The Nursing process correct answers ADPIE (assessment, diagnosis, planning, implementation,
evaluation)
hand hygiene is correct answers the single most important component to reduce risk of infection
steps of assessment process correct answers inspection, palpation, percussion, auscultation,
inspection correct answers physical exams begin with
palpation correct answers use of hands to feel texture, size, shape, consistency, location of certain
parts, and identify painful tender areas
palmar surface of fingers and finger pads are more sensitive than correct answers fingertips
palmar surface of finger and finger pads are better to determine correct answers texture, size,
consistency, masses, fluid, and crepitus
ulnar surface of hand to fifth finger is most sensitive to correct answers vibration
dorsal surface is better for assessing correct answers temperature
light palpation accomplished by correct answers pressing to a depth of approx. 1cm
light palpation used to assess correct answers skin, pulsations, and tenderness
,deep palpation accomplished by correct answers pressing to a depth of 4cm with one or two
hands
organ size and contour correct answers deep palpation used to determine
bimanual technique correct answers palpation uses both hands, one anterior and one posterior, to
entrap an organ or mass between two fingertips to assess shape and size
light palpation should always procede correct answers deep palpation because deep palpation
may cause tenderness or disrupt fluids
percussion is performed to correct answers eval, size, borders, consistency of internal organs,
detect tenderness, determine extent of fluid in body cavity
direct percussion correct answers strike finger/hand directly against patients body, eval adult
sinus by directly tapping fingers on sinus, elicit tenderness over kidney by striking costovertebral
angle (CVA) directly with fist
indirect percussion correct answers requires both hands, methods cab vary by system being
assessed,
5 percussion tones correct answers tympany, resonance, hyperresonance, dullnes, flatness
tympany correct answers is loud, high pitched sounds heard over abdomen
resonance correct answers heard over normal lung tissue
dullness correct answers heard over liver
, flatness correct answers heard over bones and muscle
auscultation correct answers listening to sounds within body; commonly use stethoscope
sphygmomanometer correct answers consists of gauge to measure pressure, a cuff enclosing an
inflatable bladder, and bulb with valve used to inflate and deflate bladder within cuff
ophthalmoscope correct answers is an instrument consisting of series of lenses, mirrors, and light
apertures to inspect internal eye structures
otoscope correct answers consists of magnification lens, light source, and speculum inserted into
auditory canal to inspect canal and tympanic membrane
tuning fork correct answers has two purposes auditory screening and assessment of vibratory
sensation
auditory screening correct answers high pitched tuning fork with frequency of 500-1000 hertz
(Hz) should be used to estimate hearing loss in range of normal speech
assessment of vibratory sensation correct answers for neurologic vibratory eval, a pitch between
100-400Hz should be used sharply strike running fork on heel of hand to engange tuning fork
percussion of reflex hammer correct answers used to test deep tendon reflexes
doppler correct answers uses ultrasonic waves to detect and amplify difficult to hear vascular
sounds such as fetal heart tones and peripheral pulses, resulting sounds nurses hear is swishing
pulsating sound
goniometer correct answers determines degree of flexion or extension of joint, two-piece ruler
jointed in middle with a protractor-type measuring device