Health Assessment-Jarvis Chapter #29

Rather than a complete head-to-toe physical examination every 24 hour, the hospitalized patient requires?

A consistent, specialized examination that focuses on specific parameters at least every 8 hours. Many assessments must be done frequently during a shift. The initial assessment helps you get to know the patient and notice anything that will need ongoing monitoring.

As you enter the room, verify any markers or flags:

At the doorway that indicate isolation precautions, latex allergies, or other conditions. Introduce yourself, and ask how the person spent the previous shift, and if there is any pain or discomfort.
Verify that the patient's name is correct on the identification band. Refer to what you heard from the previous shift.
Confirm settings on any analgesia pumps, and confirm intravenous solutions for rate and type. Wash your hands in the patient's presence.

Note the patient's general appearance, including:

Facial expression, level of consciousness, and body position. Note skin color and tone, nutritional status, and personal hygiene.

Measure baseline vital signs including:

Temperature, pulse, respirations, and blood pressure.
Note any pulse oximetry readings.
Ask the patient to rate his or her pain.
If pain medication was given, note response depending on route of administration.

Assess the neurologic system:

Assessing motor responses and verbal responses. Examine the right and left pupils, noting their size and reaction.
Assess sedation and the ability to communicate and swallow.

Focusing on the respiratory system by verifying:

The mode and fraction of inspired oxygen administration, the respiratory effort, and the breath sounds. Observe for cough, and note any mucus produced.

To assess the cardiovascular system, begin with:

Auscultation of rhythm and heart sounds. Check capillary refill and assess for edema. Palpate pulses of lower extremities.

Quantify the risk of skin breakdown.

Examine the skin, assessing color, skin temperature, and turgor. Inspect skin integrity, and observe the intravenous site and surrounding skin. Observe any dressings and their condition.

Assess the abdomen:

Noting its contour and bowel sounds in all four quadrants.
Check any drains for color and amount of drainage.
Inquire whether passing flatus or stool.
Know diet orders, and determine tolerance.

Perform a genitourinary assessment:

Inquiring whether voiding regularly. If the patient has an indwelling urinary catheter, check the urine color and clarity. Use a bladder scanner if indicated

Assess activity, knowing the specific orders:

Assess for ambulatory aid or equipment as indicated.
Ensure that sequential compression devices, TED hoses, or other devices are applied and working properly.
Quantify the risk of falling.

After the assessment, evaluate your findings:

Initiating or continuing the plan of care. Note any clinical findings that require immediate attention.

Document your findings:

For written documentation, use the SOAP acronym (Subjective data, Objective data, Assessment, and Plan).

To communicate your findings verbally:

Use the SBAR acronym (Situation, Background, Assessment, and Recommendation).

Most hospitals and clinics use a basic or comprehensive electronic health record system in place of?

A paper medical record, which maintains all relevant patient information in an easily accessible electronic system.

Electronic health records allows all providers to?

Access information, place orders, and receive timely patient status updates.

Which finding would require immediate action by the nurse if found during the physical assessment?

Oxygen saturation of 88%
Oxygen saturation of 88% represents a critical result and requires immediate action.
Systolic blood pressure of 152 mm Hg does not require immediate action, but the nurse should continue to monitor.
Heart rate of 60 beats per minute is still within normal limits.
Respirations of 20 are within normal range.

A nurse is evaluating the neurologic system of a patient. Which assessment would be included in the neurologic examination?

Observe the patient for ptosis.
Observation if the patient has ptosis (drooping of the eyelid) is part of a neurologic examination.
Checking the patient for borborygmi (hyperactive bowel sounds that are associated with the stomach making audible rumbling sounds) would be included in the gastrointestinal examination.
Asking the patient if he or she has experienced nausea or vomiting would be included in the gastrointestinal examination.
Checking capillary refill would be included in the cardiovascular examination.

A patient has a urinary catheter. Which assessment should be done each time vital signs are taken on the patient?

Observing the color of the output
The nurse should observe and note the color of the output at each vital sign check.
Emptying the drainage bag is required at change of shift and when the bag is too full according to protocol.
Repositioning the catheter should be done if there is evidence of occlusion or decreased urinary flow.
There is no need to add additional water into the system each time the vital signs are taken Because this could lead to increased pressure in the system.

