Nursing Assessment Essentials PDF

Nursing Assessment Essentials Question Answer What are the three common types of nursing assessments? 1. Emergency: life-threatening or unstable situation (Based on A, B...

Nursing Assessment Essentials Question Answer What are the three common types of nursing assessments? 1. Emergency: life-threatening or unstable situation (Based on A, B, C, D, E). 2. Comprehensive: complete health history and physical assessment performed annually for outpatients or upon hospital/ long-term care admission. 3. Focused: occurs in all settings, smaller in scope but with increased depth for specific issues. Define cultural competence in healthcare. Cultural competence is a complex combination of knowledge, attitudes, and skills healthcare providers use to deliver care that considers the total context of the patient's situation across cultural boundaries. Why is knowledge of cultural diversity essential for competent Knowledge of cultural diversity is essential because it allows nursing practice? healthcare providers to recognize and respect the differences in beliefs, practices, and values of patients from various backgrounds. What are subjective cues in a health assessment? Subjective cues are the primary source of information from the patient, including their verbal and nonverbal communication, feelings, and personal experiences. What are objective cues in a health assessment? Objective cues are measurable information obtained through observations, such as vital signs, auscultation, and visual appearance. What is the purpose of documentation in nursing? Documentation is essential for establishing a baseline, meeting HIPAA requirements of confidentiality, fulfilling legal requirements, and facilitating communication with other providers for collaborative care. What are the various forms and formats of documentation used Common formats include SOAP (Subjective, Objective, in nursing? Assessment, Plan) and SBAR (Situation, Background, Assessment, Recommendation). What are the characteristics of effective therapeutic Effective therapeutic communication includes caring, empathy, communication? and the ability to establish a nurse-patient relationship that is complex, ongoing, and interactive. List some important nonverbal communication skills in nursing. 1. Physical appearance. 2. Facial expression. 3. Posture and positioning in relation to the patient. 4. Gestures and eye contact. 5. Voice tone and use of touch. What are some nontherapeutic responses that should be avoided 1. False reassurance. in patient communication? 2. Sympathy. 3. Unwanted advice. 4. Biased questions. 5. Changes of subject. 6. Distractions. 7. Technical or overwhelming language. 8. Interrupting. What are the basic techniques used in health assessment? 1. Inspection: what is seen. 2. Palpation: what is felt. 3. Percussion: what is heard by tapping. 4. Auscultation: what is heard through a stethoscope. What is the purpose of inspection in a health assessment? The purpose of inspection is to gain an overall impression of the patient and assess the severity of the situation by consciously observing the patient and gathering data. Question Answer What are the characteristics to look for during an inspection? Characteristics to observe include: 1. Physical characteristics and behavior. 2. Odor. 3. Age and gender. 4. Level of alertness. 5. Body size and shape. 6. Skin color. 7. Hygiene. 8. Posture. 9. Level of comfort or anxiety. What types of sounds can be identified through percussion? Percussion tones include: 1. Flat. 2. Dull. 3. Resonant. 4. Tympanic. The characteristics assessed include intensity, pitch, duration, and quality. What is the primary purpose of auscultation in nursing The primary purpose of auscultation is to listen to sounds of assessments? movement from organs and tissues to assess their function. What are the descriptors used during auscultation? Descriptors include: 1. Intensity. 2. Pitch. 3. Duration. 4. Quality. Examples of sounds are crackles, gurgles, swooshing, knocking, and rhythmic sounds. What is the purpose of using an ophthalmoscope in An ophthalmoscope is used to visualize the interior structures of assessments? the eye. What is the purpose of the medical record in healthcare? The medical record serves as a legal document that can be used in civil or criminal courts for evidence, and it is essential for documenting patient care. What is HIPAA and what does it require regarding patient HIPAA, or the Health Insurance Portability and Accountability Act, information? requires the protection of specific health information, ensuring that clients' health information remains private. What does the acronym ABCDE stand for in skin assessment? ABCDE stands for: 1. Asymmetry. 2. Border. 3. Color. 