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Nurs 503 Exam 1theoretical
Foundations Of Nursing Exam Questions
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Describe how and why we perform Health Assessments
It is a methodical way by systems- head-to-toe assessment
Completed when patient comes in with problem/used to gather data to lead to a diagnosis/health screenings
Describe the Nursing Process, including key components of assessment, diagnosis, and prioritizing for the plan of care
Assessment
Diagnosis
Planning
(Including outcome identification)
Implementation
Evaluation
Discuss how EBP may be used in health care
The emphasis on research, experience, patient preference and assessment (subjective/objective data)
Describe the key components of a complete health history
Biographical data
Source of history (reliability)
Reason for seeking care (chief compliant)
History of Present Illness or Present Health
Past Health (Past Medical History)
Family Medical History
Review of Systems
Functional Assessment (including Social History)
Describe core components of nursing documentation
Subjective Data (History - What the patient says)
Objective Data (Physical exam findings
Laboratory or diagnostic test results)
Assessment (Nursing diagnoses)
Plan (what the nurse will do)
*Ideal Documentation - be thorough, concise, use appropriate terminology.
*Be truthful and factual, use 5 senses - Do NOT say "normal", say "Lung sounds are CLEAR"
Peripheral resistance (BP increases-constricted, BP decreases- dilated/relaxed)
Identify the risk factors for hypertension
Unmodifiable: family history, age, gender, race, chronic kidney disease
modifiable: exercise, diet, obesity, alcohol, sleep apnea, high cholesterol, diabetes, smoking, stress
Discuss the appropriate steps in taking a BP
- Patient should be comfortable and relaxed with both feet flat on the ground
- Measure arm with 40% width and 80% length of arm-to-cuff ratio
- Palpate brachial artery. Evenly wrap deflated cuff 1 inch above brachial artery.
- Palpate brachial artery, inflate cuff until artery pulsation is unable to be heard. Add 20-30 mmHg to that number.
5.Deflate cuff quickly and completely. Wait 15-30 seconds before re-inflating.Place diaphragm of stethoscope over brachial artery.
- Rapidly inflate cuff to the maximal level that you determined.
- Deflate slowly but evenly.
- Note when you hear first sound (systolic) and last sound (diastolic).
what can cause a false reading when taking a BP?
The wrong cuff size:
too large (Low BP)
too small (High BP)
Discuss importance of using patients terminology when recording the CC(chief complaint) versus making a diagnosis. What is the difference?
Patient's terminology is typically the symptoms they're experiencing. Sometimes patients try to self diagnose (i.e. "I have strep throat"), but it is important to ask about their signs/symptoms rather than giving a medical diagnoses as that may not be the diagnoses.
Ad hoc interpreter
using a patient's family member, friend, or child as interpreter for a patient with limited English proficiency
Confrontation
response in which examiner gives honest feedback about what he or she has seen or felt after observing a patient action
Elderspeak
infantilizing and demeaning language used by health professional
Ethnocentrism
the tendency to view your own way of life as the most desirable, acceptable, or best to act in a superior manner
instrument that illuminates the ear canal, enabling examiner to look at ear canal and tympanic membrane
Normal Range BP
BP < 120/
Abnormal Range BP
Prehypertension: 120-129 / <
Stage 1: 130-139 / 80- 89
Stage 2: ≥ 140/ ≥ 90
Hypotension: < 95 / 60
Orthostatic hypotension: laying - > standing looking for a decrease in SBP by 20 and DBP by 10, increased Pulse
Normal Temperature Ranges
Oral: 96.4-99.1 F
Rectal & Tympanic: 0.5-1.0 F higher than oral
Axillary & Temporal: 0.5-1.0 F lower than oral
98.6 F = 37 C
Abnormal Temperature Ranges
Hypothermia <95 F
Hyperthermia >99.5 F
Normal Ranges for HR
50 - 95 bpm
Abnormal Ranges for HR
Bradycardia <50 bpm
Tachycardia >100 bpm
Normal Ranges for RR
12 - 20 rpm
Obese adults: 12-22 rpm
Abnormal Ranges for RR
Bradypnea ≤ 10 rpm
Tachypnea ≤ 24 rpm
Normal Ranges for spO
95 - 99%
NANDA nursing diagnosis statement component
- Problem-Focused Diagnosis: _______ related to _______ as evidenced by ______.
- Risk: Risk for ______ as evidenced by _______.
- Health Promotion: Readiness for _______ as evidenced by _________.
CNL's role R/T nursing health assessments
- CNL works on interdisciplinary teams, act as collaborator for the patient
- Ensures patients and families have all the info and understanding to facilitate informed patients
Describe the nursing process including key components of assessment, diagnosis, and prioritizing
Assessment: interpret subjective and objective data
Diagnosis: 3 types (problem-focused, risk, or health promotion)
Prioritize:
1st level priority: ABCV (Airway, Breathing, Cardiac, Vital signs)
2nd level: Safety or Infection risks
3rd level: Lacking quality of life