Which priority action should the nurse take when performing an initial assessment of pain status of a patient who is receiving pain control via patient-controlled analgesia (PCA)?

Ask the patient to rate his or her pain on a numeric scale of 1 to 10.

The priority action would be to assess the patient's pain status at the present time so as to provide a baseline for future assessment and to determine if the present method is providing relief.

Confirming that the correct IV fluid is hanging is required; it is not the priority action at this time.
The nurse will have to review the history profile on the PCA, but it is not the priority action at this time.
Although the nurse may have to position the patient for comfort, it is not the priority assessment at this time.

The nurse is calling the health care provider about a patient's changing condition. Which of the following would be included in the SBAR communication?

Situation, background, assessment, and recommendation
SBAR communication stands for situation, background, assessment, and recommendation.

Which of the following patients should the nurse assess first?

A 48-year-old patient with shortness of breath and pulse oximeter reading of 88%
The nurse should use the ABCs to determine which order to assess the patients. The nurse should assess the 48-year-old patient with respiratory problems first (shortness of breath and pulse oximeter reading of 88%). The 52-year-old patient with an elevated white blood cell count should be assessed last. The 59-year-old patient with chest pain should be assessed second. The 89-year-old patient who is confused should be assessed third because of the confusion and risk for a fall or injury.

The nursing assistant takes the vital signs for the 12 patients on the unit. Who is responsible for interpreting the results?

The registered nurse assigned to the patient(s) should interpret the vital signs.
The registered nurse assigned to the patient(s) is responsible for interpreting the results. The registered nurse is also responsible for delegating vital signs and for supervising the nursing assistant.

The nurse administers an intravenous dose of pain medication. The nurse should reassess the patient in:

15 minutes.
After an intravenous dose of pain medication, the nurse should reassess the patient in 15 minutes. If the pain medication was oral, the nurse should reassess the patient in 60 minutes.

What is an advantage for using SBAR during staff communication?

Improves verbal communication and reduces medical errors
SBAR improves verbal communication and reduces medical errors. SBAR communication is concise and focused; SBAR does not include a complete patient health history. SBAR communication is concise and focused; SBAR communication does not include a comprehensive physical examination. SBAR communication includes "R," which is making recommendations.

The hospitalized patient does not require a full neurologic examination during every shift assessment. Which of the following may be a way of assessing the neurologic status of the hospitalized patient?

Offer the client a glass of water.

Offering the patient water is not only a courtesy but also it is an opportunity for the nurse to note the physical data: the person's ability to hear, follow directions, cross the midline, and swallow.

Unlicensed assistive personnel can?

ambulate a patient with lower extremity weakness.
detect adventitious breath sounds.
observe a change in skin lesion quality.
assess for electrolyte imbalances.

ambulate a patient with lower extremity weakness.

Unlicensed assistive personnel can assist a patient with activities of daily living such as ambulation

A 40-year-old male patient has cellulitis of the left lower extremity and no history of health problems. Which of the following findings would need further evaluation?

Calluses on both hands
Receding hairline
2+ pedal pulses bilaterally
Irregular pulse

Irregular pulse

An irregular pulse is an abnormal finding and warrants further evaluation.

An 80-year-old patient admitted with chest pain is on a monitored unit. The hearing for this patient should initially be assessed by:

normal conversation.
tuning fork tests.
the whispered voice test.
audiometric testing.

normal conversation.

During the first contact with the patient (general survey or appearance), the nurse should assess the patient's ability to hear a normal tone of voice. If the patient is not able to hear a normal tone of voice, further testing may be indicated such as the whispered voice test or audiometric testing.

A hospitalized patient has pneumonia. Which of the following assessments would not be indicated in this patient?

Swallowing assessment
Assessment of passive range of motion
Cardiac auscultation
Pain assessment

Assessment of passive range of motion

The nurse would not assess passive range of motion; the nurse should assess the patient's ability to turn in bed, dangle at the bedside, sit in a chair, and ambulate. In addition, the nurse should assess the patient's need for any ambulatory aids or equipment and the patient's risk for falling.