation
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Name the five steps of the nursing process
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Assessment, diagnosis, planning, implementation and evaluation
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What are the four sections of the nursing assessment framework?
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History of present health concern, past health history, family history and lifestyle and health practices
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What are the four basic types of assessments?
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Initial comprehensive assessment, ongoing or partial assessment, focused or problem oriented assessment and emergency assessment
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Name the four major steps of the assessment phase
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Collection of subjective data, collection of objective data, validation of data and documentation data
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Explain the importance of a contextual approach to nursing health assessment
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The client’s culture, family, community and spirituality all affect their overall health
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What is the purpose of conducting a health history interview?
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Establishing rapport and a trusting relationship with the client to elicit accurate and meaningful information and to gather information on the client’s developmental, psychological, physiologic, sociocultural and spiritual statuses
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What are the steps or phases of the health history interview?
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Introductory phase, working phase, summary and closing phase
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What are the three variations in communication that must be considered as you interview clients?
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Gerontologic, cultural and emotional
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What are the components of a complete health history?
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Biographic data, reasons for seeking health care, history of present health concern, past health history, family health history, review of body systems (ROS) for current health problems, lifestyle and health practices profile, developmental level
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What is the purpose of the physical assessment?
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To obtain objective data
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What preparation is required for conducting a physical assessment?
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Necessary equipment and how to use it, preparing the setting, onself and the client for examination and how to perform the four basic assessment techniques
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Why must subjective and objective data be verified?
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Failure to validate data may result in premature closure of the assessment or collection of inaccurate data
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What methods are used to verify data?
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Recheck objective data through reassessment, clarify with client by asking additional questions and compare your objective findings with subjective findings for discrepencies
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What is the purpose of the general survey assessment?
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To provide the nurse with an overall impression of the client’s whole being.
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What does the general survey assessment include?
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Physical development and body build, gender and sexual development, apparent age vs reported age, skin condition and color, dress and hygiene, posture and gait, LOC, behavior, body movements and affect, facial expression, speech and vital signs
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What is included in the vital signs assessment?
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Temperature, pulse, respiration, blood pressure and pain
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What is the normal temperature range of an adult?
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96-99.9 F orally 36.5-37C
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What is the normal pulse rate for an adult?
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60-100 beats per minute
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Define tachycardia
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Pulse rate of greater than 100 beats per minute
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Define bradycardia
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Pulse rate of less than 60 beats per minute
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When assessing the pulse what should the nurse note?
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Rate, rhythm, amplituded and contour
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What is the normal respiratory rate for an adult?
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12-20 per minute
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What should the nurse be assessing when observing respiration?
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Rate, rhythm and depth
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What is the normal blood pressure of an adult?
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120/80
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Older adults may experience this variation in blood pressure
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Isolated systolic hypertension 140/90
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Describe the subjective components of the pain assessment
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Pain is whatever the client says it is, directly quote description of pain use COLDSPA mneumonic
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Describe the objective components of pain assessment
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Use of pain assessment tools
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What are three types of pain assessment tools?
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Visual analog scale (VAS), numeric pain intensity scale (NRS) and simple descriptive pain intensity scale (VDS)
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What are the three classifications of pain?
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Acute pain, chronic nonmalignant pain and cancer pain
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This type of pain is usually associated with a recent injury
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Acute pain
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This type of pain is usually associated with a specific cause or injury and described as a constant pain that persists for more than six months
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Chronic nonmalignant pain
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This type of pain is usually due to the compression of peripheral nerves or meninges or from the damage to these structures following surgery, chemo, radiation or tumor growth and infiltration
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Cancer pain
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When converting inches to centimeters what is the conversion factor?
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Multiply by 2.54
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When converting pounds to kilograms what is the conversion factor?
