In order, the nursing process goes:
During which phase in the nursing progress should a nurse be documenting?
Assessment, Planning, and Evaluation.
Assessment, Diagnosis, Planning, and Evaluation.
Assessment, Diagnosis, Planning, Implementation, and Evaluation.
Establishing priorities, developing outcomes, setting timelines for outcomes, and identifying interventions are all a part of what step in the nursing process?
Check all that apply that are an example of subjective data:
The patient tells the nurse that they have a history of heart disease in their family.
The patient informs the nurse that their blood pressure was 130/95 when they went to their physician last month.
The patient heavily sighs while the nurse measures his height to be 6'0.
The patient makes an offhand comment about feeling lonely since her husband passed away.
The nurse measures the patient's pulse to be 80 bpm.
The patient recalls having the chicken pox as a child to the nurse.
What are the ways that a health professional gathers observational data?
Maslow's Hierarchy of Needs are generally a good guideline for nurses to follow when prioritizing care.
What is the ABC plus V rule used for?
Assessing high priority or first-level priority problems.
Assessing hair, skin, and nails.
Documenting properly using NANDA-!.
Remembering to be culturally competent.
Which of the following are used for evidence-based clinical decision making?
Evidence from research and evidence-based theories.
Physical examination and assessment of the patient.
Patient preferences and values.
Upholding long-standing examination traditions.
The Complete (Total Health) Database includes a complete health history and physical examination. It forms a baseline against which all future changes can be measured. It yields the first diagnosis.
Which type of database is used to evaluate any changes in the status of the patient at regular and appropriate intervals?
Complete (Total Health) Database.
Focused or Problem-Centered Database.
Poverty has the greatest influence on health status.
Which vulnerable population has the highest rates of drug-induced deaths, death from cirrhosis, death by poisoning, and chronic obstructive pulmonary disease?
What is the nurse's role in regard to patient spirituality?
Nurses may pray with a patient as long as they are comfortable.
Nurses must respect religious wishes, even if it means death.
Nurses should intervene in the event of negative religious coping.
Nurses need to understand a patient's cultural and religious beliefs.
The R-COPE can be given as a quick spiritual assessment of a patient and his or her coping of an event.
Health is defined as the _______ of the person, both within one's being and in the outside world.
Which of the following is NOT a common explanation of the cause of an illness?
Generally, how close should the nurse be to a patient with a cough during an interview?
0 -1 1/2 feet (Intimate Zone)
1 1/2 - 4 feet (Personal Distance)
4 - 12 feet (Social Distance)
12+ feet (Public Distance)
Generally, how close should the nurse be to a patient during the physical assessment?
0 - 1 1/2 feet (Intimate Zone)
1 1/2 - 4 feet ( Personal Distance)
4 - 12 feet (Social Distance)
12+ feet (Public Distance)
Which of the following are important when creating a comfortable atmosphere for the patient during an interview?
Being 9 to 10 feet away from the client.
Setting room temperature at a comfortable level.
Securing a quiet environment.
A nurse should try to write down everything a client says during an interview because a nurse cannot forget or lose important details.
Which is an example of a closed or direct question?
"Have you taken any medications in the last 48 hours?"
"How have you been feeling since your last appointment?"
"Tell me about your headaches."
"Can you describe the pain in your abdomen?"
Which of these is NOT a trap of interviewing a patient?
Providing false assurance or reassurance.
Giving unwanted advice.
Using "why?" questions.
Reflection by echoing client's words.
It is just as important to watch for nonverbal modes of communication during an interview as it is to listen to verbal communication.
Biographic Data includes:
Marital partner status.
A [blank_start]symptom[blank_end] is a subjective sensation that the person feels from the disorder.
A [blank_start]sign[blank_end] is an objective abnormality that you as the examiner could detect on physical examination or in laboratory reports.
Match the present health critical characteristic to it's definition:
[blank_start]Location[blank_end]: Be specific; ask the patient to point to the location.
[blank_start]Character or Quality[blank_end]: This calls for specific descriptive terms such as burning, sharp, dull, aching, gnawing, throbbing, shooting, viselike.
[blank_start]Quantity or Severity[blank_end]: Attempt to quantify the sign of symptom. Use a pain scale to quantify pain.
[blank_start]Timing[blank_end]: Onset, Duration, Frequency. When did the symptom first appear?
[blank_start]Setting[blank_end]: Where was the person or what was the person doing when the symptom started?
[blank_start]Aggravating or Relieving Factors[blank_end]: What makes the pain worse? What seemed to help?
[blank_start]Associated Factors[blank_end]: Is this primary symptom associated with any others?
