Nursing Process (ADPIE) and Assessments
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Questions and Answers

What is the characteristic chest appearance of a person with barrel chest?

  • Chest shows an S-shaped curve.
  • Chest has a sunken sternum.
  • Chest appears rounded or puffed up. (correct)
  • Chest appears flat and elongated.

Which condition is characterized by air in the pleural space?

  • Bronchitis
  • Fibrosis
  • Pneumothorax (correct)
  • Atelectasis

What does the tripod position indicate about a person's breathing?

  • Difficulty in lung expansion. (correct)
  • Optimal breathing capacity.
  • Normal respiratory function.
  • Increased abdominal pressure.

Which condition involves the abnormal enlargement of airspaces in the lungs?

<p>Emphysema (A)</p> Signup and view all the answers

What does consolidation in the lungs indicate?

<p>Air-filled spaces are filled with fluid or materials. (A)</p> Signup and view all the answers

What is the primary characteristic of erythema?

<p>It indicates increased blood flow to the skin's blood vessels. (C)</p> Signup and view all the answers

Which of the following is classified as a primary lesion?

<p>Macule (D)</p> Signup and view all the answers

During a turgor test, what is expected of the skin when pinched?

<p>The skin returns to normal position rapidly. (C)</p> Signup and view all the answers

What defines a secondary lesion?

<p>It arises from changes in primary lesions. (D)</p> Signup and view all the answers

What is the significance of the ABCDE of lesions when assessing skin lesions?

<p>It helps in the identification of potential malignancies. (A)</p> Signup and view all the answers

Which of the following is true about petechiae?

<p>They result from blood extravasation. (A)</p> Signup and view all the answers

What type of lesion is characterized by loss of superficial epidermis without extending to the dermis?

<p>Erosion (A)</p> Signup and view all the answers

What does a hematoma represent?

<p>A localized collection of blood (B)</p> Signup and view all the answers

What is the primary purpose of the initial assessment in the nursing process?

<p>To collect subjective and objective data about the client’s health (D)</p> Signup and view all the answers

Which phase of the nursing interview entails ensuring that the client understands the interview process?

<p>Introductory phase (C)</p> Signup and view all the answers

What differentiates an ongoing assessment from an emergency assessment?

<p>Ongoing assessments are planned, while emergency assessments are unplanned (B)</p> Signup and view all the answers

Which physical examination technique is primarily used to assess the size and density of organs?

<p>Percussion (C)</p> Signup and view all the answers

During which phase of the interview does the nurse validate the problems and goals with the client?

<p>Closing phase (A)</p> Signup and view all the answers

In what scenario would a problem-oriented assessment be most appropriate?

<p>When a client has a specific health concern to discuss (A)</p> Signup and view all the answers

Which of the following is NOT considered subjective data?

<p>A nurse's observation of a rash (A)</p> Signup and view all the answers

What is the primary focus of the evaluation step in the nursing process?

<p>Revising the plan based on outcome criteria (A)</p> Signup and view all the answers

What condition is characterized by drooping or paralysis on one side of the face?

<p>Bell’s palsy (D)</p> Signup and view all the answers

Which lymph node position is located beneath the earlobe?

<p>Jugulodigastric node (D)</p> Signup and view all the answers

Which of the following visual tests is specifically used for assessing near vision?

<p>Jaeger Test (C)</p> Signup and view all the answers

In the context of lymphadenopathy, which description indicates cancerous nodes?

<p>Hard, unilateral, non-tender, and fixed (B)</p> Signup and view all the answers

Which condition is indicated by a 'moon-shaped' face with reddened cheeks?

<p>Cushing’s syndrome (B)</p> Signup and view all the answers

What is a common symptom of hyperthyroidism?

<p>Exophthalmos (D)</p> Signup and view all the answers

Which of the following tests assesses color vision deficiencies?

<p>Ishihara Test (C)</p> Signup and view all the answers

Which facial condition is characterized by suppressed features and hollow cheeks?

<p>Cachexia (B)</p> Signup and view all the answers

What does a red macular rash that may progress to urticaria indicate?

<p>Allergic drug reaction (C)</p> Signup and view all the answers

Which skin variation is characterized by depigmentation?

<p>Vitiligo (B)</p> Signup and view all the answers

What condition is described by greasy yellow-pink lesions on the scalp and forehead?

<p>Seborrheic dermatitis (B)</p> Signup and view all the answers

What skin condition is characterized by red scaly patches with sharp margins?

<p>Squamous Cell Carcinoma (B)</p> Signup and view all the answers

Which of the following describes a common skin finding in newborns with African American, Native American, Hispanic, or Asian descent?

<p>Mongolian spots (B)</p> Signup and view all the answers

Which condition is indicated by red vesicles that rupture to form a honey-colored crust?

<p>Impetigo (B)</p> Signup and view all the answers

What skin change occurs as a brownish-black line along the abdominal midline during pregnancy?

<p>Linea Nigra (D)</p> Signup and view all the answers

Which of the following is true about basal cell carcinoma?

