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HEALTH ASSESSMENT
E-HANDOUTS (CBRC)
1 CBRC E-Hand Out: HEALTH ASSESSMENT
Nurse Licensure Examination
Subject Fundamentals of Nursing
Topic Health Assessment
Subtopic Initial Data Gathering
Objective After reading this, you will be able to:
a. Determine the steps in in initial data assessment of clients seeking care
b. Develop the standard skills in communicating and establishing the nurse-patient relationship
Discussion
What is Health Assessment?
-Health Assessment is the data gathering of an individual in all aspects including the spiritual and emotional state.
What is the nurse’s role in health assessment?
-Advocate
A nurse advocate is a nurse who works on behalf of patients to maintain quality of care and protect patient’s rights. They
intervene when there is a care concern, and following the proper channels, work to resolve any patient care issues.
Steps in Data Assessment
1. Establish Rapport
2. Obtain Health History
3. Assess level of consciousness
4. Gather equipment needed
5. Perform Hand washing
Chief Complaint
In your patient’s own words, document the chief complaint. The chief complaint may be elicited by asking one of the following
questions:
● So, tell me why you have come here today?
● Tell me what your biggest complaint right now?
● What is bothering you the most right now?
● If we could fix any of your health problems right now, what would it be?
● What is giving you the most problems right now?
If your patient has more than one complaint, discuss which one is the most troublesome for them and document the complaints
in order of importance as determined by the patient (Jarvis,2012)
Present Health Status
Obtaining information about the present health status allows the nurse to investigate current complaints. The mnemonic PQRST,
utilizes a structured format for information gathering, including evaluation of pain, and provides an efficient methodology to
communicate with other healthcare providers. Use PQRST to assess each symptom and after any intervention to evaluate any
changes or response to treatment (Jarvis,2012).
PQRST
P= Provocative or Palliative-What makes the symptom(s) better or worse?
Q= Quality-Describe the symptom(s).
R= Region or Radiation -Where in the body does the symptom occur? Is there radiation or extension of the symptom(s) to
another area of the body?
S= Severity -On a scale of 1-10, (10 being worst) how bad is the symptom(s)? Another visual scale may be appropriate for
patients that are unable to identify with this scale.
T= Timing -Does it occur in association with something else (i.e. eating, exertion, movement)?
Past Health History
It is important to ask questions about your patient’s past health history. The PHH should elicit information about the patient’s
childhood illnesses and immunizations, accidents or traumatic injuries, hospitalizations, surgeries, psychiatric or mental
illnesses, allergies, and chronic illnesses. For women, include history of menstrual cycle, how many pregnancies and how many
births (Jarvis,2012).
Family History
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Current Health Status: Information collected should also include details about your patient’s personal habits such as smoking or
drinking, nutrition, cholesterol, and if there is a history of heart disease or hypertension.
Medications: Obtain a list of current medications, including dose and frequency, as well as reason for taking them. Remember to
ask the patient about over the counter medications, vitamins, and herbal supplements (Jarvis, 2012).
HEALTH ASSESSMENT DREX Notes (CBRC)
Nurse-Patient Relationship = PROFESSIONAL
Characteristics: “HHH” = Head (Cognition), Hands (Skills), Heart (Attitude)
Goal: INDEPENDENCE OF THE CLIENT
FOCUS (ROLE): “ROLE mo then HANDWASH VS”
⮚ Rapport, Obtaining Health History, Level of Consciousness, Equipment
● Hand washing & Vital Signs (VS)
HEALTH HISTORY ASSESSMENT (SAMPLE):
⮚ Symptoms (FELT by the patient) / Signs (OBSERVED by the nurse/doctor), Allergies, Medications, Past Medical
History, Last Oral Intake, Events leading to the illness or injury
I.
RAPPORT
⮚ Reassurance, Active Listening, Posture: Gesture – affect, Privacy & Empathy , Observe Layman’s term, Respect
Culture, Touch
II.
Types of Touches:
a. Functional (BEST for patients) = PROFESSIONAL
b. Social = POLITE
c. Friendship = WARMTH
d. Love = INTIMACY
e. Sexual = AROUSAL
III.
HEALTH HISTORY
⮚ PRIMARY DATA: PATIENT
⮚ SECONDARY DATA: FAMILY or OTHER SUPPORT PERSONS, HEALTHCARE PROFESSIONALS, RECORDS AND REPORTS,
LABORATORY AND DIAGNOSTIC ANALYSES AND RELEVANT LITERATURES.
● PAST, PRESENT, FAMILY, FUTURE
IV.
LEVEL OF CONSCIOUSNESS (LOC)
1st Level: ALERT (Awake and Conversant without tangentiality, circumstantiality, and looseness of associations)
2nd Level: CONFUSION (Unclear thoughts)
3rd Level: DISORIENTATION (Cannot recall the place, date and time)
4th Level: LETHARGIC (Responsive upon VERBAL approach)
5th level: OBTUNDED (Responsive upon TACTILE approach)
6th Level: STUPOR (Responsive upon PAIN is inflicted)
7th Level: COMA (Not responsive)
1. CONSTRICTED EYES:
Drugs taken:
⮚ Heroin, Morphine, Oxycodone, Fentanyl, Methadone, Codeine, Hydrocodone
2. DILATED EYES:
Drugs taken:
⮚ Amphetamines, Methamphetamines, Cocaine or Crack, Hallucinogens (i.e. LSD or mushrooms), Opiates
(prescription painkillers), Heroin, Marijuana, Speed
3. RED EYES:
Drugs taken:
⮚ Marijuana, Cocaine or Crack, Benzodiazepines (i.e. Xanax), Depressants (i.e. Alcohol or Sedatives)
SIGN OF IMPENDING DEATH: Constant dilation of pupils
V.
HAND WASHING
1. MEDICAL:
⮚ Uses SOAP, Not less than 10 seconds
⮚ Recommendation: 20 seconds or more
2. SURGICAL
⮚ Uses STERILIUM and BETADINE, Not less than 5 minutes
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QUESTION: WHY DOES SURGICAL HANDWASHING MAKES YOUR HANDS DRY?
− Microorganisms die out on DRY surroundings.
− This is to dehydrate the microorganisms’ nuclear envelope (nucleus) which makes the RNA & DNA of the
microorganisms be destroyed.
MEDICAL ASSESSMENT V.S. NURSING ASSESSMENT
1. ASSESSMENT is the part of medical practice; the PROCESS is the SAME, OUTCOMES DIFFER.
2. BOTH ASSESSMENTS should COMPLEMENT, NOT CONTRADICT
3. Medical Assessment
⮚ for Dx and Tx
4.
Nursing Assessment:
⮚ focuses on patient as a person to the optimal level of wellness (HOLISTIC APPROACH)
⮚
contribute to IDENTIFICATION of MEDICAL PROBLEMS
● COMPREHENSIVE RECORD of the PT ….. HEALTH HISTORY!
● HEALTH HISTORY involves….. PAST & CURRENT!
● HEALTH HISTORY is focused on….. MEDICAL DX & TX AND HOLISTIC CARE!
COMPARISON OF NURSING AND MEDICAL DIANGOSES:
NURSING DX
MEDICAL DX
Ineffective
Airway Pneumonia
Clearance
Disturbed Body Image
Amputation
Risk for Unstable Blood Diabetes Mellitus
Glucose
Impaired
Urinary Post-Op Prostatectomy
Elimination
Self-Care Deficit: Dressing & Cerebrovascular Accident
Gowning
5 STAGES OF NURSING PROCESS (ADPIE)
❖ ASSESSMENT, DIAGNOSIS (NANDA), PLANNING (uses SMART), IMPLEMENTATION, EVALUATION
● SMART:
⮚ SPECIFIC (simple, sensible, significant)
⮚ MEASURABLE (meaningful, motivating)
⮚ ACHIEVABLE (agreed, attainable)
⮚ RELEVANT (reasonable, realistic and resourced, results-based)
⮚ TIME BOUND (time-based, time limited, time/cost limited, timely, time-sensitive)
FDAR CHARTING
⮚ FOCUS
⮚ DATA
✔ SUBJECTIVE = SYMPTOMS or COVERT cues include the client’s feelings and statement about his or her health
problems and are best recorded as direct quotations from the client.
✔ OBJECTIVE = SIGNS or OVERT cues, OBSERVABLE and MEASURABLE (quantitative) data that are obtained through
observation, standard assessment techniques during the physical examination and laboratory and diagnostic
testing.
⮚ ACTION
⮚ RESPONSE
DEFINITIONS AND TERMINOLOGIES:
⮚ HEALTH – is a state of complete physical, mental and social well-being and not merely the absence of disease or
infirmity (World Health Organization, WHO).
⮚ ASSESSMENT – is a systematic, dynamic process by which the nurse through interactions with client, significant others
and health care provides, collects and analyzes data about client (American Nurses Association, ANA).
⮚ HEALTH HISTORY – is a collection of SUBJECTIVE data that includes information on both the client’s past and present
health status.
⮚ PHYSICAL EXAMINATION – provides OBJECTIVE data for identifying problems and making diagnoses.
⮚ ASSESSMENT – is a systematic and deliberate process of gathering the information regarding client’s health.
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⮚ INSPECTION – involves the visual examination of the body.
⮚ PALPATION – use of tactile sensation for identifying characteristics of skin and superficial tissues.
⮚ PERCUSSION – use of tapping with fingers on the body to determine the quality of sound.
⮚ AUSCULTATION – involves listening the sounds within the body either by ears or stethoscope.
TYPES OF ASSESSMENT:
✔ COMPREHENSIVE HEALTH ASSESSMENT: COMPLETE PHYSICAL EXAMINATION and HEALTH HISTORY.
✔ ONGOING PARTIAL ASSESSMENT: Conducted at REGULAR INTERVALS DURING CARE OF THE PATIENT.
✔ FOCUSED ASSESSMENT: EXAMINATION OF A BODY AREA
✔ EMERGENCY ASSESSMENT: TYPE OF RAPID ASSESSMENT conducted to IDENTIFY THE POTENTIALLY FATAL
CONDITIONS.
CULTURAL SENSITIVITY
● Client’s health beliefs, use of alternative therapies, nutritional habits, relationship with family and comfort with
the nurses’ physical closeness during an examination and history taking MUST BE CONSIDERED.
COMPONENTS OF A NURSING HEALTH HISTORY
✔ BIOGRAPHIC DATA
✔ REASON FOR SEEKING HEALTH CARE/ CHIEF COMPLAINT
✔ HISTORY OF PRESENT ILLNESS
✔ PAST HEALTH HISTORY
● SUMMARY:
a. Immunization Status, Known Allergies, Childhood Illness, Adult Illness, Psychiatry Illness, Injuries- burns,
fractures, head injuries, Hospitalization, Surgical and Diagnostic Procedures, Medication History, Use of alcohol
and other Drugs.
✔ FAMILY HISTORY (BALD CHASM)
❖ BLOOD PRESSURE IS HIGH, ARTHRITIs, LUNG DISEASES, DIABETES, CANCERS, HEART DISEASES, ALCOHOLISM,
STROKE, MENTAL ILLNESSES (BIPOLAR, DEPRESSION, ETC.)
✔ REVIEW OF SYSTEMS
− Subjective information about what the patient feels or sees with regard to major systems of the body.
o GENERAL CONSTITUTIONAL SYMPTOMS
✔ LIFESTYLE (SHADE)
❖ SLEEP AND REST PATTERN, HABIT, ACTIVITY AND EXERCISE PATTERN, DIET, ELIMINATION PROBLEMS
✔ OBSTETRIC HISTORY
❖ MENSTRUAL PTTERN: REGULAR/IRREGULAR
❖ HISTORY OF PREGNANCY, LABOR, PUERPERIUM AND COMPLICATIONS IF ANY.
✔ SOCIO-CULTURAL HISTORY
❖ HOME ENVIRONMENT, FAMILY SITUATION, CLIENT’S ROLE IN THE FAMILY, SMOKING: PACKS PER YEAR = No.
of packs per day x no. of years smoking
✔ PSYCHOSOCIAL HISTORY
− Refers to assessment of dimensions such as self-concept and self-esteem as well as usual sources of stress
and client’s ability to cope.
− Sources of support for clients in crisis, such as family, significant others, religion, or support groups, should
be explored.
✔ PSYCHOLOGICAL HISTORY
✔ OCCUPATIONAL AND ENVIRONMENTAL HISTORY
4 PHASES OF NURSING INTERVIEW
1.
PREPARATORY PHASE (PRE ORIENTATION)
2.
INTRODUCTION PHASE (ORIENTATION)
3.
WORKING PHASE
4.
TERMINATION PHASE
NONVERBAL COMMUNCATION
⮚ HAPTICS = TOUCH
⮚ PROXEMICS = DISTANCE
✔ PUBLIC = 12 ft and beyond
✔ SOCIAL = 8-12 ft
✔ PERSONAL = 4-8 ft
✔ INTIMATE = 0-18 in (1 ½ ft)
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⮚ CHRONEMICS = TIME
⮚ PARALANGUAGE = VOICE
⮚ KINESICS = BODY LANGUAGE
BODY TYPES
⮚ ECTOMORPH = Skinny; Difficulty in gaining weight
⮚ MESOMORPH = Naturally muscular; easy gain and loses weight
⮚ ENDOMORPH = Round; Difficulty in losing weight; slower metabolism
BODY SHAPES
⮚ RECTANGLE, TRIANGLE, HOURGLASS, INVERTED TRIANGLE, ROUND
PHYSICAL EXAMINATION
A. INSPECTION
⮚ Sight & Smell
⮚ FACTORS:
a) Positioning
b) Lighting (Visualization)
− for EYE Assessment (PERRLA and VISION):
❒ SIZE of NORMAL PUPIL = 3-7 mm
✔
MYDRIASIS - >7 mm; Dilated
❖
give MYOPIC DRUGS!
✔
MIOSIS
❖
constricted
✔
ANISOCORIA - unequal pupils
❒ SHAPE = EQUALLY round
❒ NORMAL REACTION TO LIGHT
− Constriction = well lit area
− Dilation = dim or dark area
❒ NORMAL REACTION TO ACCOMODATION (NEAR OBJECT)
- Constriction
❒ DIRECT RESPONSE
− If the light or object is shone in the right eye, the right pupil constricts.
