Science Medicine Nursing
Nursing Assessment Final Exam
COMPLETE QUESTIONS AND
SOLUTIONS GRADED A+
Terms in this set (124)
subjective data what the patients says
objective data what you observe or collect, IPPA
4 categories to assess in patient 1) physical
2) mental/
psychosocial
3)orientation/cognition
4)behavior
database components objective, subjective, health history, diagnostics
complete database complete health history and a full physical examination
problem-centered database limited or short-term problem, concerns mainly one problem
of focus
follow-up database follow up with short-term or chronic health problems
emergency database rapid collection or the data, compiled concurrently with
lifesaving measures
priorities A- airway ALWAYS NUMBER ONE PRIORITY
B- breathing
C- circulation/cardiac problems
V- vital sign concerns
IPPA normal and abdomen inspection, palpation, percussion, auscultation
abdomen= inspection, auscultation, palpation, percussion
inspect use this 80% of the time! size, skin, appearance, respirations,
smell, health habits, first whole body and then do systems,
compare left to right sides, use all your senses
palpate texture, temperature, moisture, organ location, organ size or
shape, swelling, vibrations, pulsation, rigidity, lumps or masses,
tenderness, pain, guarding, facial expressions of pain
, palpation techniques use gloves and calm gentle approach, warm hands and
stethoscope, palpate tender areas last, light (1-2cm) to deep
(5-8cm), circular motion.
fingertips- skin texture, swelling, pulsations, lumps
grasping- position, shape, consistency of
organ back of hand- temperature
fingerbase- vibration
percussion quick, striking hit between knuckles under fingernail. short and
sharp strokes. indirect with finger or direct on body or blunt
with hand and fist.
resonant medium-loud, low pitch, clear and hollow, moderate duration,
over normal lung tissue.
hyperresonant louder, lower pitch, booming, longer duration, abnormal in
adult, over lungs with increased amount of air.
tympany loud, high pitch, musical and drum like, sustained longest
duration, over air-filled viscus (stomach or intestine)
dull soft, high pitch, muffled thud, short duration, dense organs as
in the liver or spleen
flat very soft, high pitched, dead stop of sound, very short
duration, no air is present, over thigh muscles or bone or
tumor.
auscultation never over clothes or gown! heart vessels, lungs, abdomen.
diaphragm for high-pitch sounds, breath, bowel, normal heart.
bell for low-pitch sounds, extra heart sounds or murmurs.
health history sequence 1) biographic
2) reason for seeking care
3) present health or history of present illness
4)past history
5) family history
6) review of systems
7) functional assessment of ADL's
nurse & medical history difference nurses plan for discharge and medical is for the problem or
diagnosis.
PQRSTU P- proactive or palliative: what brings it on? what makes it
better or worse?
Q- quality or quantity: how does it look, feel, sound,
intense/severe
S- severity scale: (1-10), getting better or worse?
T- timing: onset, duration, frequency
U- understand patient's perception: what do you think it
means?
pain 1-10 scale, everyone tolerates it different, different types are
treated differently, it is what the patient says it is, nurse needs
Nursing Assessment Final Exam
COMPLETE QUESTIONS AND
SOLUTIONS GRADED A+
Terms in this set (124)
subjective data what the patients says
objective data what you observe or collect, IPPA
4 categories to assess in patient 1) physical
2) mental/
psychosocial
3)orientation/cognition
4)behavior
database components objective, subjective, health history, diagnostics
complete database complete health history and a full physical examination
problem-centered database limited or short-term problem, concerns mainly one problem
of focus
follow-up database follow up with short-term or chronic health problems
emergency database rapid collection or the data, compiled concurrently with
lifesaving measures
priorities A- airway ALWAYS NUMBER ONE PRIORITY
B- breathing
C- circulation/cardiac problems
V- vital sign concerns
IPPA normal and abdomen inspection, palpation, percussion, auscultation
abdomen= inspection, auscultation, palpation, percussion
inspect use this 80% of the time! size, skin, appearance, respirations,
smell, health habits, first whole body and then do systems,
compare left to right sides, use all your senses
palpate texture, temperature, moisture, organ location, organ size or
shape, swelling, vibrations, pulsation, rigidity, lumps or masses,
tenderness, pain, guarding, facial expressions of pain
, palpation techniques use gloves and calm gentle approach, warm hands and
stethoscope, palpate tender areas last, light (1-2cm) to deep
(5-8cm), circular motion.
fingertips- skin texture, swelling, pulsations, lumps
grasping- position, shape, consistency of
organ back of hand- temperature
fingerbase- vibration
percussion quick, striking hit between knuckles under fingernail. short and
sharp strokes. indirect with finger or direct on body or blunt
with hand and fist.
resonant medium-loud, low pitch, clear and hollow, moderate duration,
over normal lung tissue.
hyperresonant louder, lower pitch, booming, longer duration, abnormal in
adult, over lungs with increased amount of air.
tympany loud, high pitch, musical and drum like, sustained longest
duration, over air-filled viscus (stomach or intestine)
dull soft, high pitch, muffled thud, short duration, dense organs as
in the liver or spleen
flat very soft, high pitched, dead stop of sound, very short
duration, no air is present, over thigh muscles or bone or
tumor.
auscultation never over clothes or gown! heart vessels, lungs, abdomen.
diaphragm for high-pitch sounds, breath, bowel, normal heart.
bell for low-pitch sounds, extra heart sounds or murmurs.
health history sequence 1) biographic
2) reason for seeking care
3) present health or history of present illness
4)past history
5) family history
6) review of systems
7) functional assessment of ADL's
nurse & medical history difference nurses plan for discharge and medical is for the problem or
diagnosis.
PQRSTU P- proactive or palliative: what brings it on? what makes it
better or worse?
Q- quality or quantity: how does it look, feel, sound,
intense/severe
S- severity scale: (1-10), getting better or worse?
T- timing: onset, duration, frequency
U- understand patient's perception: what do you think it
means?
pain 1-10 scale, everyone tolerates it different, different types are
treated differently, it is what the patient says it is, nurse needs
