2 tracks correct answers bedside: RN knows why client was
admitted; must review chart, assess current state, needs
clinic: RN does NOT know why client is present; must assess
current state, needs
2 types of assessment correct answers bedside: admission
history, RN asks everything, unit specific docs filled out2.
clinic: paperwork to fill out, RN asks some
4 types of data correct answers complete
focused or problem-centered
follow-up
emergency
5 factors of BP correct answers 1) cardiac output
2) vascular resistance
3) volume
4) viscosity
5) elasticity of arterial walls
ABCDE correct answers asymmetry, border, color, diameter,
elevation and enlargement
ABCDE rule correct answers Asymmetry
Border
Color
Diameter
Elevation and Enlargement
,achondroplastic dwarfism correct answers A genetic disorder in
converting cartilage to bone results in normal trunk size, short
arms and legs, and short stature.
relatively large head
midface hypoplasia, thoracic kyphosis, and lumbar lordosis
acrochordans correct answers skin tags; overgrowths of normal
skin that form a stalk and are poly-like
acrocyanosis correct answers Temporary cyanotic condition,
usually in newborns resulting in a bluish color around the lips,
hands and fingernails, feet and toenails. May last for a few hours
and disappear with warming.
acromegaly correct answers excessive secretion of growth
hormone from the pituitary gland after puberty creates an
enlarged skull and thickened cranial bones in adults and
extremities but no change in height
internal organs also enlarge and metabolic disorders may occur
actinic keratosis correct answers red-tan scaly plaques that
increase over the years to become raised and roughened
acute myocardial infarction symptoms correct answers
decreased cardiac output
hypotension
superficial blood vessels constrict to shunt blood to vital organs
cool and clammy skin
shoulder and jaw pain
,adult resp rate correct answers 14-20, depth, use of accessory
muscles to help breathe, retractions, for newborns/kids watch
abdomen rather than chest
alopecia areata correct answers Autoimmune disorder that
causes the affected hair follicles to be mistakenly attacked by a
person's own immune system; usually begins with one or more
small, round, smooth bald patches on the scalp.
annular correct answers circular shape to skin lesion
anthropomorphic measures correct answers Height
Weight
BMI
Waist-to-hip ratio
Waist circumference
Tricep skin fold
assessing legions correct answers Location
Color
Size
Pattern
Distribution
Exudate
Intention?
assessment skills correct answers Inspection
Palpation
Percussion
Auscultation
, atrophic scar correct answers the resulting skin level is
depressed with loss of tissue; a thinning of the epidermis
auscultation correct answers listening to sounds within the body
Stethoscope: use bell for soft/low pitched sounds/murmurs, and
use diaphragm for high pitch sounds like heart, bowel sounds,
lungs, ear pieces must be sloped pointing forward towards your
nose, fitting snugly
Sounds in the room
Hairy surface
Clothing
Cleaning
Temp
Learn normal first
auscultation correct answers Listening with a stethoscope
behavior correct answers facial expression, mood and affect,
speech, speech pattern, dress, personal hygiene
bitot spots correct answers Foamy plaques of the cornea that are
a sign of vitamin A deficiency
body structure correct answers stature, nutrition, symmetry,
posture, position, body build, contour
bp correct answers force required for heart to pump from
ventricles into arteries
Hypertension: Stage 1 is 130-139 OR 80-89 and Stage 2 is >140
OR >90