❒ CONSENSUAL RESPONSE
− If the light or object is shone produces constriction on the right pupil, the left pupil also constricts.
❒ LEGAL BLINDNESS = 20/200
❒ MYOPIA = Nearsightedness (CONCAVE)
❒ HYPERROPIA = Farsightedness (CONVEX)
❒ DIM LIT ROOM IS USED
❒ SNELLEN CHART (Standard)
❒ RosenBaum CHART (14 inches away from the eyes).
c) Exposure
− Expose ONLY the body part that is to be currently examined.
d) Comparison
⮚
Before INSPECTION:
a.
Establish Rapport
b.
Good Lighting
c.
Consent
⮚ IAPePa (“I Am Peter Parker”) = ABDOMEN
Reasons:
✔ To avoid alteration of assessment bowel sounds
✔ To detect presence for BRUITS (signifies AAA)
❒ NRSNG MGT: Put sign “DO NOT PALPATE!”
⮚ IPaPEA = GENERAL
B. PALPATION
✔ TYPES:
❖ LIGHT PALPATION
− Surface, Parallel alignment of hand to body surface.
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❖
DEEP PALPATION
1-3 inches (2.5-7.5 cm) deep, Delicate procedure, Requires supervision
−
⮚ FINGER PADS = Fine Discrimination
⮚ PALMAR/ULNAR = Thrills, Vibrations, Fremitus
− To know what size, shape or texture of a body area or organ.
⮚ DORSAL = Temperature
● Other Purposes for PALPATION:
● Temperature, Texture (Smoothness and roughness of the skin), Moisture, Organ size and location, Rigidity or
Spasticity, Vibration, Position, Size, Presence of lumps or masses
C. PERCUSSION
− Sense of hearing is used
− Striking approach of a surface
⮚ TYPES:
a. Direct (uses Plexor Dominant/Dominant hand) -striker
b. Indirect (uses Pleximeter/Non-dominant Hand) -Bimanual
− Being strike on the interphalangal joints.
⮚
SOUNDS:
a. Resonant (air filled lungs) - Hollow, low-pitched sounds
b. Hyperresonance (colds, emphysematous lung – hyperinflated – too much air inside alveolar sacs of the lungs)
- Booming, louder-pitched sounds
- NORMAL for PEDIATRIC LUNG.
c. Tympanic (air filled Stomach) - Drum-like
d. Dull (Diaphragm, heart, liver, spleen) - “thud-like” , Dense tissue
e. Flat (Bones, muscles, tumors) - Extremely dull (due to highly dense tissue)
D. AUSCULTATION
● TYPES:
⮚ DIRECT AUSCULTATION - uses unaided ear (not using an instrument)
⮚ INDIRECT AUSCULTATION - uses instrument (stethoscope)
● For STETHOSCOPE:
⮚ belL = LOW PITCH sounds
- For BRUITS, ABNORMAL HEART SOUNDS (S3 and S4), BLOOD PRESSURE
⮚ diapHragm = HIGH PITCH sounds
- For NORMAL and ABNORMAL BOWEL SOUNDS
● LISTENING to sounds produced by the body:
✔ Heart, Blood Vessels, Lungs, Abdomen
BODY MASS INDEX
⮚ Measurement of body fat based on weight and height
⮚ BMI = WEIGHT (kgs)/ HEIGHT (m2)
⮚ Lbs/2.2 = ____kg
BMI CATEGORIES
SEVERELY
UNDERWEIGHT
<16
UNDERWEIGHT
16-18.4
NORMAL
18.5-24.9
OVERWEIGHT
25-29.9
OBESE
>30
VITAL SIGNS
A. TEMPERATURE
⮚ Temperature center= HYPOTHALAMUS
⮚ ROUTES:
a) ORAL = MOST ACCESSIBLE and MOST CONVENIENT Contraindications: Vomiting & Seizure
b) RECTAL = MOST ACCURATE (core body) Contraindications: Diarrhea, Hemorrhoids, Cranial Nerve 10
c) TYMPANIC = FASTEST (2-3 seconds) Contraindications: Otitis Media
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⮚
⮚
B.
⮚
⮚
⮚
⮚
⮚
⮚
⮚
⮚
⮚
C.
⮚
⮚
⮚
⮚
⮚
⮚
d) AXILLA = LEAST ACCURATE; SAFE Bath for 30 minutes
CLEANING THERMOMETERS
❖ BEFORE USING: BULB to STEM
❖ AFTER USING: STEM to BULB
TYPES OF FEVER
a) Remittent = Wide Fluctations (above normal temp.)
b) Constant = Minimal Fluctuations (above normal temp.) Ex. 39.1 – 39.4 – 39.7
c) Intermittent = On and Off Fever Ex. 39.1 – 39.4 – 38.5
d) Relapsing = 1-2 days of short febrile episode
PULSE
NORMAL: 60-100 bpm
BRADYCARDIA = <60 bpm
TACHYCARDIA = >100 bpm
RADIAL PULSE is felt on the wrist, just under the thumb.
APICAL PULSE (Point of Maximal Impulse – PMI) LOCATION: 5th Intercostal space at the left midclavicular line.
SITES (6 PULSE POINTS/SITES (CBARFP) – font color RED):
a) Temporal, Carotid, Brachial, Apical, Radial, Femoral, Posterior Tibial, Popliteal, Pedal
PULSE DEFICIT
✔ Apical – Peripheral
✔ NORMAL = 0
PULSE VOLUME
a) +0 = ABSENT
b) +1 = THREADY/WEAK
c) +2 = NORMAL
d) +3 = ABOVE NORMAL
e) +4 = BOUNDING
PULSE OXIMETER
✔ NORMAL = 95-100%
✔ THREATENING = <70%
✔ SITES: FINGERS, TOES, EARLOBES, NOSETIPS, FOREHEAD – Use of PATCHES
RESPIRATION
NORMAL: 12-20 bpm
BRADYPNEA = <12 bpm
TACHYPNEA = >20 bpm
(-) APNEA = Cessation of Breathing
Difficulty of Breathing (DOB) = Dyspnea
ONE CYCLE (1 RESPIRATION) = 1 INSPIRATION THEN 1 EXPIRATION
Muscles of Inspiration
A.
Accessory
Sternocleidomastoid (elevates
sternum)
Scalenes Group (elevates upper
ribs)
C.
Principal
Muscles of Expiration
A.
Quiet Breathing
Expiration results from passive, elastic recoil of the lungs, rib cage and diaphragm.
B.
Active Breathing
Internal intercostals EXCEPT interchondral part (pull ribs down)
External
intercostals
–
interchondral part of internal
intercostals
(elevates ribs)
Abdominals
(pull ribs down, compress abdominal contents, thus, pushes diaphragm up)
Diaphragm
(dome
descends,
thus
increasing vertical dimension of
Quadratus Lumborum
(pull ribs down)
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thoracic cavity; elevates lower
ribs)
⮚
❖
❖
❖
NORMAL BREATH SOUNDS:
BRONCHIAL - High-pitched sounds that is heard over the tracheobronchial tree.
BRONCHOVESICULAR - Moderate-pitched sounds that are heard over the bronchioles.
VESICULAR - Low-pitched sounds that is heard over the lung fields.
⮚
a)
COMMON ABNORMAL BREATH SOUNDS:
RALES (CRACKLES)
✔ Small, clicking, bubbling, or rattling sounds in the lungs.
✔ Believed to occur when air opens closed air spaces.
✔ TYPES:
▪ FINE
- heard during late inspiration and may sound like hair rubbing together.
- indicates an interstitial process, such as pulmonary fibrosis or congestive heart failure.
- WHAT’S INSIDE? FLUID!!!
COARSE
▪
- are somewhat louder, lower in pitch, and last longer than fine crackles.
- Sound like opening a Velcro bag.
- indicates an airway disease, such as bronchiectasis.
- WHAT’S INSIDE? PHLEGM!!!
b) FRICTION RUB
✔ A raspy breathing sound caused by inflammation of the tissues around your lungs.
✔ is usually “grating” or “creaky.”
✔ Indicates a sign of pleurisy (inflammation of the pleural tissues around the lungs).
c) STRIDOR
✔ Wheeze-like sound heard when a person breathes.
✔ Superficial grating sounds heard during inspiration and expiration, which are not relieved by coughing.
✔ Usually occurs due to a blockage of airflow in trachea or in the back of the throat.
d)
Rhonchi
✔ Sounds that resembles snoring.
✔ They occur when air is blocked or air flow becomes rough through large airways.
e) Wheezing
✔ High-pitched, musical sounds produced by narrowed airways.
✔ Common people having acute asthma attacks.
⮚
D.
⮚
⮚
⮚
BREATHING PATTERNS:
a) BIOT’S RESPIRATIONS- Irregular cluster of breath, Very shallow breathing
b) CHEYNE STOKES- Deep to shallow with periods of apnea
c) KAUSSMAUL’S- Labored breathing, Very deep breathing
BLOOD PRESSURE
PULSE PRESSURE
✔ SYSTOLIC-DIASTOLIC: NORMAL 30-40 mmHg difference
STROKE VOLUME
✔ Amount of blood ejected per heartbeat NORMAL: 55-100 mL/heartbeat
Blood
Pressure Systolic BP
Diastolic BP
Classification
NORMAL
<120 and
<80
Prehypertension
120-139 or
80-89
Stage 1 HTN
140-159 or
90-99
Stage 2 HTN
≥ 160
≥ 100
CONSIDERATIONS IN TAKING BP:
✔ The arm must be at heart level.
✔ Duration-Deflation (15 minutes rest before taking another BP)
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✔
✔
✔
Distance – antecubital fossa (2 finger breadths)
Proper wrapping of the BP cuff is advised to avoid false high BP reading.
REPEATING BP IS ONLY ONCE!
⮚
FACTORS THAT AFFECT BP:
INCREASES BP: SMOKING, DRINKING COFFEE, EXERCISE, EATING
DECREASES BP: ALCOHOL, HEMODIALYSIS
⮚
CONSEQUENCES OF COMMON ERRORS and ARTIFACTS
-CUFF TOO WIDE: Falsely low reading
-CUFF TOO NARROW OR SMALL: Falsely high reading
-CUFF TOO LOOSE: Falsely elevated reading
-CUFF OVER A JOINT: Less likely to compress artery
-HOLE IN CUFF: Pressure leaks too fast to reliably record
-CARDIAC ARRYTHMIAS: Erratic readings
E. PAIN
⮚ <6 months (Acute) = Fast Pain
⮚ >6 months (Chronic) = Slow Pain
⮚ Pain Threshold
✔ Amount of pain stimulation required to feel pain.
⮚ Pain Tolerance
✔ Amount of duration of pain
⮚ Types of Pain
✔ Radiating Pain- Pain that travels from one body part to another.
✔ Referred Pain- The pain you feel in one part of your body is actually caused by pain or injury in another part of your
body.
✔ Intractable Pain- Pain is constant and excruciating, - Type of pain that can't be controlled with standard medical
care.
✔ Phantom Pain- Pain that feels like it's coming from a body part that's no longer there.
⮚ PQRST Pain Assessment:
✔ Precipitating/Predisposing
✔ Quality
❖ Stabbing (e.g. Angina), Crushing (e.g. Myocardial Infarction), Pounding (e.g. Hypertension), Gnawing (e.g.
Peptic Ulcer Disease), Knife-like (e.g. AAA, ruptured appendix)
✔ Region/Radiation
✔ Severity (use of Pain Scale)
✔ Time (Onset; Frequency)
F. HEARING
1. WEBER TEST: Test can detect unilateral conductive and sensorineural hearing loss. Place base of struck
tuning fork on bridge of forehead, nose or teeth.
NORMAL
No lateralization
✔
✔
✔
UNILATERAL
CONDUCTIVE HEARING
LOSS
Lateralization to affected side
UNILATERAL
SENSORINEURAL
HEARING LOSS
Lateralization to normal or better-hearing side
a hearing loss where the ear's ability to conduct sound from the outer ear and middle ear into
the inner ear is blocked or reduced.
is caused by damage to the structures in your inner ear or your auditory nerve.
SENSORINEURAL- Involving the inner ear, cochlea, or the auditory nerve.
CONDUCTIVE- involving any cause that limits the amount of external sound from gaining access to the inner
ear (e.g. cerumen impaction)
MIXED- A combination of conductive and sensorineural hearing loss
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2.
RINNE TEST:
✔ Used primarily to evaluate loss of hearing in one ear.
✔ Air conduction must be better than bone conduction.
✔ Place base of struck tuning fork on the mastoid bone
✔ Have patient indicate when sound is no longer heard
✔ Move fork (held at base) beside ear and ask if now audible
NORMAL
AC>BC (Patient can hear fork at ear)
CONDUCTIVE HEARING
LOSS
G.
BC>AC (Patient will not hear fork at ear)
MUSCULOSKELETAL
✔ ROM TEST
❖ 5 = Full ROM with against gravity, full resistance
❖ 4 = Full ROM with against gravity, some resistance
❖ 3 = Full ROM with against gravity, some resistance
❖ 2 = Full ROM with against gravity, Gravity is eliminated
❖ 1 = Small-flickering contraction
❖ 0 = No contraction
✔ Inflammation is characterized by
5 cardinal signs:
1) RUBOR (REDNESS)
2) CALOR (INCREASED HEAT)
3) TUMOR (SWELLING)
4) DOLOR (PAIN)
5) FUNCTIO LAESA (LOSS OF FUNCTION)
REFLEXES
0
NO RESPONSE
1
DIMINISHED
2
NORMAL
3
ABOVE NORMAL; BRISK
4
HYPERACTIVE
✔ REFLEXES:
❖ DEEP TENDON REFLEXES:
-Biceps Reflex (C5/C6), Brachioradialis Reflex (C6), Triceps Reflex (C7), Patellar Reflex (L4), Achilles
Tendon (S1)
❖ PLANTAR RESPONSE
❖ REFLEX TESTED IN SPECIAL SITUATIONS
-Spinal cord injury, Frontal release signs, Posturing
❖ SCALE:
0
ABSENT
1+
HYPOACTIVE
2+
NORMAL
3+
HYPERACTIVE
4+
HYPERACTIVE
WITH
CLONUS
5+
SUSTAINED CLONUS
✔ GALLEAZZI TEST (ALLIS SIGN)
- A test to assess hip displacement (Congenital or injury)
- Unequal knee length
✔
TYPES OF CLUBFOOT:
❒ Talipes Equinovarus (CLUB FOOT) - Internal rotation of foot and contracted Achilles tendon (Plantar
flexion).
