Questions and Answers
What type of data is primarily based on the patient's perception and cannot be measured directly?
Which physical assessment technique is utilized for assessing high-pitched sounds?
What is the primary reason for organizing a physical assessment in a 'head-to-toe' approach?
Which statement correctly reflects the OLDCARTS assessment method?
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Which vital sign is considered abnormal when it falls below 60 bpm?
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What assessment technique is primarily used to evaluate body odor during a general survey?
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What condition is assessed when a patient exhibits signs of being hunched over?
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What is the 'gold standard' method for assessing pain in patients?
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What is the total cholesterol level that should ideally be below?
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Which heart chambers are separated by the mitral valve?
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What does a pulse amplitude of +3 or +4 indicate?
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What should you do if you are unable to palpate a peripheral pulse?
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What does the mnemonic F.A.S.T. represent in neurological assessments?
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What is assessed when using the PERRLA acronym?
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Which chart is typically used to assess visual acuity?
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At what level of consciousness is a person considered to be at their lowest while still alive?
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What is low blood pressure commonly referred to as?
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What is a normal range for oxygen saturation in a healthy individual?
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What is a common name for fluid-filled lesions that are less than 1 cm?
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Which BMI range is classified as obese?
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What is the term for a low respiratory rate?
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Which of the following indicates signs of acute respiratory distress?
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What is the common term for skin lesions caused by a pressure injury?
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What visual acuity representation denotes perfect vision?
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What response is expected when assessing the Achilles reflex?
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How long should you listen to confirm the absence of bowel sounds?
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What is the correct definition of adduction?
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What does lordosis describe?
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What should be considered when performing a self-breast exam?
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What describes jaundice?
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What should you assess in addition to breast tissue during a self-breast exam?
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What is a common characteristic of kyphosis?
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What is the purpose of percussion of the costovertebral angle (CVA)?
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In prioritizing patient care, which concern should be addressed first?
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When recalling the cranial nerves, why is it important to know both the name and the number?
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What aspect should a nurse remember when conducting an assessment based on the nursing process?
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What is an important consideration when reading assessment questions?
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Which of the following concerns should still be evaluated after addressing an acute respiratory issue?
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Study Notes
General/Miscellaneous/Assessment Techniques
- Subjective data: Patient-reported information like pain level, feelings, or experiences.
- Objective data: Measurable facts, e.g., vitals and laboratory results.
- Physical assessment techniques include inspection, palpation, percussion, and auscultation.
- Bell of the stethoscope detects low-pitched sounds; diaphragm captures high-pitched sounds like heart and lung sounds (S1/S2).
- Equipment for head-to-toe assessment includes a stethoscope, sphygmomanometer, thermometer, and penlight.
- Organizing physical assessments "head-to-toe" ensures systematic evaluation and prevents missed findings.
- Recommended order: General survey, neurological, cardiovascular, respiratory, gastrointestinal, musculoskeletal, skin assessments.
- Start with general survey before specific body system assessments.
- Therapeutic communication techniques enhance patient comfort and trust.
Pain Assessment
- OLDCARTS and PQRST assess pain characteristics and impact.
- They do not evaluate patient's emotional or psychological history.
- The gold standard for pain assessment is self-reporting.
- Inability to self-report due to cognitive impairment necessitates observational pain assessment, monitoring non-verbal cues.
- Symptoms of acute pain include increased heart rate, hypertension, and facial grimacing.
General Survey, Vitals, & Nutritional Assessment
- General survey's purpose is to assess overall health status and identify potential areas of concern.
- Components include appearance, body structure, posture, and hygiene.
- Normal heart rate ranges from 60-100 beats per minute; bradycardia refers to a rate below 60, tachycardia above 100.
- Normal blood pressure is usually under 120/80; hypotension refers to values below 90/60.
- Avoid placing blood pressure cuffs over areas with lymphedema or injury.
- Normal oxygen saturation is above 95%; normal respiratory rate is 12-20 breaths per minute.
- BMI classifications: normal (18.5-24.9), underweight (below 18.5), overweight (25-29.9), obese (30 and above).