[blank_start]Patient's Perception[blank_end]: Find out the meaning of the symptom by asking how it affects daily activities.
Character or Quality
Quantity or Severity
Aggravating or Relieving Factors
What does the mnemonic PQRSTU for asking patient perception of a symptom stand for?
P: [blank_start]Provocative[blank_end] or [blank_start]Palliative[blank_end]
Q: [blank_start]Quality[blank_end] or [blank_start]Quantity[blank_end]
R: [blank_start]Region[blank_end] or [blank_start]Radiation[blank_end]
Which of the following would a nurse generally NOT ask about in a past health events recall?
Accident or Injury
Serious or Chronic Illness
Match the observation of the component of the mental status exam to the definition:
[blank_start]Appearance[blank_end]: The patient is sitting erect and relaxed.
[blank_start]Thought processes[blank_end]: What the patient is saying makes sense.
[blank_start]Behavior[blank_end]: The patient is awake, alert, and aware of stimuli.
[blank_start]Cognition[blank_end]: Patient is oriented to time, place, and person.
Match the observation of the component of the mental status exam to the definition:
[blank_start]Cognition[blank_end]: The patient is able to complete a thought, able to recall recent and remote memories.
[blank_start]Thought processes[blank_end]: The patient is consistently aware of reality.
[blank_start]Behavior[blank_end]: The patient's facial expressions change appropriately and laryngeal speech is effortless.
[blank_start]Appearance[blank_end]: Body movements are voluntary and deliberate.
[blank_start]Affect[blank_end] is a temporary expression of feelings or state of mind.
[blank_start]Mood[blank_end] is the more durable, prolonged display of feelings that color the whole emotional life.
Mental status examination must be:
Inferred through assessment of an individual's behaviors.
Measured through quantifiable tests.
Completed by an expert in the field.
Learned through a lifelong pattern of behavior.
Match the mental status abnormal posture finding to it's definition:
[blank_start]Hyperthyroidism[blank_end] or [blank_start]anxiety[blank_end]: Sitting on edge of chair or curled in bed, tense muscles, frowning, darting and watchful eyes, and restless pacing.
[blank_start]Depression[blank_end] or [blank_start]some organic brain disease[blank_end]: Sitting slumped in chair, slow walk, dragging feet.
some organic brain disease
Match the mental status abnormal body movement finding to it's definition:
[blank_start]Schizophrenia[blank_end]: Abnormal posturing and bizarre gestures.
[blank_start]Depression[blank_end] or [blank_start]dimentia[blank_end]: Apathy and psychomotor slowing.
[blank_start]Anxiety[blank_end]: Restless, fidgety movement or hyper-kinetic appearance.
Match the Level of Consciousness to it's definition:
[blank_start]Obtunded[blank_end]: Sleeps most of the time; difficult to arouse - needs loud shout or vigorous shake; acts confused when aroused; speech may be mumbled or incoherent.
[blank_start]Alert[blank_end]: Awake or readily aroused; oriented, fully aware of external and internal stimuli and responds appropriately.
[blank_start]Stupor[blank_end]: Spontaneously unconscious; responds only to persistent and vigorous shake or pain; has appropriate motor response; otherwise can only groan, mumble, or move restlessly.
[blank_start]Lethargic[blank_end]: Not fully alert; drifts off to sleep when not stimulated; can be aroused to name when called in a normal voice but looks drowsy; responds appropriately but inattentive.
[blank_start]Coma[blank_end]: Completely unconscious; no response to pain or any external or internal stimuli.
[blank_start]Delirium[blank_end]: Clouding of consciousness; inattentive; incoherent conversation; impaired recent memory, often agitated and having visual hallucinations.
Match the screening to the definition:
[blank_start]GAD-7[blank_end]: Screen for core anxiety symptoms.
[blank_start]PHQ-2[blank_end]: Screen for depressed mood and anhedonia.
[blank_start]Denver II[blank_end]: Screen for detecting developmental delays in infants and preschoolers.
The Mini- Mental Status Examination (MMSE) scores what component of the mental examination?
All components of mental status.
How would the nurse document a patient who is alert but only cognitively aware of his or her name and current location?
Alert and oriented (X3).
Alert and oriented (X2).
Alert and oriented to name and place.
Alert and not oriented to time.
Which of the following is an available newly developed, reliable, quick, and easily available instrument to screen for cognitive impairment in otherwise healthy older adults?
Eugene, a 70 year old man, comes in to the hospital and has difficulty speaking. His speech sounds distorted and unintelligible. His basic language is intact. The nurse would note that he has what type of speech disorder?
