NURS 143 STUDY GUIDE WITH
COMPLETE SOLUTION
Primary source of data - ANSWER Subjective data acquired directly from patient.
secondary source of data - ANSWER data acquired from another individual (such as
a family member)
tertiary source of data - ANSWER medical records
other health care providers
subjective data - ANSWER things a person tells you about that you cannot observe
through your senses; symptoms
objective data - ANSWER information that is seen, heard, felt, or smelled by an
observer; signs
Order of physical examination/ phys assessment - ANSWER 1. Inspection
2. Palpation
3. Percussion
4. Auscultation
Order of physical examination of abdomen - ANSWER 1. Inspection
2. Auscultation
3. Percussion
4. Palpation
order of abdomen palpation - ANSWER start on right lower clockwise
,Diaphragm of stethoscope - ANSWER flat endpiece of the stethoscope used for
hearing relatively high-pitched heart sounds
Bell of stethoscope - ANSWER cup-shaped end piece used for soft, low-pitched
heart sounds - vascular
Senses of the body - ANSWER Smell, taste, touch, hearing, sight
Percussion of abdomen - ANSWER percuss 3 times in each quadrant listening for
tympany
The stationary hand (percussion) - ANSWER Hyperextend the middle finger and
place its distal joint and tip firmly against the persons skin. Avoid ribs and scapulae.
Bones do not produces no data because it always sounds dull.
The striking hand (percussion) - ANSWER Use the middle finger of your dominant
hand as the striking finger. Action is all in the wrist, and it must be relaxed! Aim for
just behind the nail bed, the goal is to hit the portion of the finger thats hardest on
the surface. You need a strong percussion stroke for someone who is obese.
What are the 5 percussion tones? - ANSWER 1. Amplitude - loudness/softness of a
sound
2. Pitch - # of vibration per second
3. Quality - subjective difference in a sound's distinctive overtones
4. Duration - length of time the note lingers
environmental scan - ANSWER an analysis of outside influences that may have an
impact on an organization
when can a baby sit w/o support - ANSWER 6 months
when does a baby become aware of surrondings - ANSWER 9-12 months
when can a child understand signs? - ANSWER 1-2 yrs
,Holistic Assessment - ANSWER Focuses on the whole work activities rather than
specific elements
health screenings - ANSWER a specific physical problem or assess cognition, mood,
and functional status.
complete health assessment - ANSWER nursing history, behavioural, and physical
examination, and a cultural assessment.
complete physical examination - ANSWER head-to-toe review of each body system
that offer objective information about the patient.
Systematic Assessment - ANSWER organized method of collecting data, medical hx,
visiting reason, and phys assessment findings
comprehensive assessment - ANSWER a patient's physical status through
observation, the measurement of vital signs and self-reported symptoms. It includes
a medical history, a general survey and a complete physical examination.
medical history, a general survey and a complete physical examination.
order of pt care - ANSWER 1. health hx
2. phy exam/assessment
focused assessment - ANSWER assessment conducted to assess a specific problem;
focuses on pertinent history and body regions
complete examination - ANSWER Includes a thorough summary of all the
components of the assessment
health promotion examination - ANSWER preventive screenings, depending on the
patient's age or health risk.
When to do a focused assessment - ANSWER first if issue is there
when are observations from assessment completed? - ANSWER afterwards
, patient record - ANSWER a compilation of a patient's health information; the patient
record is the only permanent legal document that details the nurse's interactions
with the patient
Hybrid Chart - ANSWER A patient's medical record that is in both electronic and
paper format
narrative notes (narrative format) - ANSWER a paragraph indicating the contact
with the patient, what was done for the patient, and what outcomes resulted in 3rd
person
SOAP - ANSWER subjective, objective, assessment, plan
EX:
S: "I'm worried about the surgery. Last time I had a lot of pain when I
got out of bed."
O: Asking multiple questions about how postoperative pain will be
addressed.
A: Anxiety related to perceived threat of postoperative pain as
evidenced by statement of prior experience with uncontrolled
postoperative pain.