- Nutritional assessment includes dietary history, lifestyle choices, and anthropometric measurements.
Skin/Hair/Nails
- Functions of skin: protection, sensation, thermoregulation, and vitamin D synthesis.
- Fluid-filled lesions <1 cm are called vesicles; pressure ulcers may cause ulcerative lesions.
- The ABCDE mnemonic for suspicious nevi involves Asymmetry, Border irregularity, Color variation, Diameter > 6mm, and Evolving changes.
Head, Eyes, Ears, Neck, & Throat
- Assess facial sinuses via palpation and percussion, the latter involving tapping.
- External ear assessment includes inspection and otoscopy.
- Normal findings: head should be normocephalic, symmetrical; visual acuity should be 20/20.
Respiratory
- Signs of acute respiratory distress include use of accessory muscles, cyanosis, and altered mental status.
- Chronic pulmonary disease may present with wheezing and clubbing.
- Tactile fremitus assessment reveals equal vibrations in healthy lungs.
- Crackles sound like popping or bubbling; rhonchi are low-pitched, wheezing is high-pitched and indicates airflow obstruction.
- COPD patients should avoid smoking, maintain a healthy weight, and engage in regular exercise to enhance lung function.
Cardiovascular
- Assessment sequence: inspection, palpation, percussion, and auscultation.
- Ideal total cholesterol level should be below 200 mg/dL.
- Apical pulse located at the fifth intercostal space; separated by the mitral valve.
- Peripheral pulse amplitude normal between +2 to +3; absent (0), weak (+1), or bounding (+3 or +4) indicate different conditions.
- Carotid pulse assessed at the neck; radial at the wrist; femoral, popliteal, posterior tibial, and dorsalis pedis are assessed in lower extremities.
- Irregular pulses require further assessment, possibly using an EKG if unable to palpate.
Neurological & Musculoskeletal
- F.A.S.T: Face drooping, Arm weakness, Speech difficulties, Time to call emergency services.
- Each cranial nerve has specific functions: tested using various assessments including visual acuity, smell, and sensation.
- PERRLA: Pupils Equal, Round, Reactive to Light and Accommodation; requires penlight for assessment.
- Deep tendon reflexes tested with a reflex hammer; Achilles reflex should show plantar flexion.
- Range of motion movements include adduction (moving toward the body), abduction (moving away), flexion (decreasing angle), and extension (increasing angle).
- Spinal deformities: lordosis (inward curve), kyphosis (outward curve), scoliosis (lateral curvature).
Abdomen & Rectum/Anus
- Client should empty bladder before abdomen assessment.
- Sequence: inspection, auscultation, percussion, and palpation.
- Jaundice indicates liver dysfunction caused by excessive bilirubin.
- Striae are stretch marks; not typically concerning unless associated with other symptoms.
- Confirm bowel sounds' absence only after listening for 5 minutes; normal findings: 5-30 bowel sounds per minute.
- Costovertebral angle percussion assesses kidney health; tenderness may indicate inflammation.
- Assess painful areas last when palpating the abdomen. Hemorrhoids are swollen veins causing rectal symptoms.
Breast & Lymphatic
- Self-breast exams recommend monthly during the same time each month, preferably a few days after menstruation.
- Position patient comfortably; assess breast tissue, underlying structures, and lymph nodes.
- Normal lymph node findings include non-tender, mobile nodes. Abnormal findings may include fixed or enlarged nodes.
Older Adult
- Older adults may need additional time and accommodations for assessments due to slower processing and sensory deficits.
- Age-related findings may include changes in skin elasticity, decreased peripheral circulation, and altered mobility.
Tips
- Always start with assessment per nursing process.
- Recall the assessment sequence consistently to streamline care.
- Know both names and numbers of cranial nerves for effective recall.
- Prioritize issues using ABCs: address airway and breathing concerns first.
- Distinguish between objective and subjective data during assessments to enhance accuracy.
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Description
Prepare for the NUR 216 final exam with this comprehensive study guide focusing on assessment techniques and data classification. Understand the difference between subjective and objective data, and familiarize yourself with the various physical assessment tools and techniques critical for nursing professionals.