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Divide by 2.2
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Define mental status
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Client’s level of cognitive and emotional functioning and stability reflected in their speech, appearance and thought patterns
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Normal findings for level of consciousness
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Client is alert, awake and orientated to time, place, date and purpose. Responds to questions and answers appropriately
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Define lethargy
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Client opens eyes, answers questions and falls back asleep
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Define obtunded
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Client opens eyes to loud voice, responds slowly with confusion and seems unaware of environment
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Define stupor
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Client awakens to vigorous shake or painful stimuli but returns to unresponsive sleep
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Define coma
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Client remains unresponsive to all stimuli, eyes stay closed
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Define decorticate posture
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aka Abnormal flexor posture, client with lesions of the corticospinal tract draws hands up to chest when stimulated
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Define decerebrate posture
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aka Abnormal extensor posture, client with lesions of the diencephalon, midbrain or pons extends arms and legs arches neck and rotates hands and arms internally when stimulated
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What is the subjective component of a nutritional assessment?
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Client interview which may include a 24 hour dietary recall
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What is the objective component of a nutritional assessment?
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Anthropometric measurements are used to evaluate the client’s physical growth, development and nutritional status as well as physical examination and hydration assessment
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What are the three anthropometric measurements?
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Triceps skinfold (TSF), Mid upper arm circumference (MUAC), Arm muscle circumference (AMC)
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What are some indicators of good nutritional status?
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Alert, energetic, good endurance, good posture, good attention span, psychological stability, weight within range for height, age and body type, no skeletal changes, eyes bright and clear, shiny hair, skin glowing, elastic, good turgor, smooth, healthy reflexes
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What are some indicators of poor nutritional status?
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Withdrawn, apathetic, easily fatigued, stooped posture, inattentive, irritable, overweight or underweight, flaccid muscles, wasted appearance, diminished reflexes, skin dull, pasty, scaly, dry, bruised, eyes dull, hair brittle, skeletal malformations
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What factors influence dietary habits?
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Lower socioeconomic status, long working hours and fast food consumption, poor food choices, chronic dieting, chronic diseases, dental issues, limited access to sufficient food, eating disorders, illness or trauma
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What BMI is considered obese?
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30-34.9
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What waist circumference measurement is considered to put the client at risk for disease?
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35 inches or greater for women and 40 inches or greater for men
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How is BMI calculated?
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Weight in kg/height in meters squared
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What is spirituality?
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One’s search for life’s meaning and purpose
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What is religion?
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Shared practices and rituals used to express one’s faith
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What is a spiritual assessment?
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An assessment used to determine a client’s spiritual needs
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What is spiritual care?
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Actions used to assist the client in meeting spiritual needs
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What are the three types of normal breath sounds?
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Bronchial, bronchovesicular and vesicular
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Where are bronchial sounds heard?
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In the trachea and thorax
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Where are bronchovesicular sounds heard?
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Over the major bronchi: between the scapulae, around the upper sternum in the first and second ICS
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Where are vesicular sounds heard?
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In the peripheral lung fields
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What pitch do bronchial sounds have?
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High pitched
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What pitch do bronchovesicular sounds have?
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Moderate pitch
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What pitch do vesicular sounds have?
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Low pitched
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When assessing breath sounds what do you need to note?
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Pitch, quality and amplitude
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What amplitude do each of the 3 breath sounds have?
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B-loud, BV-moderate, V-soft
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What breath sound is short during inspiration and long during expiration?
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Bronchial
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What breath sound is the same during inspiration and expiration?
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Bronchovesicular
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What breath sound is long during inspiration and short during expiration?
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Vesicular
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Which lung lobe is located from 3cm above the medial 1/3 of the clavicle to the 4th rib at the right sternal border to the 5th rib at the midaxillary line to T3-T1
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Right upper lobe
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This fissure seperates the RUL from the RML
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Horizontal fissure
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Where is the right middle lobe located?
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From the 4th rib at the right sternal border to the 5th rib at the midaxillary line to the 6th rib at the midclavicular line
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This fissure seperates the RML from the RLL as well as the LUL from the LLL
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Oblique fissure
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This lung lobe is located from the 6th rib at the MCL to the 5th rib at the MAL to T3-T10 to the 8th rib at the MAL
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Right lower lobe
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Where is the left upper lobe located?
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From 3cm above the medial 1/3 of the clavicle to the 6th rib at the MCL to the 5th rib at the MAL to T3-T1
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Where is the left lower lobe located?
