1
Q
Who spends the most time with the client, knows the most about the client, and is able to communicate the client’s needs to the rest of the health care team the most effectively?
A
The Nurse!
2
Q
What are the 3 areas of assessment the nurse focuses on in order to get a complete picture of the client?
A
- Body: assess the physical systems
- Mind: assess psychosocial health
- Spirit: assess for religious or spiritual beliefs
3
Q
What is the nursing process?
A
DDPIE
- Data Collection: gather data
- Diagnosis: client problems that are based on medical diagnosis
- Plan: goals
- Implement: interventions
- Evaluate: how the client responded to the intervention
The nursing process is not linear. The nurse will jump back and forth between the steps depending on additional data acquired about the client.
4
Q
What are nursing clinical judgment skills?
A
- understanding WHY an intervention is done
- prioritizing what is important
- interpreting sign and symptom data
- gathering more information if there is not enough to make an informed decision
5
Q
When does teaching and discharge planning by the nurse begin with a client?
A
Teaching and discharge planning can begin during the assessment even while the client is being admitted.
During the admission assessment data is gathered by the nurse such as home environment and available resources, so teaching can begin right away if there are needs.
6
Q
What are the 2 purposes of doing a nursing assessment on a client?
A
- gather data (especially abnormal data) about the client to heal the client or prevent them from getting sick.
- notify the health care provider (HCP) of immediate complications or changes in the client’s condition in order to update the care plan.
The HCP can be a doctor, nurse practitioner or physician assistant.
7
Q
What is the typical assessment order for most body systems?
A
- inspect
- palpate
- percuss
- auscultate
8
Q
What is the difference between a focused health assessment and a comprehensive health assessment?
A
- A focused health assessment focuses on the immediate concern and is done when the client has a specific complaint or immediate information is needed.
- A comprehensive health assessment is when the nurse assesses the entire client head to toe.
9
Q
Which main physical systems are assessed in a comprehensive assessment starting from head to toe?
A
- neuro
- respiratory
- cardiac
- gastrointestinal
- kidneys
- musculoskeletal
- skin
10
Q
In addition to the physical assessment of the client, what additional data does the nurse look at to get an overall picture of the client?
A
- labs
- CBC, BMP or CMP
- labs specific to problem
- imaging diagnostic tests
- x-rays, CT scan, MRI, etc
- medical and surgical history and physical from HCP
- medication record
11
Q
How often should a typical nursing physical assessment be done on each of the following units:
- Post-operatively
- ICU
- Progressive or Step-down unit
- Medical-surgical unit
A
- Post-Op: focused assessments every 5- 15 minutes
- ICU: about every 1-2 hours
- Progressive or Step-down unit: about every 2-4 hours
- Medical-surgical floor: about every 4-8 hours
12
Q
What is subjective and objective data?
A
Subjective data is what the client tells you
- example: the client’s stated pain level
Objective data is what anyone can observe
- example: a set of vital signs
13
Q
Define:
Posterior and Anterior
A
- Posterior means the back of something
- Anterior means the front of something
14
Q
Define:
Distal and Proximal
A
- Distal means away from something
- Proximal means closer to something
15
Q
What is a very quick and basic neuro assessment?
A
Assess the level of consciousness by asking the client 4 questions:
- Person: What is your name?
- Place: Where are you?
- Time: What year is it? or Who is the president?
- Situation: Do you remember why you are here?
16
Q
What is PERRLA?
A
Using a light to check if pupils are:
- Equal
- Round
- React to Light
- Accommodate (pupils constrict as objects get closer)
17
Q
What is the cranial nerves“saying” in order to remember the names of the 12 cranial nerves?
A
Oh, Oh, Oh! To Touch And Feel A Good Velvet, Such Heaven!
- Olfactory
- Optic
- Oculomotor
- Trochlear
- Trigeminal
- Abducens
- Facial
- Acoustic/Vestibulocochlear
- Glossopharyngeal
- Vagus
- Spinal Accessory
- Hypoglossal
18
Q
Draw the cranial nerve face.
A
This will help you to remember the function and location of the nerves.
19
Q
What is the function of cranial nerve I?
A
I. Olfactory: smell
20
Q
What is the function of cranial nerve II?
A
II. Optic: vision
21
Q
What is the function of cranial nerve III?
A
III. Oculomotor: movement of pupils and eyelids
22
Q
What is the function of cranial nerve IV?
A
IV. Trochlear: downward and inward movement of the eyes
23
Q
What is the function of cranial nerve V?
A
V. Trigeminal: chewing
24
Q
What is the function of cranial nerve VI?
A
VI. Abducens: eye movement lateral (side to side)
25
What is the function of **cranial nerve VII**?