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H.
-MOST COMMON: Talipes Varus, Talipes Valgus, Talipes Equinus, Talipes Calcaneus
INTEGUMENTARY
✔ PARTS: Hair, Nails , Skin
✔ LAYERS OF SKIN:
❖ Epidermis
- contains cells (melanin) that produce pigment and protect immune system.
- Avascular (absence of blood vessels)
- PARTS: COLUGRASPIBA
❖
Stratum corneum, Stratum lucidum, Stratum granulosum, Stratum spinosum,
Stratum basale
❖ Dermis
- Contains nerve endings, oil and sweat glands, and hair follicles. -Vascular
- PARTS: Papillary & Reticular
❖ Subcutaneous Tissue
- Made up of fat, connective tissue, and larger blood vessels.
✔ VITILIGO - Long-term condition where pale white patches develop on the skin.
✔ ALBINISM- Group of inherited disorders that result in little or no production of the pigment melanin, which
determines the color of the skin, hair and eyes.
✔ BIRTHMARKS- are marks that result of excessive accumulations of melanin which is present at birth or
appears shortly after birth.
✔ SKIN CHANGES
❖ Pallor- Unusual lightness of skin color
- may be caused by reduced blood flow and oxygen or by a decreased number of red blood cells.
❖ Cyanosis- Bluish color to the skin or mucous membrane is usually due to a lack of oxygen in the blood.
❖ Jaundice- Yellow staining of the skin and sclerae (the whites of the eyes) by abnormally high blood
levels of the bile pigment bilirubin.
❖ Erythema- Redness of the skin that results from capillary congestion.
- can occur with inflammation, as in sunburn and allergic reactions to drugs.
✔ SKIN LESIONS
❖ PRIMARY
a)
Macule- Flat, distinct, discolored area of skin less than 1 centimeter (cm) wide.
b)
Papule- Solid, elevated lesion with no visible fluid which may be up to ½ cm. in diameter.
c)
Vesicle- A small fluid-filled blister on the skin.
d)
Pustule- a small collection of pus in the top layer of skin (epidermis) or beneath it in the dermis.
e)
Urticaria- Raised, itchy areas of skin that are usually a sign of an allergic reaction.
f)
Bullae- A fluid-filled sac or lesion that appears when fluid is trapped under a thin layer of your skin.
❖ SECONDARY
a)
Crust- are dried sebum, pus, or blood usually mixed with epithelial and sometimes bacterial debris.
b)
Ulcer- A break in skin or mucous membrane with loss of surface tissue, disintegration and necrosis of
epithelial tissue, and often pus.
c)
Necrosis- The death of body tissue.
d)
Erosion- Loss of some or all of the epidermis (the outer layer) leaving a denuded surface.
e)
Skin atrophy- The degeneration and thinning of the epidermis and dermis.
f)
Fissure- is a crack or tear in the skin.
g)
Lichenification- Thick, leathery skin, usually the result of constant scratching and rubbing.
❖ SPECIAL
a)
Purpura- Purple-colored spots and patches that occur on the skin, and in mucus membranes, including
the lining of the mouth.
b)
Telangiectasia- Dilatation of small blood vessels (arterioles, capillaries, venules), often multiple in
character.
c)
Comedone- The primary sign of acne, consisting of a widened hair follicle filled with keratin skin
debris, bacteria, and sebum (oil).
✔ NAILS
NORMAL
ABNORMAL
CONVEX SHAPE
CLUBBING OF FINGERNAILS
− Caused by lack of oxygenation and heart problems.
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DEGREE OF ANGLE
KOILONYCHIA (spoon nails)
- refers to abnormally thin nails (usually of the hand) which have lost their
convexity, becoming flat or even concave in shape.
- a sign of hypochromic anemia, especially iron-deficiency anemia.
✔
MOUTH
❖ TEETH:
NORMAL NO. OF ADULT TEETH = 32
▪
DECIDUOUS = 20
▪
❖ ABNORMALITIES
GINGIVITIS
▪
- Inflammation of the gums.
GLOSSITIS
▪
- Inflammation of the tongue.
STOMATITIS
▪
- Mouth sores
MACROGLOSSIA
▪
- Abnormal enlargement of the tongue
✔
THORAX
❒ NORMAL AP Diameter = 2:1
ABNORMALITIES
ANTERIOR
POSTERIOR
BARREL CHEST
- air retention/ air trapping
- Emphysema (PINK PUFFERS) patients
KYPHOSIS
- Excessive outward curvature of the spine
- In CPR, kyphosis patients use donut pillows.
PIGEON CHEST
- Pectus carinatum
- caused by Marfan Syndrome or rickets.
LORDOSIS
- Forward curvature of the spine.
- Commonly seen in pregnant women.
FUNNEL CHEST
- Pectus excavatum
- caused by Marfan Syndrome or rickets.
SCOLIOSIS
- Lateral curvature of the spine.
HEALTH ASSESSMENT: DIAGNOSTIC TEST NOTES
1.
Based on the paradigm of nursing, health refers to the holistic level of wellness that the person experiences. Sniper
identifies the nursing domain in a paradigm which includes:
ANSWER: Person, situation, environment, nursing
2.
Primordial prevention focuses on preventing the emergence of risk factors. Primary prevention aimed at health
promotion and includes:
ANSWER: Immunization is PRIMARY prevention.
Cancer screening is SECONDARY prevention.
Self-administration of steroid is an example of TERTIARY prevention.
3.
To check if a client has a possible Vitamin C deficiency, or scurvy, the nurse must make sure to examine the client’s:
ANSWER: Gingiva.
Scurvy is a disease characterized by soft, bleeding gums (gingivitis); along with loose teeth, pinpoint hemorrhages, muscle and
joint pain and poor wound healing.
4.
Specific prevention focuses on removing or reducing the levels of the risk factors. Mrs. Assassin was scheduled for
Cervista Test by Nurse Sage. This action is an example of:
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ANSWER: Cervista Test is an example of SECONDARY prevention.
It focuses on early identification of health problems and prompts intervention to alleviate health problems. Its goal is to identify
individuals in an early stage of disease process and to limit future disability.
5.
According to Florence Nightingale, health is a state of being well and using every power the individual possesses to the
fullest extent. Which of the following individuals appear to have taken on the sick role?
ANSWER: An employer who is ill and says “I won’t be able go to the office today.”
6.
The World Health Organization defines health as the state of complete physical, mental, and social well-being, and not
merely the absence of disease. During which stage of illness will we expect Rogue to relinquish the dependence role?
ANSWER: Recovery or Rehabilitation
During the Recovery and Rehabilitation stage, the client is expected to relinquish the dependent role and resume former roles
and responsibilities.
7.
Personal responsibility and sense of control are the key concepts for promotion of health. As the nurse reviews the
client’s level of knowledge after several health-teaching sessions, she determined that the client still fails to follow the
information provided. The nurse must respond by:
ANSWER: Reevaluate the client’s readiness to change
A client's readiness to change is often influenced by his or her perception of importance and confidence. Importance refers to
the personal value of change. Confidence relates to the mastering of the skills needed to achieve the behavior and the
situations in which behavior change will be challenging to the client.
8.
A nurse is giving a bed bath to a client who is on strict bed rest. To increase venous return, the nurse bathes the
client’s extremities by using:
ANSWER: Long, firm strokes from distal to proximal areas
Long, firm strokes in the direction of venous flow promote venous return when the extremities are bathed.
Circular strokes are used on the face.
Short, patting strokes and light strokes are not as comfortable for the client and do not promote venous return.
9.
Andrea, a critically-ill patient, who has been in deep coma for couple of days, needs eye care. The nurse then
organizes the necessary equipment to be used. Which of the following actions if made by the nurse would warrant an
immediate intervention from the nurse supervisor?
ANSWER: Wiping the eye with saline and cotton balls from the outer to the inner canthus.
Proper wiping technique moves debris away from the eye, prevent reinfection or contamination of the eye, and protects the
tear ducts.
10.
Andrea, a mother who delivered via the normal delivery, with episiorraphy has been complaining of mild discomfort.
As the nurse assigned to take care of her, which of the following should you omit in the plan of care?
ANSWER: Avoiding sitz bath
11.
When performing oral care on a comatose client the nurse should:
ANSWER: Place the client in a side-lying position, with the head of the bed lowered
12.
A registered nurse is teaching a nurse orienteer in their unit about proper bed making. Which of the following
interventions should not be part of her teaching?
ANSWER: For occupied bed, the side rail on the opposite side must be down to easily make a mitered corner.
A side rail provides safety and allows the client to assist. The side rail on your side must be down when mitering corner for the
client’s safety.
13.
Florence Nightingale defined nursing as “the act of utilizing the environment of the patient to assist him in his
recovery.” Thief, 14 years, wants to be a nurse someday as she idolizes the nurse assigned to care for her. She asked her nurse,
“What is nursing?” All of the following are not inappropriate responses to the query, except?
ANSWER: Diagnosing, treating, prescribing medication and doing minor surgery
Nursing is defined as assisting clients in the performance of activities contributing to health, its recovery or peaceful death that
clients will perform unaided, of they had the necessary will, strength or knowledge, Assisting clients toward independence
(Virginia Henderson) Nursing is the diagnosis and treatment of human response to actual or potential health problems (ANA
1980)
14.
The respiratory therapist is doing the Allen’s test erroneously if he performs which of the following?
ANSWER: Withdraws blood if the pinkness of the hand returns within 9 seconds
15.
Nurse Sarah is caring for a client with renal failure. Blood gas results indicate a pH of 7.30, a PCO2 of 32 mmHg, and a
bicarbonate concentration of 20mEq/L. Which of the following laboratory values would Nurse Sarah expect to note?
ANSWER: Potassium level of 5.2 mEq/L
Normal values:
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Sodium 135-145 mEq/L
Magnesium 1.5-2.5 mEq/L
Potassium 3.5-5.0 mEq/L
Phosphorus 2.4 to 4.1 mg/dL
16.
Nurse Sarah is caring for a client after a bronchoscopy and biopsy. Which of the following signs if noted in the client
should be reported immediately to the physician?
ANSWER: Bronchospasm
Bronchospasm and/or laryngospasm, an irritation of the airways and/or vocal cords may interfere with a bronchoscopy.
17.
Nurse Sarah is caring for a female client. Which of the following actions is the most essential that nurse Sarah must
ensure prior to Chest x-ray?
ANSWER: Ask about the first day of the last menstruation.
18.
Which of the following actions is the most essential that Nurse Sarah must ensure prior to the pulmonary angiography
of her patient?
ANSWER: Assess for allergies to iodine, seafood or other dyes.
19.
Nurse Sarah is preparing to obtain a sputum specimen from a client. Which of the following nursing actions will
facilitate obtaining the specimen?
ANSWER: Having the client take three deep breaths
20.
Nurse Sarah is conducting preoperative teaching with a client about the use of an incentive spirometer in the
postoperative period. Nurse Sarah would include which piece of information in discussion with the client?
ANSWER: The best results are achieved when the head of the bed is elevated 45 to 90 degrees
21.
Nurse Sarah’s client is unable to use the incentive spirometer device. In counseling the client, the first advice of nurse
Sarah would be to:
ANSWER: Start slowly and gradually increase volume over several sessions.
22.
Nurse Sarah must include all of the following proper instructions in deep breathing and coughing exercises to
post-operative clients except:
ANSWER: The client should perform this exercise at least twice every shift.
23.
Sister Callista Roy proposed the Adaptation Model. Who among the following theorist consider and utilize nature and
environment in the healing process?
ANSWER: Florence Nightingale
24.
A nurse orienteer states imperfectly to Nurse Sarah the proper way of doing chest physiotherapy (CPT) during their
post-conference if she specifies:
ANSWER: “If the client is receiving a tube feeding, finish the feeding and begin doing the CPT in high fowlers’ position”.
25.
Nurse Sarah has assisted a physician with the insertion of a chest tube. Nurse Sarah monitors the client and notes
fluctuation of the fluid level in the water seal chamber after the tube is inserted. Based on this assessment, which of the
following actions would be most appropriate?
ANNSWER: Continue to monitor, for this is an expected finding
The water-seal chamber is filled with sterile water to the level specified by the manufacturer. You should see fluctuation
(tidaling) of the fluid level in the water-seal chamber; if you don't, the system may not be patent or working properly, or the
patient's lung may have re-expanded.
26.
Nurse Sarah is caring for a client with a chest tube. Nurse Sarah turns the client to the side, and the chest tube
accidentally disconnects. The initial nursing action is to:
ANSWER: Place the tube in a bottle of sterile water
Creating a temporary water seal until a new drainage system is set up. A chest tube should never be clamped, except on orders
from a physical or qualified practitioner.
27.
Nurse Sarah is assisting a physician with the removal of a chest tube. Nurse Sarah will appropriately instruct the client
to:
ANSWER: Deep breathe, exhale, and bear down
When the chest tube is removed, the client is asked to perform the Valsalva maneuver (take a deep breathe, exhale and bear
down). The tube is quickly withdrawn, and an airtight dressing is taped in place. An alternative instruction is to ask the client to
take deep breath and hold the breath while the tube is removed.
28.
Nurse Sarah has observed a client self-administer a dose of Albuterol (Ventolin) via MDI. Within a short period of time,
the client begins to wheeze loudly. Nurse Sarah interprets that this is due to:
ANSWER: Paradoxical bronchospasm, which must be reported to the physician
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Get emergency medical help if you have any of these signs of an allergic reaction to albuterol: hives; difficult breathing; swelling
of your face, lips, tongue, or throat.
29.
Nurse Sarah has an order to give a client Albuterol (Ventolin) two puffs, and Budesonide (Fulmicort), two puffs, by
MDI. Nurse Sarah administers the medication by giving the:
ANSWER: Albuterol first and then the Budesonide
Inhaled B2-adrenergic agonists are first line therapies for rapid symptomatic improvement of bronchoconstriction. These
medication relax smooth muscles and reduce local congestion, reducing airway spasm, wheezing, and mucus production.
30.