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From the 6th rib at the MCL to the 5th rib at the MAL to T3-T10 to the 8th rib at the MAL
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Where is S1 best heard?
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At the apex of the heart
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Where is S2 best heard?
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At the base of the heart
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What are the 5 sites of auscultation for normal heart sounds?
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Aortic area, pulmonic area, erb’s point, tricuspid area and mitral (apical) area
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Why is it important to only palpate one carotid artery at a time?
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Bilateral palpation of the carotid arteries can result in reduced cerebral blood flow
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How long should you palpate/auscultate the apical pulse for?
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60 seconds
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Where is the aortic area of the heart?
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2nd ICS right
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Where is the pulmonic area of the heart?
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2nd ICS left
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Where is erb’s point of the heart?
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3rd ICS left
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Where is the tricuspid area of the heart?
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4th ICS left
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Where is the mitral (apical) area of the heart?
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5th-6th ICS midclavicular
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S1 can be described as this sound
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LUB
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S2 can be described as this sound
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DUB
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S1 represents
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Systole
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S2 represents
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Diastole
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A swishing sound caused by turbulent blood flow throught the heart valves or great vessels
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Murmur
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A difference between radial and apical pulses
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Pulse deficit
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Define adventitious sounds
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Abnormal breath sounds heard during auscultation of the lung fields which may include crackles, wheezes or pleural friction rubs
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Define kyphosis
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Abnormally increased forward curvature of the upper spine
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Identify 3 age related changes that occur within the lungs
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Loss of elasticity, fewer functional capillaries and loss of lung resiliency
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The vertebra prominens is also called
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C7
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Define fremitus
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Vibrations of air in the bronchial tubes transmitted to the chest wall
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Define crepitus
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Crackling sensation like bones or hairs rubbing against eachother
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Define edema
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The abnormal accumulation of fluid in interstitial spaces of tissues
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What is a wheal?
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Elevated mass with transient borders size and color may vary. ex hives or insect bites
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What is a nevus?
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aka a mole, is a flat or raised tan/brownish marking up to 6mm wide
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What is a pustule?
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A pus-filled vesicle or bulla ex. acne or impetigo
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What is a cyst?
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An encapsulated fluid-filled or semisolid mass located in the subcutaneous tissue or dermis
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What is an ulcer?
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Skin-loss extending past epidermis, necrotic tissue ex. pressure ulcer
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Cicatrix is another name for?
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A scar, a skin mark left after healing wound or lesion
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What is a fissure?
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A linear crack in the skin ex. chapped lips and athlete’s foot
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What color fluorescence indicates the presence of fungus?
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A blue-green color
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What is the Romberg test?
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Tests the client’s equilibrium, client stands with feet together and arms at sides eyes open and then closed. Client should be able to maintain the position for 20 secs with minimal or no swaying
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What is used to test distant visual acuity?
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The Snellen chart or E chart results are expressed as 20/20 representing the distance from the chart and the last line the client was able to read
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What test is used to test near visual acuity?
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The Jaeger reading card results are expressed as 14/14 representing the distance in inches from the chart and the last line the client was able to read
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What test is used to test peripheral vision?
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The confrontation test
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What are normal findings of a corneal light reflex test?
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The reflection of light on the corneas should be in the exact same spot on each eye which indicates parallel alignment
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What does the cover test detect?
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Deviation in alignment or strength and slight deviations in eye movement
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What are normal results of the cover test?
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The uncovered eye should remain fixed straight ahead, the covered eye should remain fixed and straight ahead after being uncovered
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Define estropia
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An inward turn of the eye
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Define exotropia
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An outward turn of the eye
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What does the positions test consist of?
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Testing the six cardinal positions of gaze to assess for extraocular muscle weakness or dysfunction of the cranial nerve
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When testing pupillary reaction to light what is the normal result?
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Pupils should constrict in both eyes
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When testing accomodation of pupils what is the normal result?
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Pupils constrict and eyes converge
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When palpating lymph nodes what should the nurse be assessing?
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Tenderness, mobility, size and shape
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Are the lymph nodes normally palpable?
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No

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