VII. Facial: **movement of all the facial muscles and taste**
26
What is the function of **cranial nerve VIII**?
VIII. Acoustic/Vestibulocochlear: **hearing**
27
What is the function of **cranial nerve IX**?
IX. Glossopharyngeal: **swallowing and taste**
28
What is the function of **cranial nerve X**?
X. Vagus: **swallowing and speaking**
29
What is the function of **cranial nerve XI**?
XI. Spinal Accessory: **shoulder movement**
30
What is the function of **cranial nerve XII**?
XII. Hypoglossal: **tongue strength**
31
What are the **4 areas of the brain?**
1. frontal lobe
2. parietal lobe
3. temporal lobe
4. occipital lobe
32
What is the function of the **frontal lobe**?
**controls thinking and personality changes**
33
What is the function of the **parietal lobe**?
**processes information for temperature, taste, and movement**
34
What is the function of the **temporal lobe**?
**controls hearing, language comprehension, and memories**
35
What is the function of the **occipital lobe**?
**controls vision**
36
What are the **4 regions** of the spine?
1. **Cervical:** C1-C8
2. **Thoracic:** T1-T12
3. **Lumbar:** L1-L5
4. **Sacral and Coccyx:** S1-S5
37
What do the **cervical nerves** control?
Cervical: C1-C8: nerves control **breathing, arm, and neck movement**.
38
What do the **thoracic nerves** control?
Thoracic: T1-T12: nerves control **chest, back, and abdomen strength.**
39
What do the **lumbar nerves** control?
Lumbar: L1-L5: nerves control **lower abdomen, buttock and leg strength.**
40
What do the **sacral and coccyx** nerves control?
Sacral and Coccyx: S1-S5: nerves control **thighs, lower leg strength, and genitals.**
41
What questions are asked during a nursing **lung assessment**?
1. Have you had any **difficulty breathing** at rest or with activity?
2. Have you had a **cough**?
* *If so, is it **dry or a productive** cough with mucus?*
* *If productive with **mucus**, what color is it?*
42
What are the **normal lung sounds**?
Normal lung sounds
43
Where is the **stethoscope** placed when doing a nursing lung assessment?
Place the stethoscope at the top and go **progressively down** the anterior and posterior thorax.
44
# Define:
Adventitious lung sounds
**Abnormal** breath sounds
45
What are **diminished** or **absent** breath sounds?
An area of the lungs where the **movement of air cannot be heard**.
46
# Define:
dyspnea, tachypnea, and bradypnea
* _dyspnea_: **difficulty breathing**
* _tachypnea_: **rapid respirations \> 20**
* _bradypnea_: **slow respirations \< 12**
47
What is the difference between **fine, medium,** and **coarse lung crackles**?
**Crackles** are lung sounds caused by **fluid in the lungs**.
* _fine crackles_: **a little bit of fluid in the lungs** that sound like high-pitched popping sounds: listen [HERE](https://www.youtube.com/watch?v=LHqqvrm2j6g)
* _medium crackles_: **condition is getting worse** and lower-pitched popping sounds
* _coarse crackles_: bubbling sounds from fluids, **really bad!** listen [HERE](https://www.youtube.com/watch?v=aSor2XBc9K8)
48
What are **wheezes**?
Wheezes are **high squeaky lung sounds**.
## Footnote
*They are caused by the small airways narrowing, usually in asthma.*
Listen [HERE](https://www.youtube.com/watch?v=T4qNgi4Vrvo)
49
What are **rhonchi**?
Rhonchi are **low-pitched lungs sounds that resemble snoring**.
## Footnote
*It is caused by secretions in the airway. They may clear with cough.*
Listen [HERE](https://www.youtube.com/watch?v=YgDiMpCZo0w)
50
What is **atelectasis**?
Atelectasis is **incomplete expansion** of the lung that causes diminished breath sounds.
## Footnote
*It is most common with pneumonia.*
51
What are **chene-stokes** respirations?
Chene-stokes respirations is **apnea lasting 10-60 seconds** followed by hyperventilation.
It indicates a **dying client** but may be normal it babies.
52
What is **stridor**?
Stridor is **a high-pitched, harsh sound** from an obstructed airway.
53
What is a **pleural friction rub**?
Pleural friction rub is a low-pitched grating sound from **pleurisy** (inflammation in the lungs).
## Footnote
Listen [HERE](https://www.youtube.com/watch?v=QpA5EmmyXx4)
54
What is included in a basic nursing **cardiac assessment**?