Nurse Sarah is assigned to take care of an asthmatic patient; she must administer the medications containing a
bronchodilator and a corticosteroid through nebulization. Nurse Sarah is performing this procedure imperfectly if:
ANSWER: After nebulization, rinse the bottle with tap water to remove all remaining solution and allow to dry
31.
An oxygen delivery system is prescribed for a client with Chronic Obstructive Pulmonary Disease (COPD) to deliver a
precise oxygen concentration. Which of the following types of oxygen delivery systems would Nurse Sarah anticipates to be
prescribed?
ANSWER: Venturi mask
This device uses different size adaptors to deliver a fixed or predicted FiO2. The FiO2 delivered depends on the flow rate and/or
entrainment port size. It is used for patients who have COPD when an accurate FiO2 is essential and carbon dioxide buildup
must be kept to a minimum. Humidifiers usually are not used with this device. ( 60% to 100%)
32.
Nurse Sarah is caring for a client with emphysema. The client is receiving oxygen. Nurse Sarah assesses the oxygen
flow rate to ensure that it does not exceed:
ANSWER: 2L/min
O2 therapy may be prescribed but must be used cautiously. The goal of O2 therapy is to maintain the PaO2 between 50 and 60
mmhg. The initial liter flow is usually 1-3L/min.
33.
A group of nursing students is discussing about the descriptions related to non-rebreather mask. The student
incorrectly states the proper description of non-rebreather mask to nurse Sarah if she identified which of the following?
ANSWER: “The valves should open during inhalation and close during exhalation”.
With Non-rebreather masks, make sure valves are open during expiration and closed during inhalation to prevent drastic
decrease in FIO2 (fraction of inspired oxygen)
34.
Madeleine Leininger proposed that nursing is learned humanistic and scientific profession and discipline which is
focused on the human care phenomena and activities in order to support, facilitate, or enable individuals or groups to maintain
or regain their well-being (Transcultural Nursing). Who among the following theorists conceptualized the framework for
psychiatric nursing, wherein a nurse must established a therapeutic relationship with the client?
ANSWER: Hildegard Peplau
Hildegard Peplau is known for her theory on Interpersonal Relations in Nursing.
Betty Neuman is known for the Health Care Systems Model.
Imogene King is known for the Goal Attainment Theory
Lydia Hall is known for the Care-Core-Cure Model
35.
Which nursing action by Nurse Sarah is essential to prevent hypoxemia during tracheal suctioning on her patient?
ANSWER: Administering 100% oxygen to reduce the effects of airway obstruction during suctioning.
Hyperoxygenation is performed bt increasing the intake of oxygen immediately prior to suctioning and when appropriate after
suctioning (Pedersen et al., 2008) and helps reduce the occurrence of hypoxemia. Hyper oxygenation (pre-oxygenation) before
suctioning offers some protection from a drop in arterial blood oxygen.
36.
A client requires tracheal suctioning through the nose. Which nursing action by Nurse Sarah would be incorrect?
ANSWER: Suctioning for 20 seconds
37.
In verifying and ensuring the placement of an endotracheal tube, Nurse Sarah must know that the following are
necessary EXCEPT:
ANSWER: Use maximal occlusive pressure when inflating the cuff in order to create a seal
Verifying Tube Placement. Verify the distal tip marking on endotracheal tube and immediately after ET tube is inserted,
placement should be verified. The most accurate ways to verify placement are by checking end-tidal carbon dioxide levels and
by chest x-ray. Assess for breath sounds bilaterally, sound over the gastric area, symmetric chest movement, and air emerging
from ET tube. Auscultate over the trachea for presence of air leak.
38.
Nurse Sarah is caring for a client immediately after removal of the endotracheal tube following radical neck dissection.
Nurse Sarah reports which of the following signs immediately if experienced by the client?
ANSWER: Stridor
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Auscultate breath sounds as needed. In the immediate postoperative period, place stethoscope over the trachea to assess for
Stridor. Abnormal breath sounds may indicate ineffective ventilation, decreased perfusion, and fluid accumulation. Stridor a
harsh, high-pitched sound primarily heard on inspiration indicates airway obstruction.
39.
Nurse Sarah is changing the tapes on a tracheostomy tube. The client coughs and the tube is dislodged. The initial
nursing action is to:
ANSWER: Grasp the retention sutures to spread the opening
40.
A nurse is taking care of a client with Rheumatoid Arthritis and was ordered to collect feces for occult blood exam.
Which of the following statements if made by the client need for further instructions?
ANSWER: “I may continue taking my Arcoxia 72 hours prior to collection of the sample”.
41.
The client being seen in a physician’s office has just been scheduled for a barium swallow the next day. The nurse
writes down which of the following instructions for the client to follow before the test?
ANSWER: Fast for 8 hours before the test
The patient should maintain NPO status after midnight. Food and fluid in the stomach prevents barium from accurately outlining
the GI tract, and the radiographic result may be misleading.
42.
A nurse is taking care of client who has just been scheduled for a barium swallow the next day. The nurse must
provide the following instructions for the client after the test except:
ANSWER: Expect that the bowel movement not to occur within 2 days
The evening before the BE, administer cathartics such as magnesium citrate (laxative) or other cathartics designated by
institution policy. After the BE study, assess the patient for excavation of the barium. Retained barium may cause a hardened
impaction (increase OFI). Stool will be light colored until all barium has expelled.
43.
The client has undergone esophagogastroduodenoscopy. The nurse places highest priority on which of the following
items as part of the client’s care plan?
ANSWER: Assessing for the return of the gag reflex
The patient is usually given a preprocedure intravenous (IV) sedative such as midazolam (Versed). The patient pharynx is
anesthetized by spraying it with lidocaine hydrochloride (Xylocaine). Therefore do not allow the patient to eat or drink until gag
reflex returns (usually about 2 to 4 hours).
44.
The nurse determines that the client needs further information if the client makes which of the following statements?
ANSWER: “I’m glad I don’t have to lie still for this procedure”.
45.
The science of Unitary Human Being and Principles of Homeodynamics are proposed by Martha Rogers. According to
Benner’s stages of nursing expertise, a nurse with 2 to 3 years of experience who can coordinate multiple complex nursing care
demands is at which stage?
ANSWER: Competent
Novice - No experience, governed by rules, limited and inflexible, task oriented.
Advance Beginner - Demonstrates marginally acceptable performance
Competent - has 2-3 yrs. of experience, consciously plans nursing care
Proficient - >3-5 yrs. of experience, perceives the situation as a whole rather than parts
Expert - Has intuitive grasp of nursing situation.
46.
The nurse has given post-procedure instructions to a client who underwent colonoscopy. The nurse determines that
the client needs further instructions if the client stated that:
ANSWER: It is all right to drive once the client has been home for an hour or so
47.
The nurse is caring for a client who is receiving total parenteral nutrition (TPN) via a central line. Which nursing
intervention specifically would provide assessment data related to the most common complication related to TPN?
ANSWER: Monitoring the temperature – infection
Infection is always a concern because the high concentration of dextrose contained in TPN provides excellent medium for
bacterial growth. Strict aseptic technique is important while changing bottles containing the TPN solution, tubing, filters, and
dressings. Because the catheter is in major blood vessel, any infection would spread rapidly throughout the body.
48.
A nurse is preparing to change the TPN solution bag and tubing. The client’s central venous line is located in the right
subclavian vein. The nurse asks the client to do who of the following most essential items during the tubing change?
ANSWER: Take a deep breath, hold it, and bear down.
The client should be asked to perform the Valsalva maneuver during tubing changes. This helps avoid air embolism during
tubing changes. The nurse asks the client to take a deep breath, hold it, and bear down. If the IV line is on the right, the client
turns his or her head to the left. This position will increase intrathoracic pressure. Options A and C are inappropriate and could
cause the potential for an air embolism during the tubing change.
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49.
A nurse is making initial rounds at the beginning of the shift. The TPN bag of an assigned client is empty. Which of the
following solutions readily available on the nursing unit should the nurse hang until another TPN solution is mixed and delivered
to the nursing unit?
ANSWER: 10% dextrose in water
50.
A nurse is inserting a nasogastric tube in an adult client. During the procedure, the client begins to cough and has
difficulty of breathing. Which of the following is the most appropriate nursing action?
ANSWER: Pull back on the tube and wait until the respiratory distress subsides
51.
The nurse checks for residual before administering a bolus tube feeding to a client with nasogastric tube and obtains a
residual amount of 150 mL. What is the appropriate action for the nurse to take?
ANSWER: Hold the feeding.
52.
A nurse is preparing to administer medication through a nasogastric tube that is connected to suction. To administer
accurately, the nurse would:
ANSWER: Clamp the nasogastric tube for 30 minutes following administration of the medication
53.
A diabetes nurse educator is providing health teaching regarding the proper method of blood glucose determination
through skin puncture. The nurse needs to reinforce the teaching if the client identifies which of the following statements?
ANSWER: “I should select the central tip of the finger which has more dense blood supply”.
54.
What is the most important intervention the nurse can perform to prevent nosocomial infections associated with
enteral nutrition?
ANSWER: Wearing clean gloves when handling the feeding system
55.
The nurse is assessing a stoma prolapse in a client with colostomy. The nurse would observe which of the following if
the stoma prolapsed occurred?
ANSWER: Protruding stoma
A prolapsed stoma is one which the bowel protruded through the stoma.
A stoma retraction is characterized by sinking of the stoma.
Ischemia of the stoma would be associated with dusky or bluish color
. A stoma with a narrowed opening at the level of the skin or fascia is said to be stenosed.
56.
Goal Attainment Theory is proposed by Imogene King. A student nurse asked her clinical instructor about Benner’s
“Proficient” nurse level. The C.I. did not incorrectly answer the question when she stated that the nurses under this level:
ANSWER: Perceives situation as a whole rather than in terms of parts
57.
The client with a new colostomy is concerned about the odor from stool in the ostomy drainage bag. The nurse
teaches the client to include which of the following foods in the diet to reduce odor?
ANSWER: Yogurt
The client should be taught to include deodorizing foods in the diet, such a beet greens, parsley, buttermilk, and yogurt.
Spinach also reduces odor but is a gas forming food as well.
Broccoli, cucumbers, and eggs are gas forming foods.
58.
The nurse instructs the ileostomy client to do which of the following as part of essential care of the stoma?
ANSWER: Cleanse the peristomal skin meticulously
The peristomal skin must receive meticulous cleansing because the ileostomy drainage has more enzymes and is more caustic to
the skin than colostomy drainage.
Foods such as nuts and those with seeds will pass through the ileostomy. The client should be taught that these foods will
remain undigested.
The area below the ileostomy may be massaged if needed if the ileostomy becomes blocked by high fiber foods.
Fluid intake should be maintained to at least six to eight glasses of water per day to prevent dehydration.
59.
The client has just had surgery to create an ileostomy. The nurse assesses the client in the immediate post-operative
period for which of the following most frequent complication of this type of surgery?
ANSWER: Fluid and electrolyte imbalance
60.
A client has an order for “enemas until clear” before major bowel surgery. After preparing the equipment and
solution, the nurse assists the client into which of the following positions to administer the enema?
ANSWER: Left-lateral Sim’s position
Ask the client to lie on the side (preferably the Left-lateral Sim’s position). The colon’s position within the body makes this
position the most effective.
61.
You are to perform a complete physical assessment to Mr. Mogul Khan, 48 years old, diagnosed with a certain chronic
obstructive pulmonary disease. You expect to hear which of the following sounds during percussion of his lung fields?
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ANSWER: Hyper resonance
Flat Sound- Extremely dull (Elicited in Muscles and bones)
Dull Sound- Muffled (elicited in liver, spleen and heart)
Resonant- Hallow (elicited in a normal lung);
Hyperresonant- Booming (elicited in lungs with COPD)
Tympany - Drum-like (elicited in Stomach)
62.
You were assigned to care for a patient who has suffered from second-degree burns all over his upper extremities just
last night. During examination, you noted circumscribed, oval masses, filled with serous fluids that are more than 1 cm. You
properly document this as:
ANSWER: Bullae
Pustule- Circumscribed elevation of skin filled with serous fluid and pus
Bullae- thin walled blister greater than .5 cm with serous fluid
Vesicle- translucent circumscribed filled with serous fluid or blood lesser than .5 cm
Wheal- collection of edema fluid
63.
Nurse Gyrocopter was assigned to assist a patient who was admitted due to a certain central nervous system disorder.
While he’s reviewing his patient’s chart, he reads: “Right pupil – 7 mm in diameter, left pupil – 4 mm in diameter.
ANSWER: The patient has anisocoria
Anisocoria is a condition where the pupil of one eye differs in size from the pupil of the other.
Normal size of pupil is 3-7mm
64.
After Nurse Tinker has performed visual assessment, using a Snellen chart, to her patient Drow Ranger, she
documented that this patient’s visual acuity is 20/40. She understands that:
ANSWER: The patient can read at distance of 20 feet away from the Snellen chart, that an individual with normal vision can
read from 40 feet distance.
A normal eye has a vision of 20/20.
The definition of legal blindness is 20/200.
The numerator is the distance of the patient from the Snellen chart while the denominator is the distance of an individual with a
normal vision.
65.
Windrunner, 27, is admitted after a massive car accident. Nurse Necrolyte, is to assess this patient’s pupil reactions
and accommodation. Which of the following indicates an abnormal response?
ANSWER: Windrunner’s pupil constricts when looking at the far object.
66.
Nurse Slayer was tasked to perform a cephalocaudal assessment to her patient on the EENT ward. After the
examination, she documented the findings accordingly. Upon reading the chart, one entry reads: “Weber negative”. This can be
interpreted as:
ANSWER: A normal finding
67.
According to the American Nurses Association, nursing is the diagnosis and treatment of human responses to actual or
potential health problems. The World Health Organization (WHO) defines health as:
ANSWER: A state of complete physical, mental, and social well-being
The World Health Organization (WHO) takes a more holistic view of health. Its constitution define health as "a state of complete
physical, mental and social well-being and not merely the absence of disease or infirmity"
68.
Mr. Lifestealer, 57 years old, has been suffering from emphysema for five years. He was admitted in the hospital due to
exacerbation of his disease. Upon assessment his chest, you expect to find?