Mary Sue, age 84, is a lifelong smoker. She has difficulty and discomfort and talking. Her voice sounds whispered, but articulation and language are intact. What kind of speech disorder does the nurse make a note of?
Match the type of aphasia to the condition:
[blank_start]Global aphasia:[blank_end] The most common and severe form. Spontaneous speech is absent or reduced to a few stereotyped words or sounds. Comprehension is absent or reduced to the person's own name and a few select words.
[blank_start]Broca aphasia[blank_end]: Expressive aphasia. The person can understand language but not express himself or herself using language. This is characterized by nonfluent, dysarthric, and effortful speech.
[blank_start]Wernicke aphasia[blank_end]: Receptive aphasia. The person can hear sounds and words but cannot relate them to previous experiences. Speech is fluent, effortless, and well articulated but has many paraphasias and neologisms and often lacks substantive words.
Match the abnormal mood and affect to the clinical example:
[blank_start]Flat affect[blank_end]: Topic varies, expression does not.
[blank_start]Fear[blank_end]: Fear of flying in airplanes.
[blank_start]Anxiety[blank_end]: "I feel nervous and high-strung. I worry all the time."
[blank_start]Lability[blank_end]: Person expresses euphoric, tearful, angry feelings in rapid succession.
[blank_start]Depersonalization[blank_end]: "I don't feel real. I feel like I'm not really here."
[blank_start]Rage[blank_end]: Person has expressed violence toward self or others.
[blank_start]Inappropriate affect[blank_end]: Laughs while discussing admission for liver biopsy.
[blank_start]Euphoria[blank_end]: "I feel on top of the world!"
[blank_start]Depression[blank_end]: "I've got the blues."
[blank_start]Ambivalence[blank_end]: A person feels love and hate toward another person at the same time.
[blank_start]Elation[blank_end]: "I'm feeling very happy."
[blank_start]Irritability[blank_end]: Person internalizes a feeling of tension, and a seemingly mild stimulus "sets him or her off"
Which type of anxiety disorder could a person with anxiety experience in a crowded train to work?
Social Anxiety Disorder.
Generalized Anxiety Disorder.
Match the correct mental disorder to the definition:
[blank_start]Delirium[blank_end]: An acute confusional state, potentially preventable in hospitalized persons. Characterized by disorientation, disordered thinking perceptions, defective memory, agitation, inattention.
[blank_start]Dementia[blank_end]: A chronic progressive loss of cognitive function and intellectual functions, although perception and consciousness are intact. Characterized by disorientation, impaired judgement, memory loss.
[blank_start]Depression[blank_end]: A long-term depressed mood, with a lack of pleasure; disturbed sleep and appetite; feelings of hopelessness, guilt, worthlessness, sadness, loneliness, and despair; suicide ideation.
Match the abnormal thought process to the clinical example:
[blank_start]Blocking[blank_end]: "Forgot what I was going to say."
[blank_start]Confabulation[blank_end]: Gives detailed description of his long walk around the hospital although you know patient remained in his room all afternoon.
[blank_start]Neologism[blank_end]: "I have to turn on my thinkilator."
[blank_start]Circumlocution[blank_end]: Says "the thing you open the door with" instead of "key".
[blank_start]Circumstantiality[blank_end]: "When was my surgery? Well I was 28, I was living with my aunt, she's the one with psoriasis, she had it bad that year because of the heat, the heat was worse then than it was the summer of '92..."
[blank_start]Loosening associations[blank_end]: "My boss is angry with me, and it wasn't even my fault. (pause) I saw that movie too, Lassie. I felt really bad about it. But she kept trying to land the airplane and she never knew what was going on."
[blank_start]Flight of ideas[blank_end]: "Take this pill? The pill is blue. I feel blue. (sings) She wore blue velvet."
[blank_start]Word salad[blank_end]: "Beauty, red-based five, pigeon, the street corner, soft of."
[blank_start]Perseveration[blank_end]: "I'm going to lock the door, lock the door. I walk every day, and I lock the door. I usually take the dog, and I lock the door."
[blank_start]Echolalia[blank_end]: Nurse, "I want you to take your pill." Patient (mocking), "Take your pill. Take your pill."
[blank_start]Clanging[blank_end]: "My feet are cold. Cold, bold, told. The bell tolled for me."
Flight of ideas
An illusion is a created sensory perception where there is none.
Hallucinations are sensory perceptions for which there are no external stimuli; may strike any sense.
Match the characteristics of an eating problem to the definition:
[blank_start]Bulimia Nervosa[blank_end]: Recurrent episodes of uncontrollable binging followed by inappropriate compensatory behaviors (vomiting, laxatives, diuretics).