* asking the client about **chest pain** or chest discomfort
* listening to **heart sounds**
* checking **pulses**
* checking **capillary refill**
* checking **skin temperature** and **color**
* checking for **edema and skin turgor**
* assessing **cardiac rhythm strip**
55
# Define:
Brady and Tachy
* _Brady_ means **slow**
* _Tachy_ means **fast**
## Footnote
* Bradycardia means a heart rate \< 60*
* Tachycardia means a heart rate \>100*
56
Where are the **5 heart sounds located**?
* aortic, pulmonic, Erb's point, tricuspid, mitral
Use the mnemonic: "APE To Man" to remember.
57
What are the heart sounds **S1 and S2**?
**S1 and S2** are the normal heart sounds. It is sometimes known as "lub dub". Listen [HERE](https://www.youtube.com/watch?v=FtXNnmifbhE)
58
What are the heart sounds **S3 and S4**?
* **S3** is usually an abnormal heart sound. Listen [HERE](https://www.youtube.com/watch?v=_i2D1KZkN1w)
* **S4** is almost always associated with cardiac disease. Listen [HERE](https://www.youtube.com/watch?v=KcMF8rJDTIk)
## Footnote
*S3 and S4 are associated with fluid volume overload.*
59
What is a **heart murmur**?
A heart murmur is an abnormal heart sound other than "lub-dub". It can be a **whooshing, swishing or clicking noise.**
## Footnote
Listen [HERE](https://www.youtube.com/watch?v=MzORJbyHTT0).
60
Label the pulses on the diagram from the following choices:
* brachial, carotid, dorsalis pedis, femoral, posterior tibial, radial, ulna
61
What are the **4 pulse strengths** and what do they **indicate**?
* **4+**: strong and bounding - indicates fluid volume overload
* **3+**: full pulse - less severe fluid volume overload
* **2+**: normal - easily palpable
* **1+**: weak, barely palpable - indicates fluid volume deficit
62
What is **edema** and **pitting edema** and how is it assessed?
_Edema_ is **too much fluid in the body**. It can be localized or throughout the body.
_Pitting edema_ is when the **skin remains indented** after pressing with a finger.
* 1+, 2mm: a small pit and rebounds in a few seconds
* 2+, 4mm: a medium pit and rebounds in a few seconds
* 3+, 6mm: a deep pit and rebounds in 10-20 seconds
* 4+, 8mm: very severe edema and rebounds in \>30 seconds
63
What is **anasarca**?
Anasarca is another word for **generalized edema**.
64
What is **skin turgor** and how is it assessed?
Skin turgor is **assessing the client's fluid status** by pinching a fold of skin.
* If the _skin tents up_, it indicates **dehydration** or fluid volume deficit.
* if the _skin returns to the normal position_, there is **no fluid issue**
65
How is **capillary refill** assessed?
Capillary refill is assessed by **pressing down on the nail bed**.
* if the pink color comes back in \< 3 seconds, that is normal.
* if the pink color comes back in \> 3 seconds, it is abnormal.
## Footnote
*Cap refill assesses the client's blood circulation.*
66
Label the gastrointestinal **organs** on the diagram from the following choices:
* appendix, esophagus, gallbladder, large intestine, liver, pancreas, rectum, small intestine, stomach
67
What does a basic nursing **gastrointestinal assessment** include?
* listening to **bowel sounds**
* ask when **last bowel movement** was
* ask if **passing gas**
* experiencing any **nausea/vomiting**
* determining **appetite**
68
What is the **unique nursing assessment order** for the abdomen/GI?
1. **inspect**
2. **auscultate**
3. **percuss**
4. **palpate**
## Footnote
*It is done from least to most invasive in order to not disturb the abdomen and cause inaccurate findings.*
69
What are the **four areas of the abdomen** and **how long** is each quadrant listened to before deciding if there are bowel sounds?
Listen to **each quadrant for 5 minutes** = a total of 20 minutes
* *start at upper left, upper right, lower right, lower left*
* *go in a counterclockwise direction*
70
What are the **different types** of bowel sounds?
1. **absent:** no bowel sounds
2. **hypoactive:** 1 sound every 3-5 minutes
3. **normal:** 5-30 clicks or gurgles per minute
4. **hyperactive:** \> 30 sounds per minute or an increase from the client's baseline
71
How is the **body mass index (BMI)** calculated?
**BMI = kg ÷ m2**
* normal weight = 18.5 to \< 25
* overweight = 25 to \< 30
* obese = \> 30
*Example: if a client weighs 70 kg and is 1.8 meters tall, the BMI is 70* ÷ *1.82 = **21.6***
72
# Define:
NPO
NPO means **nothing by mouth**.
## Footnote
*Don't allow the client to eat or drink anything. This is a common order for preventing aspiration during surgeries and procedures or when having an acute GI issue.*
73
What are the 2 main **functions** of the **pancreas**?