ANSWER: Barrel chest
Pectus Carinatum is expected in patients with Vitamin D. Deficiency (condition: Rickets)
Pectus Excavatum is congenital and is expected to have a depressed sternum
Barrel Chest is expected in COPD which is an effect of the Carbon Dioxide accumulation in the lungs leading to the increasing of
its AP diameter.
AP diameter is greater than or equal to Transverse Diameter.
69.
You are to examine your patient’s breath sounds admitted for general check-up. Which of the following sounds will be
considered normal?
ANSWER: Soft-intensity, low-pitched sounds heard at the base of the lungs.
Soft intensity, low pitched sounds heard at the base of the lungs is called Vesicular sounds which are a normal finding.
Option B is Crackles
Option C is Wheezes
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Option D is Ronchi. These are all abnormal sounds.
70.
You are to perform abdominal assessment to your patient who has been complaining of pain on the left upper
quadrant. You know that to properly execute the procedure, you should:
ANSWER: Palpate the left upper quadrant last
71.
A patient was rushed into the Emergency Department who was complaining of abdominal pain. Based on initial
assessment, appendicitis is suspected. The nurse expects that the patient will be pointing pain on which of the following
abdominal regions?
ANSWER: Right inguinal
72.
The nurse is preparing a Snellen chart for the physical examination. This is used to assess which of the following
cranial nerve/s?
ANSWER: Cranial nerve II
Cranial Nerve Number II is responsible for the sense of sight, using the Snellen Chart is the most appropriate test for visual
acquity
CN III, IV and VI are for extraoccular movement
VII is for Facial expressions 2/3 anterior 73. portion of the tongue (taste).
73.
Mr. Grand Magus was admitted to the hospital after falling from the stairs. Upon examination, Nurse Neruvian called
the patient’s name and that’s the only time he opened his eyes. The patient raised his legs and hands when asked to do so. The
patient was also oriented to time, place, and person. The patient’s GCS score is:
ANSWER: M: 6, V: 5, E: 3
Eye( 4- spontaneous,3- to verbal command, 2- to pain, 1- no response)
Verbal(5- Oriented and Conversant, 4- disoriented and conversant, 3-Inapprpriate words, 2- Incomprehensible, sound 1- No
response)
Motor(6- to verbal command, 5-to localized pain, 4-flexes and withdraws, 3- Decorticate, 2- decerebrate, 1- No response)
74.
Mrs. Naga Siren, who is suspected to have developed a sensory ataxia, had a positive Romberg’s test. The positive
result means that:
ANSWER: The patient cannot maintain balance while standing with eyes closed
Romberg’s test is a test of imbalance. The patient is instructed to stand on both feet and be instructed to close the eyes. A heavy
sway or misbalance would mean a positive Romberg’s test.
75.
When asked about the place where he lives during a mini-mental status exam, Mr. Warlock said, “It’s been a while
since I went home. When I’m home, I can do so many things. I can paint, I can sing, dance, and watch movies. I want to go home
now.” After what he has said, he was not able to provide the information requested. The client apparently has:
ANSWER: Tangentiality
76.
You will receive this injection in a clinic or hospital setting as part of a medical test. Edrophonium (Tensilon) is used for
the diagnosis of myasthenia gravis because this drug will cause a temporary increase in:
ANSWER: Muscle strength
Tensilon, an anticholinesterase drug, causes temporary relief of symptoms of myasthenia gravis in clients who have the disease
and is therefore an effective diagnostic aid.
77.
During the previous few months, a 55 year old woman felt brief twinges of chest pain while working in her garden and
has had frequent episodes of indigestion. She comes to the hospital after experiencing severe anterior chest pain while raking
leaves. Her evaluation confirms a diagnosis of stable angina pectoris. Evaluation of the effectiveness of nitroglycerin SL is based
on:
ANSWER: Improved cardiac output
78.
As per R.A. 9173, promotion of health and prevention of illness are the primary responsibilities of nurses as
independent practitioners. As a member of health team, nurses shall collaborate with other health care providers for the
curative, preventive, and rehabilitative aspects of care, restoration of health, alleviation of suffering, and when recovery is not
possible, towards a peaceful death. Nurse Monk is conducting a series of promotive and preventive programs for a group of
clients. All of the following activities are not considered promotive nursing actions, except?
ANSWER: Implementation of PD 491
PD 996 is the Expanded Program on Immunization
RA 9288 is the Newborn Screening Act, both are preventive nursing actions
Only PD 491 is a promotive nursing action which is the Nutrition Program.
79.
A client with heart failure is receiving digoxin (Lanoxin) and will continue taking the drug after discharge. Before giving
the medication, the nurse should assess the patient’s:
ANSWER: Apical heart rate
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Because digoxin slows the heart rate, the apical pulse should be counted for 1 minute before administration. If the apical rate is
below 60, digoxin should be withheld because its administration could further depress the heart rate.
80.
A client is receiving heparin sodium and warfarin sodium (Coumadin) concurrently for a partial occlusion of the left
common carotid artery. The client expresses concern about why both heparin and Coumadin are needed. The nurse’s
explanation is based on the knowledge that the plan:
ANSWER: Provides anticoagulant intravenously until the oral drug reaches its therapeutic level.
81.
The drug that the nurse should expect the physician to order if symptoms of warfarin (Coumadin) overdose are
observed would be:
ANSWER: Vitamin K
Warfarin depresses prothrombin activity and inhibits the formation of vitamin K dependent clotting factors by the liver. Its
antagonist is vitamin K which is involved in prothrombin formation.
82.
Which statement should the nurse make when teaching the client about taking oral glucocorticoids?
ANSWER: “Take your medication with meals.”
83.
The nurse administers neomycin to a client with hepatic cirrhosis to prevent the formation of:
ANSWER: Ammonia
Neomycin destroy intestinal flora, which breaks down protein and in the process gives off ammonia. Ammonia at this time is
poorly detoxified by the liver and can build up to toxic levels.
84.
What is the rationale that supports multidrug treatment for clients with tuberculosis?
ANSWER: Multiple drugs reduce development of resistant strains of the bacteria
Use of a combination of anti-tuberculosis drugs slows the rate at which the organism develops drug resistance. Combination
therapy also appears to be more effective than single-drug therapy. Regimens that use only single drugs result in the rapid
development of resistance and treatment failure.
85.
Jose, a recent graduate of BS Nursing is attending a review class for the November 2014 board exam. The topic of the
lecture is Pharmacokinetics. Jose likes to know more about the concept of Pharmacokinetics so he asks the lecturer about the
importance of knowing the Pharmacokinetics of a particular drug. The lecturer will mention the following importance of
Pharmacokinetics:
ANSWER: Pharmacokinetics will explain the details of the chemical interaction between the drug and the target cell, tissue or
organ
Pharmacokinetics does not discuss the mechanism of action of the drug to the body, instead it describes how the drug moves in
the body, and therefore it can help in determining the serum drug concentration
86.
The following situations demonstrate an application of a Nurses’ knowledge about the Pharmacodynamics of a given
drug, EXCEPT:
ANSWER: The Nurse instructs a diabetic patient to avoid rubbing the injection site after SubQ injection of insulin
87.
Nurse Kelly noticed that the dose of the opioids given P.O. is higher than that of the I.M. route. Nurse Kelly will be
correct in her interpretation by stating that:
ANSWER: If the drug is given by the oral route is will be subjected to first pass metabolism.
A higher dose of a drug is required if the drug undergoes first pass effect because the drug will be subjected first to metabolism
in the liver, therefore inactivating the drug before it reach the systemic circulation
88.
If a highly protein bound drugs like Diazepam (98% protein bound), Lorazepam (92% protein bound) or Valproic Acid
(92% protein bound) is given to a patient with a liver disease, you will expect:
ANSWER: An increased amount of unbound drugs in the blood, therefore more drugs are released into the systemic
circulation, increasing its effect
89.
Primary level of prevention includes health promotion and illness prevention. Clown Gypsy Group of Companies
establishes a physical exercise area in the workplace and encourages all employees to use it. This is an example of which level of
prevention?
ANSWER: Primary prevention
90.
A patient is taking a drug that is known to be toxic to the liver. The patient is being discharged to home. What teaching
points related to liver toxicity of the drug that the nurse needs to teach the patient to report to the physician:
ANSWER: Body malaise, change in the color of the stool
91.
Which of the following will NOT be included in your health teachings when dealing with the excretion of drugs?
ANSWER: An acid ash diet will increase the excretion of weak acidic drugs
An acid ash diet will acidify the urine therefore promoting the excretion of alkaline drugs like atropine. An alkaline ash diet will
alkalinize the urine therefore promoting the excretion of acidic drugs
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92.
Nurse Michelle is studying different classes of anti-hypertensive, and notes their respective mechanism of action.
Which of the following sets of drugs produce an effect of enzyme inhibition to exert their therapeutic action of decreasing the
blood pressure?
ANSWER: Captopril, Perindopril, Enalapril
Losartan, Valsartan and Telmisartan are Angiotensin II receptor antagonist
Metoprolol, Atenolol and Propranolol are beta receptor antagonist
Methyldopa and Clonidine are Alpha 2 receptor agonists, these drugs do not directly affect enzymes, but reacts with receptors
causing or inhibiting a response
Captopril, Perindopril and Enalapril are Angiotensin Converting Enzyme Inhibitors that prevents the formation of Angiotensin II
that can cause vasoconstriction
93.
Nurse Marilyn is taking care of end stage cancer patient. She will be administering Morphine Sulfate and Tramadol for
pain. She is aware that it can result to additive interaction, causing greater pain control. She is aware of the other potential
advantage of this type of interaction which includes:
ANSWER: Lower doses of each drug can be administered, which can decrease the probability of adverse reactions
94.
A client confided to you that she experiences cramping abdominal pains and diarrheic episodes upon ingestion of milk
and dairy products. She expressed her curiosity regarding lactose intolerance and requested information regarding this
condition. All of the following are inappropriate health teaching, aside from:
ANSWER: “It’s a condition associated with insufficient lactase, a digestive enzyme.”
Lactose intolerance is a condition associated with insufficient or absent lactase, a disaccharidase needed to transform lactose
into galactose and glucose.
The lack of lactase means the intestines cannot absorb lactose which results in the typical symptoms of LI: diarrhea, abdominal
pain, distention, flatulence, nausea etc.
Milk with a lower fat content has a higher concentration of lactose. It is not an allergic reaction (milk allergy is a completely
separate condition).
95.
You have noted that client with a history of cardiovascular diseases was advised to increase his intake of soluble fiber.
This dietary modification, in this case, is necessary because:
ANSWER: Soluble fiber has been proven to decrease serum cholesterol levels.
Soluble fiber is known to decrease serum LDL and cholesterol levels, helpful in clients with CVDs.
Choices B and D are health benefits from ingesting insoluble fiber, not soluble.
Choice C, although partly true, is not the top priority as the situation did not state that the client has a weight problem.
96.
Nurse Arya is conducting a nutritional assessment of Lito, a child who is an inhabitant of a rural village which had been
hit with drought and famine. Which of the following assessment findings would most likely lead Nurse Arya to suspect that the
Lito has kwashiorkor?
ANSWER: Presence of a pot belly
The main symptom of kwashiorkor is extensive edema hence a child suffering from this condition would have a puffy
appearance and abdominal edema (Choice B).
Choices A, C and D are all more commonly associated with marasmus and not kwashiorkor.
97.
Mr. Snorlax is a 38-year old client who wants to institute dietary and lifestyle changes in order to decrease his chances
of having a cardiac-related event in the future. All of the following must be included in your health teaching, aside from:
ANSWER: “A low HDL level means you are reducing your chances of having heart disease.”
98. While conducting a health class on the benefits of eating food with unsaturated fat instead of saturated, you would know
that further teaching is unnecessary if the client states:
ANSWER: “I should stop using coconut oil when cooking.”
Coconut oil, palm oil and chocolate, although coming from plant sources, contain substantially more saturated fat than
unsaturated.
Choice B is wrong because fish, especially fatty fish, contain Omega-3 fatty acid, a type of polyunsaturated fat that is helpful in
decreasing the chances for heart disease.
Choice D is also incorrect. Hydrogenation is process that turns unsaturated fat into saturated fat; hence hydrogenated margarine
is very high in saturated fat.
99.
Mio is a 28-year old married woman who wants to use topical retinoic acid (Avita) to decrease the fine wrinkles on her
face, and asks you about what she should know about this medication. Which of the following would be a suitable answer?
ANSWER: “We have to ascertain first that you are not pregnant.”
ODB: NURSING FACTS AND BELIEFS NURSING THERAPEUTIC 1
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Nursing Care/Positioning AFTER the procedure:
1.
Thoracentesis- Unaffected side
2.
Lobectomy- Unaffected side, with chest tube
3.
Segmentectomy- Unaffected side, with chest tube
4.
Pneumonectomy- Affected side (slightly affected side) No complete lateral turning to prev. mediastinal shift), No chest
tube
5.
Eye surgery- Unoperated side down (unaffected side)
6.
Liver biopsy- Right side
7.
Lumbar puncture- Flat on bed
8.
Lower spinal surgery- Flat on bed, log rolling (turning technique)
9.
Cervical spinal surgery- Slight elevation of head
10. Cardiac catheterization- Bed rest X 24 hours, affected extremity in Extension, sand bag over site, assess peripheral pulses
11. Hip replacement- Affected limb Abducted
12. Amputation- Elevate extremity for 24 hours
13. Supratentorial surgery- Semi-Fowler’s position
14. Infratentorial surgery- Flat position, avoid neck flexion
Nursing care/positioning DURING the procedure:
1. Paracentesis- Sitting position
2. Thoracentesis- Upright leaning on overbed table, sitting Straddling a chair
3. Insertion of TPN catheter- Trendelenburg position
4. Enema Adult- left lateral position Infant/small children- dorsal recumbent
5. TURP- Lithotomy position, cystoclysis
6. Female Catheterization- Dorsal recumbent
Important Nursing Care BEFORE THE PROCEDURE
1. Paracentesis- Empty bladder, weigh patient
2. Bowel surgery/colonoscopy- Cleansing Enema
3. Liver Biopsy- Administer Vitamin K to prevent bleeding
4. CT Scan with dye/IVP- Assess allergy
5. MRI- Asses for claustrophobia. Remove metals
6. Ultrasound of KUB-P- Full Bladder
7. Ultrasound of LGBP- NPO FMN, Laxative HS
8. ABG- determination Allen’s Test
9. Giving Digitalis- Assess Apical Pulse (5th L ICS MCL)
10. Giving Narcotics- Assess RR
POSITIONING FOR
1. Arterial disorders- Put leg on dependent position
2. Venous disorders- Elevate extremity
3. Increased ICP- Head elevated 15 to 30 degrees & Avoid neck flexion
4. COPD- Upright position
NURSING ALERTS!