4. Diameter. 5. Evolution. What does visual acuity refer to? Visual acuity refers to the clarity or sharpness of vision, often assessed using a Snellen chart. What are the three distinct portions of the ear? The ear consists of three distinct portions: 1. External ear (auricle, external auditory canal, tympanic membrane). 2. Middle ear (contains ossicles and connects to the eustachian tube). 3. Inner ear (responsible for sound translation and maintaining equilibrium). What cranial nerve is responsible for the sensory function of the The Facial Nerve (Cranial Nerve VII) is responsible for sensory face and mouth? function related to the face and mouth. What are common symptoms associated with nose and sinus Common symptoms include facial pressure, pain, headache, assessment? nasal congestion, epistaxis (nosebleeds), and halitosis. Question Answer What are the subjective data collection components in thorax and Subjective data collection includes: lung assessment? 1. Past medical history. 2. Lifestyle and personal habits. 3. Occupational history. 4. Environmental exposures. 5. Medications. 6. Family history. What techniques are utilized in the assessment of the thorax and Techniques include inspection of the client, palpation of the lungs? chest, chest expansion assessment, tactile fremitus, percussion of the chest, and auscultation. What are the components of the anterior chest examination? Inspection, Palpation, Auscultation. What are the components of the posterior chest examination? Inspection, Palpation, Tactile fremitus, Symmetric Expansion, Percussion, Auscultation. What are common subjective data to collect during a Chest pain, Dyspnea, Cough, Fatigue, Edema, Nocturia, comprehensive physical assessment? Palpitations. What are the components of the carotid arteries assessment? Inspection, Palpation, Auscultation. What does the precordium assessment identify? Rate and rhythm, S1 and S2, Extra heart sounds, murmurs. What are the types of joints classified in the musculoskeletal Fibrous (synarthrotic), Cartilaginous (amphiarthrotic), Synovial assessment? (diarthrotic). What are the main joints assessed in the musculoskeletal Temporomandibular joint (TMJ), Shoulder, Elbow, Wrist and assessment? hand, Hip, Knee, Ankle, Foot, Spine. How is muscular strength documented? Having the client push and pull against resistance from the examiner, bilaterally, in upper and lower extremities. What cultural variations and health disparities exist regarding African Americans are 2 times more likely to die from a stroke stroke risk? than White Americans. Hispanics and Native Americans also have increased risk, while Asian Americans are less affected. What is the recommended functional status by the Office of Walk up to 10 steps without resting, sit for about 2 hours, reach Minority Health? overhead, use fingers to grasp or handle small objects, lift or carry something about 4 kg (10 lb), go out to participate in social activities. What are the cranial nerves and their functions? I Olfactory - Smell; II Optic - Pupillary response; III Oculomotor - Consensual pupillary response; IV Trochlear; V Trigeminal - Clench jaw; VI Abducens - Follow my finger and then to your nose; VII Facial - Smile, puff, and raise eyebrows; VIII Vestibulocochlear - Did patient follow directions/hear?; IX Glossopharyngeal - Move tongue side to side; X Vagus - Say 'ah' with uvula elevating and midline; XI Spinal Accessory - Shrug shoulders and move head side to side with resistance; XII Hypoglossal - Stick out tongue. What are the priority urgent assessments for significant changes Acute change in mental status, Unexplained changes in in neurological status? consciousness, Seizure activity/posturing, Pupil size changes/ decreased reactivity to light in one or both pupils, Progressing weakness or paralysis (unilateral), Changes in ability to identify sensation, Significant changes in vital signs. What advanced practice assessments are mentioned? Deep Tendon Reflexes, Weber and Rinne tests with tuning fork, Phalen Test. What assessment is performed to assess Level of Glasgow Coma Scale (scores range from 3 to 15). Consciousness (LOC)? What is the acronym for identifying a patient with a possible F.A.S.T. stroke? What are the F.A.S.T. warning signs of a stroke? F - Face Drooping (one side of the face droop or numbness); A - Arm Weakness (one arm weak or numb); S - Speech Difficulty (speech slurred); T - Time to call 911 (stroke is an emergency). Question Answer What is ptosis? Drooping of the eyelid. What is dysphagia? Difficulty swallowing. Who is most at risk for having a stroke? Individuals aged 55 or older, male, African American, with hypertension, smoking, consuming more than 3 alcoholic drinks per day, and obstructive sleep apnea (OSA).