<p>It is the most common type of skin cancer. (C)</p> Signup and view all the answers

Which of the following terms describes a condition where words are easily understood and louder over areas of increased density in the lungs?

<p>Bronchophony (C)</p> Signup and view all the answers

What is the respiratory rate defined as tachypnea?

<p>More than 24 breaths/min (C)</p> Signup and view all the answers

What respiratory pattern is characterized by rapid, deep, labored breathing?

<p>Kussmaul breathing (A)</p> Signup and view all the answers

At what age should clinical breast exams start every three years?

<p>In the 20s to 30s (B)</p> Signup and view all the answers

What does the presence of stridor in infants typically indicate?

<p>Upper airway obstruction (D)</p> Signup and view all the answers

Which of the following changes may occur in the respiratory system of pregnant women?

<p>Widening of the thoracic cage (D)</p> Signup and view all the answers

What does the term 'hypoventilation' refer to?

<p>Decreased rate, decreased depth, and irregular pattern (A)</p> Signup and view all the answers

What should be observed during the retraction of the breast examination?

<p>Movement symmetry during arm lifting (D)</p> Signup and view all the answers

Flashcards

Emphysema

An abnormal enlargement of airspaces in the lungs, leading to the destruction of alveolar walls without fibrosis.

Funnel Chest

A sunken sternum and adjacent cartilages (Pectus excavatum).

Pigeon Chest

A forward protrusion of the sternum causing the adjacent ribs to slope backward (Pectus carinatum).

Bronchospasm

Sudden tightening of the muscles surrounding the airways in the lungs, leading to a constriction of the airways.

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Consolidation

The air-filled spaces in the lungs are filled with fluid, pus, blood, or other materials, leading to a solid or opaque appearance on imaging tests like X-rays or CT scans.

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Erythema

Redness of the skin due to increased blood flow.

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Diaphoresis

Excessive sweating.

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Edema

Fluid accumulation in the intercellular spaces.

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Turgor Test

A test where you pinch up a fold of skin to check for dehydration.

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Primary Lesions

Lesions that arise from normal skin due to irritation or disease.

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Secondary Lesions

Lesions that arise from changes in primary lesions.

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Macule

A small, flat discoloration of the skin, less than 1 cm in size.

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Papule

A raised, solid bump on the skin, less than 0.5 cm in size.

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Assessment

The first step in the nursing process, it involves gathering information about the patient through subjective and objective data.

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Subjective Data

Information gathered from the patient's perspective, including their feelings, beliefs, and experiences.

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Objective Data

Information gathered through observation and tests, like vital signs and physical examination findings.

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Interview

A structured conversation between the nurse and patient to gather subjective data.

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Initial Assessment

The initial assessment performed at the start of patient care, encompassing all aspects of the patient's health history.

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Emergency Assessment

A quick and focused assessment performed in emergencies, addressing life-threatening concerns.

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Inspection

Using sight to observe the patient's physical appearance and behavior.

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Palpation

Using touch to assess texture, temperature, and tenderness.

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Bronchophony

Words are easily understood and louder over areas of increased density in the lungs.

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Egophony

Sound is louder and sounds like the letter 'A' during auscultation.

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Whispered Pectoriloquy

Whispered sounds are transmitted clearly and distinctly over the lungs.

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Tachypnea

More than 24 breaths per minute and shallow.

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Bradypnea

Less than 10 breaths per minute and regular.

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Hyperventilation

Increased rate and depth of breathing.

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Hypoventilation

Decreased rate, depth, and irregular pattern of breathing.

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Kussmaul breathing

Rapid, deep, and labored breathing.

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Freckle

A flat, small, pigmented macule that appears after sun exposure.

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Vitiligo

A loss of pigmentation in the skin, resulting in white patches.

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Basal Cell Carcinoma

A type of skin cancer that starts as a skin-colored papule and develops pearly borders with a red center. It is slow growing.

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Squamous Cell Carcinoma

A type of skin cancer that appears as a red, scaly patch with sharp margins. It is less common than basal cell carcinoma, but grows rapidly.

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Diaper Dermatitis

Red, moist, diffuse macular rash often seen in infants.

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Ringworm

A fungal infection that produces scales and can cause permanent hair loss.

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Measles (Rubeola)

Red macular/papular rash behind ears that spreads to the body.

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Linea Nigra

A brownish-black line that appears along the abdominal midline during pregnancy.

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What is Bell's Palsy?

A facial condition characterized by drooping, weakness, or paralysis on one side of the face.

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What is Acromegaly?

Enlargement of facial features like the nose, ears, hands, and feet, caused by excess growth hormone production after skeletal maturity.

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What is Cushing's syndrome?

A condition characterized by a moon-shaped face with reddened cheeks and increased facial hair, often caused by high levels of cortisol.

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What is Scleroderma?

A condition characterized by tightened and hard facial skin, often accompanied by thinning of the skin.

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What is Hyperthyroidism?

A condition characterized by bulging eyes, or exophthalmos.

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What are the characteristics of lymph nodes during acute infection?