[blank_start]Anorexia Nervosa[blank_end]: Intense fear of weight gain, restricted caloric intake.
[blank_start]Binge Eating[blank_end]: Recurrent episodes of uncontrollable binging without compensatory behaviors.
Where would you expect to hear the following characteristics of percussion notes?
[blank_start]Resonant[blank_end]: Over normal lung tissue.
[blank_start]Hyperresonant[blank_end]: Normal over child's lung (abnormal in adult), increased amount of air as in emphysema.
[blank_start]Tympany[blank_end]: Over air-filled viscus (stomach, intestine)
[blank_start]Dull[blank_end]: Relatively dense organ as lives or spleen.
[blank_start]Flat[blank_end]: When no air present, over thigh muscles or bone or over tumor.
The bell endpiece of the stethoscope is best for high-pitched sounds - breath, bowel, and normal heart sounds.
How should the nurse hold his or her hand when percussing?
Hyperextend middle finger on dominant hand only and pull all other fingers back.
Extend index, middle, and ring finger and tuck pinky and thumb.
Curl hand into fist and swing as hard as possible.
Extend index and middle finger, tuck all other fingers away.
When does the nurse wash his or her hands?
Before and after every physical patient encounter.
After contact with blood, bodily fluids, secretions, and excretions.
After contact with any equipment contaminated with bodily fluids.
After removing gloves.
The vital signs are:
Height and weight.
The nurse should be palpating and taking note of:
Rigidity or spasticity.
Presence of lumps or masses.
Presence of tenderness or pain.
Vibration or pulsation
What part of the hand is used for what part of palpation?
[blank_start]Fingertips[blank_end]: Fine tactile discrimination (skin texture, swelling, pulsation, lumps)
[blank_start]Fingers and thumb grasping[blank_end]: Detect position, shape, and consistency of an organ or mass.
[blank_start]Dorsa (backs) of hands and fingers[blank_end]: Determine temperature.
[blank_start]Base of fingers or ulnar surface of hand[blank_end]: Vibration.
Fingers and thumb grasping
Dorsa (backs) of hands and fingers
Base of fingers or ulnar surface of hand
If a waist circumfrerence of __ inches or more in women and __ inches or more in men, then that person is at higher risk for heart disease and type 2 diabetes.
Match the heart rate diagnosis to the definition:
[blank_start]Bradycardia[blank_end]: The adult has a resting heart rate of less than 50 beats/min.
[blank_start]Tachycardia[blank_end]: The adult has a resting heart rate of greater than 95 beats/min.
[blank_start]Sinus arrhythmia[blank_end]: The heart varies with the respiratory cycle, speeding up and slowing down.
Which forms of temperature measurement are considered core temperatures?
Tympanic membrane temperature.
The first sound heard after beginning to deflate the blood pressure cuff is the [blank_start]systolic[blank_end] pressure.
The last audible sound heard after deflating the blood pressure cuff is the [blank_start]diastolic[blank_end] pressure.
The pulse oximeter is a noninvasive method to assess the arterial oxygen saturation (SpO2).
The abnormal characteristics of pigmented lesions are summarized in the mnemonic ABCDE, which stands for:
Match the abnormal skin coloring to the definition:
[blank_start]Pallor[blank_end]: The skin takes on the color of connective tissue, which is mostly white.
[blank_start]Erthyema[blank_end]: Intense redness of the skin from excess blood in dilated superficial capillaries.
[blank_start]Cyanosis[blank_end]: Blueish mottled color from decreased perfusion.
[blank_start]Jaundice[blank_end]: A yellowish skin color indicates rising amounts of bilirubin in the blood.
Match the abnormal skin coloring to the condition it could indicate:
The patient is profusely sweating at the time of the interview. The nurse would note that the patient is currently undergoing what skin condition?
Edema is scored on a four-point scale. A score of 2+ would indicate what?
Mild pitting; slight indentation; no perceptible swelling of the leg.
Moderate pitting; indentation subsides rapidly.
Deep pitting; indentation remains for a short time; leg looks swollen.
Very deep pitting; indentation lasts a long time; leg is very swollen.
The nurse imprints with his or her thumb against a patient's ankle malleolus. It pits deeply and the indentation lasts for a short time. What score would the nurse give the patient?
Anasarca is what kind of edema?
The nurse palpates that the skin feels very smooth and soft, like velvet. This could be a sign of what?
What age group would the nurse expect to have cherry (senile) angiomas?
Adults older than 30 years.
A secondary lesion...
... develops on previously unaltered skin.
... changes over time or changes because of scratching or infection.
... develops as a result of being immunocompromised.
... is normal and part of the epidermis.
At what size should a client seek treatment for a growing pigmented lesion?
