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Questions and Answers
What is the characteristic chest appearance of a person with barrel chest?
What is the characteristic chest appearance of a person with barrel chest?
Which condition is characterized by air in the pleural space?
Which condition is characterized by air in the pleural space?
What does the tripod position indicate about a person's breathing?
What does the tripod position indicate about a person's breathing?
Which condition involves the abnormal enlargement of airspaces in the lungs?
Which condition involves the abnormal enlargement of airspaces in the lungs?
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What does consolidation in the lungs indicate?
What does consolidation in the lungs indicate?
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What is the primary characteristic of erythema?
What is the primary characteristic of erythema?
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Which of the following is classified as a primary lesion?
Which of the following is classified as a primary lesion?
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During a turgor test, what is expected of the skin when pinched?
During a turgor test, what is expected of the skin when pinched?
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What defines a secondary lesion?
What defines a secondary lesion?
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What is the significance of the ABCDE of lesions when assessing skin lesions?
What is the significance of the ABCDE of lesions when assessing skin lesions?
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Which of the following is true about petechiae?
Which of the following is true about petechiae?
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What type of lesion is characterized by loss of superficial epidermis without extending to the dermis?
What type of lesion is characterized by loss of superficial epidermis without extending to the dermis?
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What does a hematoma represent?
What does a hematoma represent?
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What is the primary purpose of the initial assessment in the nursing process?
What is the primary purpose of the initial assessment in the nursing process?
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Which phase of the nursing interview entails ensuring that the client understands the interview process?
Which phase of the nursing interview entails ensuring that the client understands the interview process?
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What differentiates an ongoing assessment from an emergency assessment?
What differentiates an ongoing assessment from an emergency assessment?
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Which physical examination technique is primarily used to assess the size and density of organs?
Which physical examination technique is primarily used to assess the size and density of organs?
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During which phase of the interview does the nurse validate the problems and goals with the client?
During which phase of the interview does the nurse validate the problems and goals with the client?
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In what scenario would a problem-oriented assessment be most appropriate?
In what scenario would a problem-oriented assessment be most appropriate?
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Which of the following is NOT considered subjective data?
Which of the following is NOT considered subjective data?
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What is the primary focus of the evaluation step in the nursing process?
What is the primary focus of the evaluation step in the nursing process?
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What condition is characterized by drooping or paralysis on one side of the face?
What condition is characterized by drooping or paralysis on one side of the face?
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Which lymph node position is located beneath the earlobe?
Which lymph node position is located beneath the earlobe?
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Which of the following visual tests is specifically used for assessing near vision?
Which of the following visual tests is specifically used for assessing near vision?
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In the context of lymphadenopathy, which description indicates cancerous nodes?
In the context of lymphadenopathy, which description indicates cancerous nodes?
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Which condition is indicated by a 'moon-shaped' face with reddened cheeks?
Which condition is indicated by a 'moon-shaped' face with reddened cheeks?
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What is a common symptom of hyperthyroidism?
What is a common symptom of hyperthyroidism?
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Which of the following tests assesses color vision deficiencies?
Which of the following tests assesses color vision deficiencies?
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Which facial condition is characterized by suppressed features and hollow cheeks?
Which facial condition is characterized by suppressed features and hollow cheeks?
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What does a red macular rash that may progress to urticaria indicate?
What does a red macular rash that may progress to urticaria indicate?
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Which skin variation is characterized by depigmentation?
Which skin variation is characterized by depigmentation?
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What condition is described by greasy yellow-pink lesions on the scalp and forehead?
What condition is described by greasy yellow-pink lesions on the scalp and forehead?
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What skin condition is characterized by red scaly patches with sharp margins?
What skin condition is characterized by red scaly patches with sharp margins?
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Which of the following describes a common skin finding in newborns with African American, Native American, Hispanic, or Asian descent?
Which of the following describes a common skin finding in newborns with African American, Native American, Hispanic, or Asian descent?
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Which condition is indicated by red vesicles that rupture to form a honey-colored crust?
Which condition is indicated by red vesicles that rupture to form a honey-colored crust?
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What skin change occurs as a brownish-black line along the abdominal midline during pregnancy?
What skin change occurs as a brownish-black line along the abdominal midline during pregnancy?
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Which of the following is true about basal cell carcinoma?
Which of the following is true about basal cell carcinoma?
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Which of the following terms describes a condition where words are easily understood and louder over areas of increased density in the lungs?
Which of the following terms describes a condition where words are easily understood and louder over areas of increased density in the lungs?
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What is the respiratory rate defined as tachypnea?
What is the respiratory rate defined as tachypnea?
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What respiratory pattern is characterized by rapid, deep, labored breathing?
What respiratory pattern is characterized by rapid, deep, labored breathing?
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At what age should clinical breast exams start every three years?
At what age should clinical breast exams start every three years?
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What does the presence of stridor in infants typically indicate?
What does the presence of stridor in infants typically indicate?
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Which of the following changes may occur in the respiratory system of pregnant women?
Which of the following changes may occur in the respiratory system of pregnant women?
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What does the term 'hypoventilation' refer to?
What does the term 'hypoventilation' refer to?
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What should be observed during the retraction of the breast examination?
What should be observed during the retraction of the breast examination?
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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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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.