Nodes are bilateral, enlarged, warm, tender and firm but moveable.

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What are the characteristics of lymph nodes due to cancer?

Nodes are hard, unilateral, non-tender and fixed.

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What are the characteristics of lymph nodes during chronic inflammation?

Nodes may be clumped and asymmetrical.

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Study Notes

Nursing Process (ADPIE)

  • Assessment: Collecting subjective and objective data
  • Diagnosis: Analyzing data to make a professional nursing judgment (diagnoses, collaborative problems, or referrals)
  • Planning: Determining outcome criteria and developing a plan
  • Implementation: Carrying out the plan
  • Evaluation: Assessing if outcomes were met and revising the plan as needed

Types of Assessments

  • Initial: Gathering complete subjective and objective data on a patient's health history, lifestyle, and physical examination.
  • Ongoing/Partial: Performed when a nurse has an encounter with a patient, usually after a comprehensive assessment
  • Focused/Problem-Oriented: Conducted when the patient has a specific concern and a comprehensive database already exists
  • Emergency: Rapid assessment in life-threatening situations

Steps of Health Assessment

  • Collection of Subjective Data:
    • Includes sensations, feelings, perceptions, desires, preferences, beliefs, ideas, values, and personal information.
    • The introductory phase explains interview purpose, confidential information, and notes taking.
    • The working phase elicits information about:
      • major biographical data
      • reason for seeking care
      • history of the present health concern
      • past health history
      • family history
      • review of body systems
      • lifestyle and health practices
      • developmental level
    • The closing phase summarizes information, and validates problems and goals.
  • Collection of Objective Data:
    • Obtained by observation and physical examination techniques.
    • Inspection, palpation, percussion, and auscultation are common physical exam techniques
  • Validating Data:
    • Verifying collected data's accuracy and reliability.
    • Techniques to validate include: rechecking, clarifying, verifying, and comparing data.
    • Ensures complete relevant data collection and avoids documentation of inaccurate data.

Pain

  • An unpleasant sensory and emotional experience.
  • Associated with tissue damage or both.
  • Involves central and peripheral nervous systems.
  • Nociceptors transmit signals to the CNS

Types of Pain

  • Acute: Recent onset, less than 6 months, usually associated with injury.
  • Chronic/Non-malignant: Persistent pain lasting more than 6 months associated with a specific cause or injury.
  • Cancer Pain: Resulting from nerve compression, damage, or tumor growth.

Vital Signs

  • Body Temperature:
    • Core temperature (internal body tissues): relatively stable
    • Surface temperature (skin, subcutaneous tissue): varies
    • Measured using rectal, oral, axillary, tympanic, or temporal.
  • Pulse Rate:
    • Reflects heartbeat, normal rate is 60-100 bpm (adults) and 80-180 bpm (newborns)
    • Types include peripheral, apical
    • Factors affecting pulse rate include age, sex, exercise, fever, medications, etc.
  • Respiratory Rate:
    • Measured in breaths per minute, normal range is 12-20 breaths/min
    • Types of respiration include external, internal, and factors affecting respiration.
  • Blood Pressure:
    • Pressure exerted by blood on blood vessel walls
  • Direct: Invasive, inserting a catheter
  • Indirect (Non-invasive): Based on auscultation (listening).

Body Temperature – Types of Fever

  • Intermittent fever
  • Remittent fever
  • Relapsing fever
  • Constant fever

Factors Affecting Heat Exchange

  • Conduction
  • Convection
  • Radiation
  • Evaporation

Assessing Skin, Hair, and Nails

  • General Appearance:
    • Includes color, temperature, moisture, turgor, lesions, rashes, turgor
  • Lesions: Classify lesions as primary or secondary based on formation
  • Hair: Assess for color, distribution, texture, and abnormalities
  • Nails: Assessment includes shape, color, texture, and abnormalities

Assessing the Head and Neck, Eyes

  • Inspect: Observe for symmetry in shape, appearance, and size and note any abnormalities
  • Palpate: Test for tenderness, pain, lumps
  • Eye Assessment: Include vision acuity testing, confrontation testing, and pupillary responses

Assessing the Mouth, Throat, Nose, and Sinuses

  • Inspect: Assess the overall appearance of the mouth, throat, nose, and sinuses
  • Palpate: Assess the tonsils, sinuses, and for tenderness, pain, and abnormal growths.

Assessing the Thorax and Lungs

  • Inspect: Note the chest wall's shape, symmetry, and breathing pattern
  • Auscultate: Listen for breath sounds, including vesicular and bronchial sounds.
  • Continuous and adventitious sounds should be described.
  • Percussion: Assess for resonance and detect abnormalities

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Related Documents

Health Assessment Lecture Notes PDF (NCM101LC, 2024-2025)

Description

Explore the crucial steps of the Nursing Process, known as ADPIE, which include Assessment, Diagnosis, Planning, Implementation, and Evaluation. This quiz also covers the various types of assessments nursing professionals conduct, from initial to emergency assessments. Test your understanding of these essential nursing concepts.

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