2026\2027 A+ Grade
medical dx
- correct answer only made by doctors
nursing dx
- correct answer used to evaluate the response of the whole person to actual or potential health
problems
nursing process
- correct answer - iterative process allowing practitioners to move back and forth while caring for the
needs of complex pts.
- Includes six phases: assessment, diagnosis, outcome identification, planning, implementation,
evaluation
"A Delicious Orange PIE"
- correct answer Assessment- collect data
Diagnosis- interpret data
Outcome identification- identify the expected outcomes
Planning
Implementation- doing what you planned
Evaluation- was the outcome we wanted achieved?
inspection phase
- correct answer concentrated watching. Checking for abnormalities before continuing. Inspection
begins the moment you first meet a person and develop a "general survey"
,purpose of percussion
- correct answer - mapping out the location and size of an organ by exploring where the percussion note
changes b/n the borders of an organ and its neighbors
- signaling the density (air, fluid, or solid) of a structure by a characteristic note
- detecting an abnormal mass if its fairly superficial; the percussion vibrations penetrate a/b 5 cm deep--
-a deeper mass would give no change in percussion
- eliciting a deep tendon reflex using the percussion hammer
diaphragm
- correct answer used for high-pitched sounds → breath, bowel, and normal heart sounds. Hold the
diaphragm firmly a/g the person's skin, firm enough to leave a slight ring afterwards
bell
- correct answer used for soft,low-pitched sounds such as extra heart sounds or murmurs. Hold it lightly
a/g the person's skin, just enough that it forms a perfect seal
1st level priorities
- correct answer emergent, life threatening
airway, breathing, circulation, vital signs
2nd level priorities
- correct answer requires prompt intervention to forestall further deterioration
acute pain, mental status change, abnormal labs, risk of infection
3rd level priorities
- correct answer those that are important to the pt's health but can be addressed after more urgent
problems. Interventions to treat these problems are more long term, and the response to treatment is
expected to take more time
subjective data
- correct answer what the pt says, biased
objective data
- correct answer unbiased, what the pt cannot see, labs
, how do you prioritize patient problems/diagnosis?
- correct answer airway → breathing → circulation → perfusion
spirituality
- correct answer broader term focused on a connection to something larger than oneself and a belief in
transcendence
religion
- correct answer organized system of beliefs concerning the cause, nature, and purpose of the universe,
as well as the attendance of regular services
role of nurse with DM
- correct answer for neglect in the elderly and children, report your suspicions to the proper authorities.
No evidence is needed, when in doubt, REPORT
BMI
- correct answer weight (lbs.) / height (in.) * 703
- normal = 18.5-24.9
- <18.8 → underweight
- want to be less than 25 > 30 = obese
negative effects on elderly nutritional status
- correct answer lack of taste, medications, teeth issues, decreased GI motility, decrease visual acuity,
decreased saliva production
how long would you monitor a heart rate if it is irregular
- correct answer 1 full minute
proper way to take a BP
- correct answer palpate pulse in radial artery,
Let air out 2-4 mmHg/second.