6 mm (the size of a pencil eraser).
2 mm (the size of a pencil tip).
10 mm (the size of a fingernail).
14 mm (the size of a dime).
Poor turgor suggests what?
The profile sign of a nail should be about what?
The nurse examines the capillary refill on a healthy-looking patient. What should he or she expect?
Instant or nearly instant refill.
1 to 2 seconds refill.
1 to 2 minutes refill.
25 to 35 seconds refill.
If a newborn has 6 or more of these spots, each more than 1.5cm in diameter, it is diagnostic of neurofibromatosis. What are the spots?
Cafe au lait spot.
Match the population at risk to the condition:
Neonates: [blank_start]permeable skin causes fluid loss[blank_end]
Pregnant Woman: [blank_start]Vascular spiders and striae[blank_end]
Older Adults: [blank_start]Senile lentigines[blank_end].
permeable skin causes fluid loss
Vascular spiders and striae
Match the description of the common shapes and configurations of lesions to the definition:
[blank_start]Annular[blank_end]: circular, begins in center and spreads to periphery
[blank_start]Confluent[blank_end]: lesions run together
[blank_start]Discrete[blank_end]: individual lesions that remain seperate
[blank_start]Gyrate[blank_end]: twisted, coiled spiral, snakelike
[blank_start]Grouped[blank_end]: clusters of lesions
[blank_start]Linear[blank_end]: a scratch, streak, line, or stripe
[blank_start]Target[blank_end]: iris, concentric rings of color in lesions
[blank_start]Zosteriform[blank_end]: linear arrangement along unilateral nerve route
[blank_start]Polycyclic[blank_end]: annular lesions grow together
When would be a perfect time to perform a skin assessment?
During bed bath time.
The entire time the nurse sees the patient.
When checking vital signs.
When conducting the interview.
Match the skin etiology to the observation:
[blank_start]Albinism[blank_end]: whitish, creamy, pink color throughout the integument.
[blank_start]Vitiligo[blank_end]: Patchy milky-white spots, often symmetric bilaterally.
[blank_start]Carotenemia[blank_end]: Yellow-orange tinge.
[blank_start]Uremia[blank_end]: Orange-green or gray overlying pallor of anemia.
[blank_start]Addison disease[blank_end]: Bronzed appearance, especially around trunk.
[blank_start]Cafe au lait spots[blank_end]: Tan to light brown, irregular shaped, oval patch.
Cafe au lait spots
What shape and configuration are urticaria (hives)?
Match the primary skin lesion to its definition:
[blank_start]Macule[blank_end]: Solely a color change, flat and circumscribed, less than 1 cm.
[blank_start]Papule[blank_end]: Something you can feel, solid, raised, circumscribed, less than 1 cm.
[blank_start]Patch[blank_end]: Macules that are larger than 1 cm.
[blank_start]Plaque[blank_end]: Surface elevation that is pleateaulike, wider than 1 cm.
[blank_start]Nodule[blank_end]: Solid, elevated, hard or soft, not fluid filled, larger than 1 cm.
[blank_start]Wheal[blank_end]: Superficial, raised, transient, and erythematous, slight irregular shape.
[blank_start]Tumor[blank_end]: Larger than a few cm's in diameter.
[blank_start]Vesicle[blank_end]: Elevated cavity containing free fluid, up to 1 cm.
[blank_start]Bulla[blank_end]: Larger than 1 cm diameter, fluid filled.
[blank_start]Cyst[blank_end]: Encapsulated fluid-filled cavity in dermis, elevating skin.
[blank_start]Pustule[blank_end]: Turbid fluid in the cavity. Circumscribed and elevated.
Match the secondary skin lesion to its definition:
[blank_start]Crust[blank_end]: Thickened, dried-out exudate left when vesicles/pustules dry up.
[blank_start]Scale[blank_end]: Compact, desiccated flakes of skin, dry or greasy, silvery or white.
[blank_start]Fissure[blank_end]: Linear crack with abrupt edges, deep into dermis.
[blank_start]Erosion[blank_end]: Scooped out but shallow depression.
[blank_start]Ulcer[blank_end]: Deeper depression extending into dermis, irregular shape.
[blank_start]Excoriation[blank_end]: Self-inflicted abrasion.
[blank_start]Scar[blank_end]: After tissue repair, collagen replaces normal tissue.
[blank_start]Atrophic scar[blank_end]: Skin level is depressed with loss of dermis.
[blank_start]Lichenification[blank_end]: Prolonged exposure to irritant thickens skin, becomes leathery.
[blank_start]Keloid[blank_end]: Excess of scar tissue beyond sites of injury.