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NUR-275 EXAM 1 QUESTIONS AND CORRECT ANSWERS
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NUR-275 EXAM 1 QUESTIONS AND CORRECT ANSWERS...
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NUR-275 EXAM 1 QUESTIONS AND CORRECT ANSWERSwhat is holistic assessment
looks at whole person; includes physical, emotional, mental, social, etc
4 types of nursing physical exam
inspection (looking), auscultation (listening), palpation (feeling), percussion (tapping)
inspection (looking)
head-to-toe. tools: penlight, cm ruler, tongue depressor
auscultation (hearing)
listening to sounds of heart, lungs, stomach, intestines, and arteries. tools: stethoscope
and doppler
what are the 2 parts of a stethoscope and what are they used for?
diaphragm (larger): high-pitched, breathing, heart, bowel.
bell (smaller): low pitched, extra heart sounds, murmur
doppler
ultrasound device for blood flow and circulation sounds
palpation (feeling)
using dorsal (back) side of hand to feel areas of body (temp/moisture/etc). tools: gloves,
cotton applicator (to test for sensation)
percussion (tapping)
quick tapping to determine vibrations and sounds (can determine density- fluid/air/solid)
phases of nursing process
assessment, analysis, planning, implementation, evaluation
assessment
nurse gathers subjective and objective data
subjective data
symptoms patient reported
, objective data
measurements and observations
analysis
anaylize data to develop plan of care
planning
collab between nurse, client, and sometimes family; uses evidence-based practice
What is evidence based practice?
based on clinical research, trends, and client preferences
Implementation
closely monitor progress
evaluation (of each step)
evaluate if effective and achievable goals/adjustments must be made. (communication is
very important).
framework for interviewing
ISBARR
I- Identity (who, name/title)
S- Situation (what are the circumstances
B- background (data)
A- assessment (vital signs and other data)
R- recommendations (suggestions)
R- read back orders (verify)
phases in interviewing
1. introductory phase (state your name)
2. information gathering phase
3. closing phase (summary, answer questions, thank)
General assessment: appearance
facial features, emotional state, eye contact, level of consciousness, skin
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