UWEC Nurs. 267 Exam 1 Review

What is the most important principle related to physical exams?

maintaining safety of the patient and the nurse

When assessing HEENT, what kind of findings may vary in different cultures? What differences might you see in the mouth?

Why do nurses use evidence-based practice (EBP)?

because the recommendations are based on research, clinical experience, and patient preferences

What does EBP include?

observation, assessment, evaluation, documentation

What is the nursing process? Why do nurses use it?

it’s a problem-solving tool used to identify and manage a patient’s health care needs

What are the phases of the nursing process?

Assessment, diagnosis, planning, implementation, evaluation

What is the purpose of Assessment?

gathering data for the patient

What is the purpose of diagnosis?

using clinical judgment to interpret clinical findings

What is the purpose of planning?

formulate goals and outcomes in collaboration with the patient

What is the purpose of implementation?

put the plan in place

What is the purpose of Evaluation?

recheck and determine if the outcome was achieved

What are some actions of nursing clinical judgement? Identifying priority problems, noticing changes in a patient’s status, assessing data about a situation, generating possible solutions, making decisions based on implications of patient situations

In any culture what should be done?

ask permission prior to touching a patient

Dring the nursing interview what kind of data is collected?

subjective (what the patient says) and Objective (what is obtained through assessment)

What should be remembered during the interviewing process?

keep note taking to a minimum

Why should note taking be kept low?

it breaks eye contact, and takes attention away from the patient

What are some therapeutic methods to interviewing?

facilitation, silence, reflection/ echoing, empathy, clarification, confrontation, interpretation, explanation, and summery

How should the nursing interview be closed?

should be gradual, don’t introduce new topics, provide a final statement, and what is going to happen next

What should be remembered when doing a interview with an older adult?

typically the interview will take longer, because they have lived a longer life, and maybe slower at remembering information

What acronym is used for clear concise effective communication transfer?

SBAR

What does SBAR stand for?

situation, background, assessment, and recommendation

What is a normal temperature?

98.6F of 37C

Where can the temperature be taken?

oral, temporal, tympanic, or rectal

What is a normal resting pulse for a adult?

50-95 bpm

What does it mean if someone’s pulse is 0?

absent

What does it mean if someone’s pulse is 1+?

weak/thready

What does it mean if someone’s pulse is 2+?

normal

What does it mean if someone’s pulse is 3+?

full/ bounding

What is bradycardia?

resting pulse less than 50 (expect for athletes)

What is tachycardia?

resting pulse more than 100

What is normal respirations in an adult?

10-20 breaths/ min

What is the primary prevention in BP?

education

What are some markers of pain?

bracing and guarding

What eye chart do you use to test visual acuity distance?

Snellen Chart

What chart would you use if your patient didn’t read or speak English?

Snellen E chart

What test is used to assess near vision?

Jaeger or Rosenbaum test

What does the cardinal fields of gaze test?

extra ocular eye movements

What is normal pupillary reflex?

both pupils should constrict in response to bright light

How do you maneuver an adult ear if you want to look into it with an otoscope?

up and back

How do you maneuver a child’s ear if you want to look into it with an otoscope?

down and forward/out

What should a normal ear look like on the inside?

tympanic membrane should be gray, pearly, and slightly concave

What are some signs someone can’t hear during interview?

patient is lip reading, leaning forward, turning head to one side

How do I document normal findings to light response to the eyes?

Pupils are equal, round and reactive to light and accommodation, cardinal fields of gaze are intact

How do I document normal findings for the nose?

nose symmetrical in the middle of face, with no deformities or lesions, nares patent, bilaterally, septum midline

What technique is used if you are going to use an otoscope to look up the nose?

When looking up the nose with an otoscope make sure to avoid touching the septum, as well don’t insert the otoscope up the nose too far

What are some signs/symptoms of dehydration that you can notice in the mouth?

deep fissures in the tongue, cracked lips, thickened saliva, dry mouth

What is the primary exam technique for hair/skin/nails?

inspection

How can you check the skin for dehydration?

can pinch a fold of skin on the top of the hand or by the clavicle. If the skin stays tented this can indicate severe dehydration.

What is the acronym for the warning signs of skin cancer?

ABCDEF

What does the acronym ABCDEF stand for in checking for skin cancer?

Asymmetry, border irregular, color variation, diameter greater than 6mm, elevation, funny looking

The acronym for skin cancer can help to identify a potentially aggressive form of skin cancer which is called ___?

melanoma

What is the most important environmental risk factors for skin cancer?

Ultraviolet (UV) Radiation

What does a nail angle larger than 160 indicate?

clubbing

What does clubbing indicate?

chronic hypoxia

Nurses are the ______ of _______ against medication errors

Last line, defense

What are the 5 rights of medication administration?

Medication, Dose, Patient, Time, and Route

The nurse has a “hunch” the patient’s elevated BP is due to their pain level, however, the patient received BP and pain medication 45 min ago. What should the nurse consider regarding the “hunch”? and state why.

a. Research supports that pain and blood pressure medication will take 30 min to become effective. The nurse should wait until the next prescribed time and reevaluate the pain level.

b. The nurse should consider consulting with pain management team to evaluate the effectiveness of the pain management regimen.

c. The nurse should disregard the hunch because hunches are not effective at incorporating evidence-based practice.

d. The nurse should administer pain medication based on the hunch

b. this takes a collaborative approach and gives multiple people to back up the hunch

A patient is crying and says, “Please get me something to relieve this pain” What should the nurse do next? and state why

 a. Verify that the patient has an order for pain medication and administer as directed

b. Assess the level of pain and give pain medication according to pain level and reassess pain

c. Reposition patient, then reassess pain level after intervention

d. Assess the level of pain and ask the patient what usually works for their pain, administer pain medication as needed, then reassess pain level.

d. the patient must be a active participant in their medical treatment and decisions

What must the nurse assess first when providing culturally competent health care to an Asian American patient? and state why.

a. The tradition of the Asian American culture and the health care practices r/t health and wellness

b. The nurse’s heritage-based culture, values, beliefs, attitudes and practices

c. Any differences between the nurse’s culture and the Asian American culture

d. The attitudes of Asian American cultures to the health care system of the United States

b. nurses must first be able to determine what biases or differences exist first before caring for another culture

when do you perform hand hygiene?

before and after each patient