P: Explain routine postoperative analgesic plan of care. Encourage to
inform nursing staff as soon as possible if pain is not relieved. Explain
rationale for early postoperative ambulation and demonstrate TCDB
exercises. Provide teaching booklet on postoperative care
PIE - ANSWER Problem—Intervention—Evaluation
COMPLETE SOLUTION
Primary source of data - ANSWER Subjective data acquired directly from patient.
secondary source of data - ANSWER data acquired from another individual (such as
a family member)
tertiary source of data - ANSWER medical records
other health care providers
subjective data - ANSWER things a person tells you about that you cannot observe
through your senses; symptoms
objective data - ANSWER information that is seen, heard, felt, or smelled by an
observer; signs
Order of physical examination/ phys assessment - ANSWER 1. Inspection
2. Palpation
3. Percussion
4. Auscultation
Order of physical examination of abdomen - ANSWER 1. Inspection
2. Auscultation
3. Percussion
4. Palpation
order of abdomen palpation - ANSWER start on right lower clockwise
,Diaphragm of stethoscope - ANSWER flat endpiece of the stethoscope used for
hearing relatively high-pitched heart sounds
Bell of stethoscope - ANSWER cup-shaped end piece used for soft, low-pitched
heart sounds - vascular
Senses of the body - ANSWER Smell, taste, touch, hearing, sight
Percussion of abdomen - ANSWER percuss 3 times in each quadrant listening for
tympany
The stationary hand (percussion) - ANSWER Hyperextend the middle finger and
place its distal joint and tip firmly against the persons skin. Avoid ribs and scapulae.
Bones do not produces no data because it always sounds dull.
The striking hand (percussion) - ANSWER Use the middle finger of your dominant
hand as the striking finger. Action is all in the wrist, and it must be relaxed! Aim for
just behind the nail bed, the goal is to hit the portion of the finger thats hardest on
the surface. You need a strong percussion stroke for someone who is obese.
What are the 5 percussion tones? - ANSWER 1. Amplitude - loudness/softness of a
sound
2. Pitch - # of vibration per second
3. Quality - subjective difference in a sound's distinctive overtones
4. Duration - length of time the note lingers
environmental scan - ANSWER an analysis of outside influences that may have an
impact on an organization
when can a baby sit w/o support - ANSWER 6 months
when does a baby become aware of surrondings - ANSWER 9-12 months
when can a child understand signs? - ANSWER 1-2 yrs
,Holistic Assessment - ANSWER Focuses on the whole work activities rather than
specific elements
health screenings - ANSWER a specific physical problem or assess cognition, mood,
and functional status.
complete health assessment - ANSWER nursing history, behavioural, and physical
examination, and a cultural assessment.
complete physical examination - ANSWER head-to-toe review of each body system
that offer objective information about the patient.
Systematic Assessment - ANSWER organized method of collecting data, medical hx,
visiting reason, and phys assessment findings
comprehensive assessment - ANSWER a patient's physical status through
observation, the measurement of vital signs and self-reported symptoms. It includes
a medical history, a general survey and a complete physical examination.
medical history, a general survey and a complete physical examination.
order of pt care - ANSWER 1. health hx
2. phy exam/assessment
focused assessment - ANSWER assessment conducted to assess a specific problem;
focuses on pertinent history and body regions
complete examination - ANSWER Includes a thorough summary of all the
components of the assessment
health promotion examination - ANSWER preventive screenings, depending on the
patient's age or health risk.
When to do a focused assessment - ANSWER first if issue is there
when are observations from assessment completed? - ANSWER afterwards
, patient record - ANSWER a compilation of a patient's health information; the patient
record is the only permanent legal document that details the nurse's interactions
with the patient
Hybrid Chart - ANSWER A patient's medical record that is in both electronic and
paper format
narrative notes (narrative format) - ANSWER a paragraph indicating the contact
with the patient, what was done for the patient, and what outcomes resulted in 3rd
person
SOAP - ANSWER subjective, objective, assessment, plan
EX:
S: "I'm worried about the surgery. Last time I had a lot of pain when I
got out of bed."
O: Asking multiple questions about how postoperative pain will be
addressed.
A: Anxiety related to perceived threat of postoperative pain as
evidenced by statement of prior experience with uncontrolled
postoperative pain.
P: Explain routine postoperative analgesic plan of care. Encourage to
inform nursing staff as soon as possible if pain is not relieved. Explain
rationale for early postoperative ambulation and demonstrate TCDB
exercises. Provide teaching booklet on postoperative care
PIE - ANSWER Problem—Intervention—Evaluation