1. _endocrine organ:_ **to release insulin** so the body can regulate glucose/sugar
2. _exocrine organ:_ **to release enzymes** for food digestion
74
What is the **function** of the gallbladder?
The function of the gallbladder is to **store bile** that's made by the liver for **food digestion**.
75
What are the **4 main** **functions** of the **liver**?
1. **to make clotting factors** to prevent bleeding
2. **to make proteins** so all the organs and cells can function
3. **to metabolize toxins** and cholesterol
4. **to make bile** for digestion
76
What does a basic **renal/urinary assessment** include?
* checking urine output and color
* monitoring intake and output
* checking labs: BUN, creatinine, GFR, electrolytes
* urinalysis
77
What is the **minimum urine output** for an adult and newborn?
* **adult:** at least 30 mL/hour
* **infant** (up to 1 year): at least 2ml/kg/hour
78
What does a basic nursing **musculoskeletal assessment** include?
* checking muscle strength and range of motion
* asking about pain, numbness, and tingling
* checking electrolytes and other labs
* imaging tests for the spine and head
79
What are the assigned numbers for **muscle strength**?
* 0 is no muscle strength
* 5 is normal muscle strength
80
Label the **bones** on the diagram from the following:
* cranium, femur, fibula, humerus, patella, pelvis, radius, ribs, scapula, sternum, talus, tibia, ulna, vertebra
81
What is **kyphosis**?
Kyphosis is a **curved thoracic spine** (hunchback).
## Footnote
*It is common in the elderly with osteoporosis.*
82
What are the **deep tendon reflex** grading numbers and what do they indicate?
**Deep tendon reflex grading:**
* 0 = no response (always abnormal)
* 1+ = a slight but present response (may or may not be normal)
* 2+ = a brisk response (normal)
* 3+ = a very brisk response (may or may not be normal)
* 4+ = a tap elicits a repeating reflex/clonus (always abnormal)
83
What is **scoliosis**?
Scoliosis is **lateral spine curvature**.
## Footnote
*It is tested in teenagers.*
84
What does a basic nursing **skin assessment** include?
**A basic nursing skin assessment includes:**
* skin color
* wounds (especially on bony areas)
* rashes
* bruising
* abnormal moles/freckles
* asking about new meds or exposure to infectious diseases
* *many cause rashes*
85
# Define:
urticaria and pruritis
* urticara: **hives**
* pruritis: **itching**
86
# Define:
Cyanosis
Cyanosis is when the skin has a **blue tint** due to a low oxygen reading.
87
How is **cyanosis** assessed in a **dark-skinned client**?
Look for a bluish color by checking **lips, tongue, nail beds, palm soles, and conjunctiva.**
88
# Define:
erythema
Erythema is **redness of the skin**.
## Footnote
*It indicates injury, inflammation or infection.*
89
# Define:
pallor
Pallor is skin that is **lighter than what the client is normally**.
## Footnote
*It can indicate decreased blood flow.*
90
# Define:
jaundice
Jaundice is **yellowing** of the skin, mucous membranes, and whites of the eyes.
## Footnote
*It indicates liver failure.*
91
# Define:
ecchymosis
Ecchymosis is **bruising** of the skin.
92
What questions are asked for a nursing **pain assessment**?
* **Location:** where is the pain?
* **Severity:** how bad is it? Use appropriate pain scale.
* **Character:** what does it feel like?
* **Onset:** when did it begin?
* **Associated factors:** are there other symptoms that occur with it?
* **Pattern:** what makes it better? what makes it worse?
* **What pain meds do you take?**
* **Do you use alternative therapies to manage pain?**
93
What are basic **documentation guidelines** for nursing?
* use black ink
* date/time/name on each entry
* document right after activity
* be factual
* use quotes for subjective data
* document refusals of treatments and calls to HCP
94
How should an **error** be documented in a client's medical chart?
Draw one line through the error, initial and date.
95
What is **u****nacceptable** for nursing documentation?
* do **_NOT_** document for others
* do **_NOT_** leave blank spaces on forms
* do **_NOT_** use unacceptable abbreviations
NCLEX-PN (1) Fundamentals
flashcards
Decks in class (15)
# Cards
-
Positions37
-
Lab Values46
-
Health & Physical Assessment95
-
Lab Interpretation61
-
Fluids23
-
Electrolytes55
-
Acid-Base Imbalance31
-
Diagnostic Tests73
-
Perioperative Nursing47
-
Nutrition and Diets45
-
Tubes56
-
Complementary and Alternative Medicine15
-
Culture & Religion27
-
Growth and Developmental Theories21
-
Community Health27