1. Post Hip Replacement- Avoid Hip Flexion/adduction
2. Pulsating abdominal mass- Avoid abdominal palpation
3. Glaucoma- Avoid Mydriatics (Atropine)
4. DVT. Thrombophlebitis- Avoid massaging legs vigorously
5. Suspected Appendicits- Avoid applying heat, giving laxative, Enema
6. Post spinal cord injury- Avoid flexion of the neck
7. Increased ICP/IOP- Avoid coughing, vomiting, Valsalva
CHARACTERISTIC SIGNS/SYMPTOMS AND DISORDERS
● Meniere’s Disease- Vertigo, tinnitus and hearing loss
● Retinal detachment- Flashes, floaters and veils
● Glaucoma- Increased IOP, loss of peripheral vision, tunnel vision and Halos, rainbows around lights
● Cataract- Opacity of the lens, painless loss of vision
● Parkinson’s disease- Bradykinesia, cogwheel rigidity, shuffling propulsive gait and Pill rolling tremor
● Guillain Barre syndrome- Ascending paralysis
● Myasthenia Graves- Ptosis, dysphagia, respiratory paralysis
● Multiple Sclerosis- Charcot’s Triad (scanning speech, intention tremors, nystagmus)
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Poliomyelitis- Flaccid paralysis
Fracture- Crepitus
Abdominal aortic aneurysm- Pulsating abdominal mass
Gouty arthritis- Tophi
Rheumatoid arthritis- Subcutaneous nodules, morning stiffness
Osteoarthritis- Heberdens nodules, Bouchard nodules
Acromegaly- Coarse facial features, wide hands and feet
Cretinism- Physical and mental retardation
Graves disease- Exopthalmos, tachycardia, heat intolerance
Syndrome of inappropriate antidiuretic hormone secretion (SIADH)- Water intoxication, hyponatremia
Diabetes insipidus- Polyuria, decreased specific gravity of urine
Diabetes mellitus- Polyphagia, polyuria, polydipsia, hyperglycemia
Diabetic ketoacidosis (DKA)- Kussmaull respiration, ketonemia, ketonuria, fruity odor in breath
Pheochromocytoma- Marked hypertension
Increased ICP- Cushing’s Sign (increased systolic BP. Bradycardia, decreased RR) Altered LOC, wide pulse pressure
Meningitis- Kernig’s sign, Brudzinski sign, nuchal rigidity
Hypocalcemia- Chvostek’s sign, Trousseau’s sign, tetany, cramps
Pancreatitis- Cullen’s sign
Deep vein thrombosis, thrombophlebitis- Homans sign
Cholecystitis- Right upper quadrant pain, nausea and vomiting, fat intolerance
Glomerulonephritis- Periorbital edema, increased ASO titer
AIDS- Kaposis’ sarcoma, Pneumocystiiis carinii pneumonia infection
Addison’s disease- Bronze skin pigmentation, hypotension
Alzheimer’s disease- Progressive memory loss
Pernicious anemia- Beefy red tongue, lack of intrinsic factor
Angina Pectoris- Chest pain relieved by rest and nitroglycerin
Appendicitis- Right lower quadrant pain, rebound tenderness, + Blumberg sign + Psoas sign
Paralytic ileus- Boardlike abdomen/abdominal rigidity, absent bowel sounds
Ascites- Abdominal distension, + fluid wave
Laryngeal Cancer- Persistent hoarseness
Bronchogenic Cancer- Chronic cough, hemoptysis
Cancer- Anorexia, weight loss, cachexia
Colorectal Cancer lower GI bleeding -Hematochezia
Upper GI bleeding- Melena
Emphysema- Pink puffer, barrel shaped chest
Chronic Bronchitis- Blue bloater
Asthma- Wheezes, mucoid cough, allergic reaction
Pneumococcal pneumonia- Rusty sputum
Pulmonary Tuberculosis- Night sweat, hemoptysis, (+) mantoux test
Systemic lupus erythematosus (SLE)- Butterfly rash
Hodgkin’s disease- Painless cervical lymph node enlargement
Breast Cancer- Orange peel appearance, dimpling, retraction of nipple
Bell’s Palsy- Paralysis of one side of face
Benign prostatic hyperplasia (BPH)- Decreased urinary stream, nocturia
Arterial disorder (ASO, TAO)- Intermittent claudication
2nd degree burn- Epidermal and dermal involvement with blister/vesicles
Gastric Cancer- Dyspepsia, early satiety
Cardiac tamponade Hypotension- muffled heart sounds
Right side heart failure- Jugular vein distension, ascites, pitting dependent edema
Left side heart failure- pulmonary edema Crackles/rales, PND, increased PAP, Increased PCWP
Cerebrovascular accident (CVA)-Hemiplegia/hemiparesis, aphasia, homonymous hemianopsia
Scoliosis- Lateral curvature of spine
Pott’s disease- Gibbus formation
Flail chest- Paradoxical chest movement, dyspnea
Diverticulitis- Left lower quadrant pain
Biliary obstruction- Jaundice, icteric sclerae, acholic stool, tea-colored urine output
Hepatic encephalopathy- Altered LOC, Flapping tremor (asterixis)
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Hiatal hernia- Heartburn
Polycythemia Vera- Reddish-purple hue of skin and mucosa
Carbon monoxide poisoning- Cherry red skin
Valvular heart disease- Murmur
Peripheral Vascular Occlusion- Bruit
Pericarditis Pericardial- friction rub
Pleuritis- Pleural friction rub
Trigeminal Neuralgia- Severe shooting pain in one side of the face
Ulcerative colitis- Bloody mucoid diarrhea
ODB: NURSING FACTS AND BELIEFS
NURSING THERAPEUTIC 2
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Hypothalamus controls body’s temperature Temperature is the balance between heat production and heat losses
Factors that affect temperature are BMR, Age, thyroxine output, Hormones, time, stress
Alteration in temperature includes pyrexia (38.1C above),hyperpyrexia (41C) and hypothermia (35 C below)
Tympanic temperature reading best reflect core temperature
Pulse is control by the Autonomic Nervous System
Factors that affect pulse rate are age, gender, position,medication, stress
Apical pulse should be assess on a lying position
Carotid pulse is assessed for cardiac arrest for adult and brachial pulse for infant and child.
Defibrillation kills the heart temporarily
Respiration is controlled by Medulla oblongata and Pons
Factors that affect respiration are age, environment, altitude, stress, medication
Blood pressure is determined by blood volume, elasticity of the blood vessels, hematocrit level and peripheral
resistance
Orthostatic Blood pressure measurement is used to monitor the drop of blood pressure.
Physical assessment is used to confirm, validate and refuse a data
Cephalocaudal approach is used when doing physical assessment
The four modes of physical assessment are Inspection, palpation, percussion and auscultation
Consent must be obtained for physical assessment
Privacy should be observed in conducting physical assessment
Thermotherapy increased superficial temperature and local metabolic rate,
Heat therapy is contraindicated for acute muscle injury, impaired circulation, sensory impairment, bruises and open
wound
In most hospital, the water temperature is controlled at a temperature not to exceed 43.3 C to prevent injury
Petroleum jelly may be used to prevent tissue damage when hot packs are applied
Monitor Vital sign frequently when systemic cold is applied
When using hypothermia blanket, use towel to wrap hands and feet to protect skin from injury
Observe skin for purplish color, and check client for numb feeling after cold application are removed
Do not allow the client to lie on a “constant heat source” such as heating pad or aquathermic pad
Do not apply heat to an edematous area until the reason for edema has been determined
Gel packs provide more aggressive cooling than ice bags, so deserve grater caution
During cold therapy, erythema will occur
The four stages of cold progression are cold, stinging,
burning, numbness
Discontinue cold therapy upon numbness
Never apply a fully cooled cold packs directly to the skin
Bony areas usually requires half the treatment time as fatty areas
Do not apply an instant chemical pack to the face and never use pins to secure pack
Elderly clients are more susceptible to injury from heat and cold therapy as a result of physiologic changes or medical
conditions
Vital signs and frequent assessment may need to be carried out during heat and cold therapy as vasodilation from
heat or vasoconstriction from cold can cause changes in cardiac function and blood pressure
Pressure sore is caused by three basic factors: pressure, friction, shearing force
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Factors that might be at risk in developing a pressure sore are: malnutrition, increased temperature, decreased
protein intake, decreased sensation, decreased mental capacity, immobility
Pressure ulcer are graded from stage 1 to 4
The three major phases of wound healing are inflammation, proliferation and maturation
The RYB (red, yellow, black) classifies open wounds that are healing by secondary or delayed primary intention in both
acute and chronic wound
The three types of wound healing are primary, secondary and tertiary intention
The goals of wound healing includes: remove necrotic tissue, prevent infection, absorb drainage, maintain a moist
environment, protect wound from further injury
Ensure that skin is kept clean and prevent it from getting too dry
Provide a balanced diet high in protein, vitamins and mineral for tissue repair
Ensure a fluid intake of 2,000 mL/day for adequate hydration
Do not elevate head of the bed more than 30 degrees
Reposition a bedridden client at least every 2 hours and achair bound client every hour
Common fecal elimination problem includes constipation, diarrhea, incontinence, flatulence
Lack of exercise, irregular defecation habits, bland diet and overuse of laxative are all thought to contribute to
constipation
Sufficient fluid and fiber intake are required to keep feces soft
An adverse effect of constipation is straining during defecation
An adverse effect of prolonged diarrhea is fluid and electrolyte imbalances
When inspecting the client stool, the nurse must observe its color, consistency, shape, amount, odor, and the
constituents
Digital removal of an impaction should be carried out gently
Enema is used to relieve constipation, fecal impaction, flatulence and is also used for evacuation and in lowering body
temperature
Proper positioning must be observed in doing enema. Left lateral position for adults and dorsal recumbent position for
child and infants
Urinary elimination depends on normal functioning of the urinary, cardiovascular and nervous system
Alteration in urine production and elimination includes polyuria, oliguria, anuria, frequency, nocturia, urgency,
enuresis, hematuria, incontinence and retention
Incontinence can be physically and emotionally distressing to client
Clients with urinary retention is at risk for tract infection
The most common cause of urinary tract infection is invasive procedure
Goals for client with problems with urinary elimination problems includes maintaining or restoring normal elimination
patterns and preventing skin breakdown
Urinary catheterization is frequently required for clients with urinary retention but is only performed when all other
measures to facilitate voiding fails
Gradual decompression should be done in doing straight catheterization
Fr 16 – 18 is used from male client and Fr 12 – 14 is used for female client for catheterization
For retention catheter, inflate the balloon with 5 ml of sterile NSS
For client with retention catheter, acidifying urine is a must. Food such as meat, fish, eggs and cereals
Normal pH of urine is 6 or a range of 4.6 – 8
Clean voided specimen is used for routine urinalysis
Midstream urine specimen is used for urine culture
Timed urine specimen collection is used to assess the ability of the kidney to concentrate and dilute urine; determine
level of specific constituents; determine disorders of glucose metabolism
If the client or staff forgets and discard the client’s urine during times collection, the procedure must be restarted
from the beginning
To collect a stool specimen for infant, the stool is scraped from the diaper
For occult blood examination, the client should be instructed to avoid dark-colored food, red meat, iron andn
hemoglobin rich food for 48 – 74 hours
Avoid collecting specimen during menstrual period
Sputum specimen is best collected early morning to help the client expectorate all the secretions that has been
accumulated at night
Method of sputum collection includes deep breathing and coughing exercise, suctioning and chest physiotherapy
Blood test are the most commonly used diagnostic test and can provide valuable information about the hematologic
system and other body system
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Walker promotes more stability compare to cane and crutches
Crutches observes different gaits such as: 4 point gait, 3 point gait and 2 point gait, plus swing to and swing through
Cane should always be places on the stronger side of the body
Client should always be free from restraint
Reason for placing the client on a restraint includes: disruptive behavior, procedure and transfer
Never anchor the restraint on the side rail
Free movement should be provided when placing the client on a restraint
Two types of visualization are direct and indirect. Direct methods make use of gadget or instrument to visualize a body
area/organ. Indirect methods make use of dye, electrical impulses
● KUB X-ray (kidney, ureters, bladders) are painless
● For voiding cystourethrogram films are taken before, during and after voiding
● Retrograde pyelogram (RPG) outlines the pelvis and ureters. Epinephrine at the bedside should be prepared
● A pink tinged urine is normal after cystoscopy because of the irritation of the mucus membrane
● Distending bladder for KUB ultrasound is done for better imaging
● A 24 hours bed rest after renal biopsy is encouraged to prevent bleeding
● Blood Transfusion is used to improve the oxygen carrying capacity of the blood and restore the blood volume
● 0.9% NaCl is the only fluid solution allowed for blood transfusion
● Label the blood and warm the blood at a room temperature
● Use needle gauge 18 or 19 for BT to allow easy flow of the blood
● Do not mix medication with blood transfusion
● Stop the transfusion immediately for any complication that might occur during blood transfusion
Fundamentals of Nursing Notes 1
1.
A blood pressure cuff that’s too narrow can cause a falsely elevated blood pressure reading.
2.
When preparing a single injection for a patient who takes regular and neutral protein Hagedorn insulin, the nurse
should draw the regular insulin into the syringe first so that it does not contaminate the regular insulin.
3.
Rhonchi are the rumbling sounds heard on lung auscultation. They are more pronounced during expiration than
during inspiration.
4.
Gavage is forced feeding, usually through a gastric tube (a tube passed into the stomach through the mouth).
5.
According to Maslow’s hierarchy of needs, physiologic needs (air, water, food, shelter, sex, activity, and comfort) have
the highest priority.
6.
The safest and surest way to verify a patient’s identity is to check the identification band on his wrist.
7.
In the therapeutic environment, the patient’s safety is the primary concern.
8.
Fluid oscillation in the tubing of a chest drainage system indicates that the system is working properly.
9.
