Questions and Answers
During a prone examination, what should a nurse assess with light palpation?
Texture and masses
Why is the lithotomy position used for assessing the female rectum and vagina?
To enable easy access to the relevant anatomical structures
What is a key challenge in performing deep palpation on the posterior thorax in elderly patients?
Cardiovascular problems
What should a nurse be cautious about when conducting a bimanual deep palpation?
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Why is the lithotomy position noted to be uncomfortable for some elderly individuals?
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Symmetry is an essential aspect to observe during examination. What does it refer to in this context?
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Odors are an important part of assessment. What could indicate an abnormal odor during an examination?
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Location plays a crucial role in assessment. Which statement best describes the importance of assessing location?
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Size assessment is critical during examinations. What aspect does assessing size primarily help determine?
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Sounds are part of the assessment process. What kind of sounds might a nurse pay attention to when examining a client?
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Study Notes
Nursing Process
- Nursing process is a treatment based on clinical judgment and knowledge that a nurse performs to enhance patient outcomes
- It involves five phases: assessment, diagnosis, planning, implementation, and evaluation
Assessment
- Involves collecting data about the client's health status through various methods such as inspection, palpation, percussion, and auscultation
- Types of assessment: initial, ongoing, and terminal
- Vital signs to be assessed: temperature (36.5-37.2°C), pulse rate (60-100 bpm), and respiration rate (16-20 breaths/min)
- Factors affecting vital signs: activity, talking, chewing gum, and anxiety
Diagnosis
- A clinical judgment about a client's health problem
- Example: asthma, cerebrovascular accident, amputation, appendicitis
Planning
- Deliberative and systematic phase involving decision-making and problem-solving
- Involves setting goals and outcomes, and designing a nursing care plan (NCP)
- NCP is the blueprint of the nursing process, involving individualized care for the client
Implementation
- The "doing" phase, involving direct and indirect care interventions
- Direct care: treatments performed through interaction with the patient, e.g., medication administration, vital sign checking
- Indirect care: treatments performed away from the patient, e.g., safety and infection control, delegating nurse care
- Types of interventions: dependent, collaborative, and interdependent
Evaluation
- The final step of the nursing process, assessing the client's response to nursing care and the effectiveness of the NCP
- Types of evaluation: ongoing, initial, and terminal
- Crucial to determine if the patient's condition has improved or worsened after application of the first four steps of the nursing process
