NURS 251 EXAM 1 questions with correct answers

assessment the systematic process of gathering, verifying, and communicating data 4 types of assessment initial comprehensive, ongoing, focused, emergency initial comprehensive assessment occurs when client first presents to health care system, overall picture, subjective and objective data ongoing/partial assessment after comprehensive, reassessment of initial problem of baseline, looking for improvement/deterioration focused/problem assessment occurs in relation to specific health concern emergency assessment rapidly when life saving action needs to be taken, immediate diagnosis to begin treatment subjective data info stated by patient objective data directly observed by examiner inspection the use of senses to observe the general status of the client palpation use of touch and feel to identify types of palpation light - less than one cm moderate - 1-2 cm deep 2.5-5 cm percussion discrimination of sounds produced when striking the hand over different organs and cavities direct percussion 1-2 fingertips blunt percussion nondominant hand flat on organ, dominant hand hits nondominant hand indirect percussion most common, tap finger on other finger percussion sounds resonance, hyperresonance, tympanic, dull, flat resonance air in lung hyperresonant emphysematous (a lot of air) tympanic air in gastric region (abdomen) dull thud like, solid organ (liver) flat extreme dullness (thigh) auscultation listening for sounds of movement within body (stethoscope) diaphragm of stethoscope flat surface, conducts high pitched sounds bell of stethoscope domed surface, conducts low pitched sounds body temperature difference between heat production and heat loss range for temperature 36.5-37.7 degrees C 96.9-99.9 degrees F pulse shock wave produced by blood pumped from heart as it travels through artery pulse range 60-100 bpm for adults pulse characteristics rate, rhythm, amplitude, elasticity respiration range 12-20 breaths per minute tachypnea greater than 24 breaths per minute bradypnea less than 10 breaths per minute blood pressure pressure exerted on the walls of the arteries when the ventricles contract and relax systolic range 90-120 diastolic range 60-80 pain