The nurse should place a patient who has a Sengstaken-Blakemore tube in semi-Fowler position.
10.
The nurse can elicit Trousseau’s sign by occluding the brachial or radial artery. Hand and finger spasms that occur
during occlusion indicate Trousseau’s sign and suggest hypocalcemia.
11.
For blood transfusion in an adult, the appropriate needle size is 16 to 20G.
12.
Intractable pain is pain that incapacitates a patient and can’t be relieved by drugs.
13.
In an emergency, consent for treatment can be obtained by fax, telephone, or other telegraphic means.
14.
Decibel is the unit of measurement of sound.
15.
Informed consent is required for any invasive procedure.
16.
A patient who can’t write his name to give consent for treatment must make an X in the presence of two witnesses,
such as a nurse, priest, or physician.
17.
The Z-track I.M. injection technique seals the drug deep into the muscle, thereby minimizing skin irritation and
staining. It requires a needle that’s 1″ (2.5 cm) or longer.
18.
In the event of fire, the acronym most often used is RACE. (R) Remove the patient. (A) Activate the alarm. (C) Attempt
to contain the fire by closing the door. (E) Extinguish the fire if it can be done safely.
19.
A registered nurse should assign a licensed vocational nurse or licensed practical nurse to perform bedside care, such
as suctioning and drug administration.
20.
If a patient can’t void, the first nursing action should be bladder palpation to assess for bladder distention.
21.
The patient who uses a cane should carry it on the unaffected side and advance it at the same time as the affected
extremity.
22.
To fit a supine patient for crutches, the nurse should measure from the axilla to the sole and add 2″ (5 cm) to that
measurement.
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23.
Assessment begins with the nurse’s first encounter with the patient and continues throughout the patient’s stay. The
nurse obtains assessment data through the health history, physical examination, and review of diagnostic studies.
24.
The appropriate needle size for insulin injection is 25G and 5/8″ long.
25.
Residual urine is urine that remains in the bladder after voiding. The amount of residual urine is normally 50 to 100
ml.
26.
The five stages of the nursing process are assessment, nursing diagnosis, planning, implementation, and evaluation.
27.
Assessment is the stage of the nursing process in which the nurse continuously collects data to identify a patient’s
actual and potential health needs.
28.
Nursing diagnosis is the stage of the nursing process in which the nurse makes a clinical judgment about individual,
family, or community responses to actual or potential health problems or life processes.
29.
Planning is the stage of the nursing process in which the nurse assigns priorities to nursing diagnoses, defines
short-term and long-term goals and expected outcomes, and establishes the nursing care plan.
30.
Implementation is the stage of the nursing process in which the nurse puts the nursing care plan into action, delegates
specific nursing interventions to members of the nursing team, and charts patient responses to nursing interventions.
31.
Evaluation is the stage of the nursing process in which the nurse compares objective and subjective data with the
outcome criteria and, if needed, modifies the nursing care plan.
32.
Before administering any “as needed” pain medication, the nurse should ask the patient to indicate the location of the
pain.
33.
Jehovah’s Witnesses believe that they shouldn’t receive blood components donated by other people.
34.
To test visual acuity, the nurse should ask the patient to cover each eye separately and to read the eye chart with
glasses and without, as appropriate.
35.
When providing oral care for an unconscious patient, to minimize the risk of aspiration, the nurse should position the
patient on the side.
36.
During assessment of distance vision, the patient should stand 20′ (6.1 m) from the chart.
37.
For a geriatric patient or one who is extremely ill, the ideal room temperature is 66° to 76° F (18.8° to 24.4° C).
38.
Normal room humidity is 30% to 60%.
39.
Hand washing is the single best method of limiting the spread of microorganisms. Once gloves are removed after
routine contact with a patient, hands should be washed for 10 to 15 seconds.
40.
To perform catheterization, the nurse should place a woman in the dorsal recumbent position.
41.
A positive Homan’s sign may indicate thrombophlebitis.
42.
Electrolytes in a solution are measured in milliequivalents per liter (mEq/L). A milliequivalent is the number of
milligrams per 100 milliliters of a solution.
43.
Metabolism occurs in two phases: anabolism (the constructive phase) and catabolism (the destructive phase).
44.
The basal metabolic rate is the amount of energy needed to maintain essential body functions. It’s measured when
the patient is awake and resting, hasn’t eaten for 14 to 18 hours, and is in a comfortable, warm environment.
45.
The basal metabolic rate is expressed in calories consumed per hour per kilogram of body weight.
46.
Dietary fiber (roughage), which is derived from cellulose, supplies bulk, maintains intestinal motility, and helps to
establish regular bowel habits.
47.
Alcohol is metabolized primarily in the liver. Smaller amounts are metabolized by the kidneys and lungs.
48.
Petechiae are tiny, round, purplish red spots that appear on the skin and mucous membranes as a result of
intradermal or submucosal hemorrhage.
49.
Purpura is a purple discoloration of the skin that’s caused by blood extravasation.
50.
According to the standard precautions recommended by the Centers for Disease Control and Prevention, the nurse
shouldn’t recap needles after use. Most needle sticks result from missed needle recapping.
51.
The nurse administers a drug by I.V. push by using a needle and syringe to deliver the dose directly into a vein, I.V.
tubing, or a catheter.
52.
When changing the ties on a tracheostomy tube, the nurse should leave the old ties in place until the new ones are
applied.
53.
A nurse should have assistance when changing the ties on a tracheostomy tube.
54.
A filter is always used for blood transfusions.
55.
A four-point (quad) cane is indicated when a patient needs more stability than a regular cane can provide.
56.
A good way to begin a patient interview is to ask, “What made you seek medical help?”
57.
When caring for any patient, the nurse should follow standard precautions for handling blood and body fluids.
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58.
Potassium (K+) is the most abundant cation in intracellular fluid.
59.
In the four-point, or alternating, gait, the patient first moves the right crutch followed by the left foot and then the left
crutch followed by the right foot.
60.
In the three-point gait, the patient moves two crutches and the affected leg simultaneously and then moves the
unaffected leg.
61.
In the two-point gait, the patient moves the right leg and the left crutch simultaneously and then moves the left leg
and the right crutch simultaneously.
62.
The vitamin B complex, the water-soluble vitamins that are essential for metabolism, include thiamine (B1), riboflavin
(B2), niacin (B3), pyridoxine (B6), and cyanocobalamin (B12).
63.
When being weighed, an adult patient should be lightly dressed and shoeless.
64.
Before taking an adult’s temperature orally, the nurse should ensure that the patient hasn’t smoked or consumed hot
or cold substances in the previous 15 minutes.
65.
The nurse shouldn’t take an adult’s temperature rectally if the patient has a cardiac disorder, anal lesions, or bleeding
hemorrhoids or has recently undergone rectal surgery.
66.
In a patient who has a cardiac disorder, measuring temperature rectally may stimulate a vagal response and lead to
vasodilation and decreased cardiac output.
67.
When recording pulse amplitude and rhythm, the nurse should use these descriptive measures: +3, bounding pulse
(readily palpable and forceful); +2, normal pulse (easily palpable); +1, thready or weak pulse (difficult to detect); and 0, absent
pulse (not detectable).
68.
The intraoperative period begins when a patient is transferred to the operating room bed and ends when the patient
is admitted to the postanesthesia care unit.
69.
On the morning of surgery, the nurse should ensure that the informed consent form has been signed; that the patient
hasn’t taken anything by mouth since midnight, has taken a shower with antimicrobial soap, has had mouth care (without
swallowing the water), has removed common jewelry, and has received preoperative medication as prescribed; and that vital
signs have been taken and recorded. Artificial limbs and other prostheses are usually removed.
70.
Comfort measures, such as positioning the patient, rubbing the patient’s back, and providing a restful environment,
may decrease the patient’s need for analgesics or may enhance their effectiveness.
71.
A drug has three names: generic name, which is used in official publications; trade, or brand, name (such as Tylenol),
which is selected by the drug company; and chemical name, which describes the drug’s chemical composition.
72.
To avoid staining the teeth, the patient should take a liquid iron preparation through a straw.
73.
The nurse should use the Z-track method to administer an I.M. injection of iron dextran (Imferon).
74.
An organism may enter the body through the nose, mouth, rectum, urinary or reproductive tract, or skin.
75.
In descending order, the levels of consciousness are alertness, lethargy, stupor, light coma, and deep coma.
76.
To turn a patient by logrolling, the nurse folds the patient’s arms across the chest; extends the patient’s legs and
inserts a pillow between them, if needed; places a draw sheet under the patient; and turns the patient by slowly and gently
pulling on the draw sheet.
77.
The diaphragm of the stethoscope is used to hear high-pitched sounds, such as breath sounds.
78.
A slight difference in blood pressure (5 to 10 mm Hg) between the right and the left arms is normal.
79.
The nurse should place the blood pressure cuff 1″ (2.5 cm) above the antecubital fossa.
80.
When instilling ophthalmic ointments, the nurse should waste the first bead of ointment and then apply the ointment
from the inner canthus to the outer canthus.
81.
The nurse should use a leg cuff to measure blood pressure in an obese patient.
82.
If a blood pressure cuff is applied too loosely, the reading will be falsely lowered.
83.
Ptosis is drooping of the eyelid.
84.
A tilt table is useful for a patient with a spinal cord injury, orthostatic hypotension, or brain damage because it can
move the patient gradually from a horizontal to a vertical (upright) position.
85.
To perform venipuncture with the least injury to the vessel, the nurse should turn the bevel upward when the vessel’s
lumen is larger than the needle and turn it downward when the lumen is only slightly larger than the needle.
86.
To move a patient to the edge of the bed for transfer, the nurse should follow these steps: Move the patient’s head
and shoulders toward the edge of the bed. Move the patient’s feet and legs to the edge of the bed (crescent position). Place
both arms well under the patient’s hips, and straighten the back while moving the patient toward the edge of the bed.
87.
When being measured for crutches, a patient should wear shoes.
88.
The nurse should attach a restraint to the part of the bed frame that moves with the head, not to the mattress or side
rails.
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89.
The mist in a mist tent should never become so dense that it obscures clear visualization of the patient’s respiratory
pattern.
90.
To administer heparin subcutaneously, the nurse should follow these steps: Clean, but don’t rub, the site with alcohol.
Stretch the skin taut or pick up a well-defined skin fold. Hold the shaft of the needle in a dart position. Insert the needle into the
skin at a right (90-degree) angle. Firmly depress the plunger, but don’t aspirate. Leave the needle in place for 10 seconds.
Withdraw the needle gently at the angle of insertion. Apply pressure to the injection site with an alcohol pad.
91.
For a sigmoidoscopy, the nurse should place the patient in the knee-chest position or Sims’ position, depending on the
physician’s preference.
92.
Maslow’s hierarchy of needs must be met in the following order: physiologic (oxygen, food, water, sex, rest, and
comfort), safety and security, love and belonging, self-esteem and recognition, and self-actualization.
93.
When caring for a patient who has a nasogastric tube, the nurse should apply a water-soluble lubricant to the nostril
to prevent soreness.
94.
During gastric lavage, a nasogastric tube is inserted, the stomach is flushed, and ingested substances are removed
through the tube.
95.
In documenting drainage on a surgical dressing, the nurse should include the size, color, and consistency of the
drainage (for example, “10 mm of brown mucoid drainage noted on dressing”).
96.
To elicit Babinski’s reflex, the nurse strokes the sole of the patient’s foot with a moderately sharp object, such as a
thumbnail.
97.
A positive Babinski’s reflex is shown by dorsiflexion of the great toe and fanning out of the other toes.
98.
When assessing a patient for bladder distention, the nurse should check the contour of the lower abdomen for a
rounded mass above the symphysis pubis.
99.
The best way to prevent pressure ulcers is to reposition the bedridden patient at least every 2 hours.
100.
Antiembolism stockings decompress the superficial blood vessels, reducing the risk of thrombus formation.
101.
In adults, the most convenient veins for venipuncture are the basilic and median cubital veins in the antecubital space.
102.
Two to three hours before beginning a tube feeding, the nurse should aspirate the patient’s stomach contents to verify
that gastric emptying is adequate.
103.
People with type O blood are considered universal donors.
104.
People with type AB blood are considered universal recipients.
105.
Hertz (Hz) is the unit of measurement of sound frequency.
106.
Hearing protection is required when the sound intensity exceeds 84 dB. Double hearing protection is required if it
exceeds 104 dB.
107.
Prothrombin, a clotting factor, is produced in the liver.
108.
If a patient is menstruating when a urine sample is collected, the nurse should note this on the laboratory request.
109.
During lumbar puncture, the nurse must note the initial intracranial pressure and the color of the cerebrospinal fluid.
110.
If a patient can’t cough to provide a sputum sample for culture, a heated aerosol treatment can be used to help to
obtain a sample.
111.
If eye ointment and eyedrops must be instilled in the same eye, the eyedrops should be instilled first.
112.
When leaving an isolation room, the nurse should remove her gloves before her mask because fewer pathogens are
on the mask.
113.
Skeletal traction, which is applied to a bone with wire pins or tongs, is the most effective means of traction.
114.
The total parenteral nutrition solution should be stored in a refrigerator and removed 30 to 60 minutes before use.
Delivery of a chilled solution can cause pain, hypothermia, venous spasm, and venous constriction.
115.
Drugs aren’t routinely injected intramuscularly into edematous tissue because they may not be absorbed.
116.
When caring for a comatose patient, the nurse should explain each action to the patient in a normal voice.
117.
Dentures should be cleaned in a sink that’s lined with a washcloth.
118.
A patient should void within 8 hours after surgery.
119.
An EEG identifies normal and abnormal brain waves.
120.
Samples of feces for ova and parasite tests should be delivered to the laboratory without delay and without
refrigeration.
121.
The autonomic nervous system regulates the cardiovascular and respiratory systems.
122.
When providing tracheostomy care, the nurse should insert the catheter gently into the tracheostomy tube. When
withdrawing the catheter, the nurse should apply intermittent suction for no more than 15 seconds and use a slight twisting
motion.
123.
A low-residue diet includes such foods as roasted chicken, rice, and pasta.
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124.
A rectal tube shouldn’t be inserted for longer than 20 minutes because it can irritate the rectal mucosa and cause loss
of sphincter control.
125.
A patient’s bed bath should proceed in this order: face, neck, arms, hands, chest, abdomen, back, legs, perineum.
126.
To prevent injury when lifting and moving a patient, the nurse should primarily use the upper leg muscles.
127.
Patient preparation for cholecystography includes ingestion of a contrast medium and a low-fat evening meal.
128.
While an occupied bed is being changed, the patient should be covered with a bath blanket to promote warmth and
prevent exposure.
129.
Anticipatory grief is mourning that occurs for an extended time when the patient realizes that death is inevitable.
130.
The following foods can alter the color of the feces: beets (red), cocoa (dark red or brown), licorice (black), spinach
(green), and meat protein (dark brown).
131.
When preparing for a skull X-ray, the patient should remove all jewelry and dentures.
132.
The fight-or-flight response is a sympathetic nervous system response.
133.
Bronchovesicular breath sounds in peripheral lung fields are abnormal and suggest pneumonia.
134.
Wheezing is an abnormal, high-pitched breath sound that’s accentuated on expiration.
135.
Wax or a foreign body in the ear should be flushed out gently by irrigation with warm saline solution.
136.
If a patient complains that his hearing aid is “not working,” the nurse should check the switch first to see if it’s turned
on and then check the batteries.
137.
The nurse should grade hyperactive biceps and triceps reflexes as +4.
138.
If two eye medications are prescribed for twice-daily instillation, they should be administered 5 minutes apart.
139.
In a postoperative patient, forcing fluids helps prevent constipation.
140.
A nurse must provide care in accordance with standards of care established by the American Nurses Association, state
regulations, and facility policy.
141.
The kilocalorie (kcal) is a unit of energy measurement that represents the amount of heat needed to raise the
temperature of 1 kilogram of water 1° C.
142.
As nutrients move through the body, they undergo ingestion, digestion, absorption, transport, cell metabolism, and
excretion.
143.
The body metabolizes alcohol at a fixed rate, regardless of serum concentration.
144.
In an alcoholic beverage, proof reflects the percentage of alcohol multiplied by 2. For example, a 100-proof beverage
contains 50% alcohol.
145.
A living will is a witnessed document that states a patient’s desire for certain types of care and treatment. These
decisions are based on the patient’s wishes and views on quality of life.
146.
The nurse should flush a peripheral heparin lock every 8 hours (if it wasn’t used during the previous 8 hours) and as
needed with normal saline solution to maintain patency.
147.
Quality assurance is a method of determining whether nursing actions and practices meet established standards.
148.
The five rights of medication administration are the right patient, right drug, right dose, right route of administration,
and right time.
149.
The evaluation phase of the nursing process is to determine whether nursing interventions have enabled the patient
to meet the desired goals.
150.
Outside of the hospital setting, only the sublingual and translingual forms of nitroglycerin should be used to relieve
acute anginal attacks.
151.
The implementation phase of the nursing process involves recording the patient’s response to the nursing plan,
putting the nursing plan into action, delegating specific nursing interventions, and coordinating the patient’s activities.
152.
The Patient’s Bill of Rights offers patients guidance and protection by stating the responsibilities of the hospital and its
staff toward patients and their families during hospitalization.
153.
To minimize omission and distortion of facts, the nurse should record information as soon as it’s gathered.
154.
When assessing a patient’s health history, the nurse should record the current illness chronologically, beginning with
the onset of the problem and continuing to the present.
155.
When assessing a patient’s health history, the nurse should record the current illness chronologically, beginning with
the onset of the problem and continuing to the present.
156.
A nurse shouldn’t give false assurance to a patient.
157.
After receiving preoperative medication, a patient isn’t competent to sign an informed consent form.
158.
When lifting a patient, a nurse uses the weight of her body instead of the strength in her arms.
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159.
A nurse may clarify a physician’s explanation about an operation or a procedure to a patient, but must refer questions
about informed consent to the physician.
160.
When obtaining a health history from an acutely ill or agitated patient, the nurse should limit questions to those that
provide necessary information.
161.
If a chest drainage system line is broken or interrupted, the nurse should clamp the tube immediately.
162.
The nurse shouldn’t use her thumb to take a patient’s pulse rate because the thumb has a pulse that may be confused
with the patient’s pulse.
163.
An inspiration and an expiration count as one respiration.
164.
Eupnea is normal respiration.
165.
During blood pressure measurement, the patient should rest the arm against a surface. Using muscle strength to hold
up the arm may raise the blood pressure.
166.
Major, unalterable risk factors for coronary artery disease include heredity, sex, race, and age.
167.
Inspection is the most frequently used assessment technique.
168.
Family members of an elderly person in a long-term care facility should transfer some personal items (such as
photographs, a favorite chair, and knickknacks) to the person’s room to provide a comfortable atmosphere.
169.
Pulsus alternans is a regular pulse rhythm with alternating weak and strong beats. It occurs in ventricular enlargement
because the stroke volume varies with each heartbeat.
170.
The upper respiratory tract warms and humidifies inspired air and plays a role in taste, smell, and mastication.
171.
Signs of accessory muscle use include shoulder elevation, intercostal muscle retraction, and scalene and
sternocleidomastoid muscle use during respiration.
172.
When patients use axillary crutches, their palms should bear the brunt of the weight.
173.
Activities of daily living include eating, bathing, dressing, grooming, toileting, and interacting socially.
174.
Normal gait has two phases: the stance phase, in which the patient’s foot rests on the ground, and the swing phase, in
which the patient’s foot moves forward.
175.
The phases of mitosis are prophase, metaphase, anaphase, and telophase.
176.
The nurse should follow standard precautions in the routine care of all patients.
177.
The nurse should use the bell of the stethoscope to listen for venous hums and cardiac murmurs.
178.
The nurse can assess a patient’s general knowledge by asking questions such as “Who is the president of the United
States?”
179.
Cold packs are applied for the first 20 to 48 hours after an injury; then heat is applied. During cold application, the
pack is applied for 20 minutes and then removed for 10 to 15 minutes to prevent reflex dilation (rebound phenomenon) and
frostbite injury.
180.
The pons is located above the medulla and consists of white matter (sensory and motor tracts) and gray matter (reflex
centers).
181.
The autonomic nervous system controls the smooth muscles.
182.
A correctly written patient goal expresses the desired patient behavior, criteria for measurement, time frame for
achievement, and conditions under which the behavior will occur. It’s developed in collaboration with the patient.
183.
Percussion causes five basic notes: tympany (loud intensity, as heard over a gastric air bubble or puffed out cheek),
hyperresonance (very loud, as heard over an emphysematous lung), resonance (loud, as heard over a normal lung), dullness
(medium intensity, as heard over the liver or other solid organ), and flatness (soft, as heard over the thigh).
184.
The optic disk is yellowish pink and circular, with a distinct border.
185.
A primary disability is caused by a pathologic process. A secondary disability is caused by inactivity.
186.
Nurses are commonly held liable for failing to keep an accurate count of sponges and other devices during surgery.
187.
The best dietary sources of vitamin B6 are liver, kidney, pork, soybeans, corn, and whole-grain cereals.
188.
Iron-rich foods, such as organ meats, nuts, legumes, dried fruit, green leafy vegetables, eggs, and whole grains,
commonly have a low water content.
189.
Collaboration is joint communication and decision making between nurses and physicians. It’s designed to meet
patients’ needs by integrating the care regimens of both professions into one comprehensive approach.
190.
Bradycardia is a heart rate of fewer than 60 beats/minute.
191.
A nursing diagnosis is a statement of a patient’s actual or potential health problem that can be resolved, diminished,
or otherwise changed by nursing interventions.
192.
During the assessment phase of the nursing process, the nurse collects and analyzes three types of data: health
history, physical examination, and laboratory and diagnostic test data.
193.
The patient’s health history consists primarily of subjective data, information that’s supplied by the patient.
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194.
The physical examination includes objective data obtained by inspection, palpation, percussion, and auscultation.
195.
When documenting patient care, the nurse should write legibly, use only standard abbreviations, and sign each entry.
The nurse should never destroy or attempt to obliterate documentation or leave vacant lines.
196.
Factors that affect body temperature include time of day, age, physical activity, phase of menstrual cycle, and
pregnancy.
197.
The most accessible and commonly used artery for measuring a patient’s pulse rate is the radial artery. To take the
pulse rate, the artery is compressed against the radius.
198.
In a resting adult, the normal pulse rate is 60 to 100 beats/minute. The rate is slightly faster in women than in men
and much faster in children than in adults.
199.
Laboratory test results are an objective form of assessment data.
200.
The measurement systems most commonly used in clinical practice are the metric system, apothecaries’ system, and
household system.
201.
Before signing an informed consent form, the patient should know whether other treatment options are available and
should understand what will occur during the preoperative, intraoperative, and postoperative phases; the risks involved; and
the possible complications. The patient should also have a general idea of the time required from surgery to recovery. In
addition, he should have an opportunity to ask questions.
202.
A patient must sign a separate informed consent form for each procedure.
203.
During percussion, the nurse uses quick, sharp tapping of the fingers or hands against body surfaces to produce
sounds. This procedure is done to determine the size, shape, position, and density of underlying organs and tissues; elicit
tenderness; or assess reflexes.
204.
Ballottement is a form of light palpation involving gentle, repetitive bouncing of tissues against the hand and feeling
their rebound.
205.
A foot cradle keeps bed linen off the patient’s feet to prevent skin irritation and breakdown, especially in a patient
who has peripheral vascular disease or neuropathy.
206.
Gastric lavage is flushing of the stomach and removal of ingested substances through a nasogastric tube. It’s used to
treat poisoning or drug overdose.
207.
During the evaluation step of the nursing process, the nurse assesses the patient’s response to therapy.
208.
Bruits commonly indicate life- or limb-threatening vascular disease.
209.
O.U. means each eye. O.D. is the right eye, and O.S. is the left eye.
210.
To remove a patient’s artificial eye, the nurse depresses the lower lid.
211.
The nurse should use a warm saline solution to clean an artificial eye.
212.
A thready pulse is very fine and scarcely perceptible.
213.
Axillary temperature is usually 1° F lower than oral temperature.
214.
After suctioning a tracheostomy tube, the nurse must document the color, amount, consistency, and odor of
secretions.
215.
On a drug prescription, the abbreviation p.c. means that the drug should be administered after meals.
216.
After bladder irrigation, the nurse should document the amount, color, and clarity of the urine and the presence of
clots or sediment.
217.
After bladder irrigation, the nurse should document the amount, color, and clarity of the urine and the presence of
clots or sediment.
218.
Laws regarding patient self-determination vary from state to state. Therefore, the nurse must be familiar with the laws
of the state in which she works.
219.
Gauge is the inside diameter of a needle: the smaller the gauge, the larger the diameter.
220.
An adult normally has 32 permanent teeth.
Fundamentals of Nursing Notes 2
1. After turning a patient, the nurse should document the position used, the time that the patient was turned, and the findings
of skin assessment.
2. PERRLA is an abbreviation for normal pupil assessment findings: pupils equal, round, and reactive to light with
accommodation.
3. When percussing a patient’s chest for postural drainage, the nurse’s hands should be cupped.
4. When measuring a patient’s pulse, the nurse should assess its rate, rhythm, quality, and strength.
5. Before transferring a patient from a bed to a wheelchair, the nurse should push the wheelchair footrests to the sides and lock
its wheels.
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6. When assessing respirations, the nurse should document their rate, rhythm, depth, and quality.
7. For a subcutaneous injection, the nurse should use a 5/8″ to 1″ 25G needle.
8. The notation “AA & O × 3” indicates that the patient is awake, alert, and oriented to person (knows who he is), place (knows
where he is), and time (knows the date and time).
9. Fluid intake includes all fluids taken by mouth, including foods that are liquid at room temperature, such as gelatin, custard,
and ice cream; I.V. fluids; and fluids administered in feeding tubes. Fluid output includes urine, vomitus, and drainage (such as
from a nasogastric tube or from a wound) as well as blood loss, diarrhea or feces, and perspiration.
10. After administering an intradermal injection, the nurse shouldn’t massage the area because massage can irritate the site and
interfere with results.
11. When administering an intradermal injection, the nurse should hold the syringe almost flat against the patient’s skin (at
about a 15-degree angle), with the bevel up.
12. To obtain an accurate blood pressure, the nurse should inflate the manometer to 20 to 30 mm Hg above the disappearance
of the radial pulse before releasing the cuff pressure.
13. The nurse should count an irregular pulse for 1 full minute.
14. A patient who is vomiting while lying down should be placed in a lateral position to prevent aspiration of vomitus.
15. Prophylaxis is disease prevention.
16. Body alignment is achieved when body parts are in proper relation to their natural position.
17. Trust is the foundation of a nurse-patient relationship.
18. Blood pressure is the force exerted by the circulating volume of blood on the arterial walls.
19. Malpractice is a professional’s wrongful conduct, improper discharge of duties, or failure to meet standards of care that
causes harm to another.
20. As a general rule, nurses can’t refuse a patient care assignment; however, in most states, they may refuse to participate in
abortions.
21. A nurse can be found negligent if a patient is injured because the nurse failed to perform a duty that a reasonable and
prudent person would perform or because the nurse performed an act that a reasonable and prudent person wouldn’t perform.
22. States have enacted Good Samaritan laws to encourage professionals to provide medical assistance at the scene of an
accident without fear of a lawsuit arising from the assistance. These laws don’t apply to care provided in a health care facility.
23. A physician should sign verbal and telephone orders within the time established by facility policy, usually 24 hours.
24. A competent adult has the right to refuse lifesaving medical treatment; however, the individual should be fully informed of
the consequences of his refusal.
25. Although a patient’s health record, or chart, is the health care facility’s physical property, its contents belong to the patient.
26. Before a patient’s health record can be released to a third party, the patient or the patient’s legal guardian must give written
consent.
27. Under the Controlled Substances Act, every dose of a controlled drug that’s dispensed by the pharmacy must be accounted
for, whether the dose was administered to a patient or discarded accidentally.
28. A nurse can’t perform duties that violate a rule or regulation established by a state licensing board, even if they are
authorized by a health care facility or physician.
29. To minimize interruptions during a patient interview, the nurse should select a private room, preferably one with a door that
can be closed.
30. In categorizing nursing diagnoses, the nurse addresses life-threatening problems first, followed by potentially
life-threatening concerns.
31. The major components of a nursing care plan are outcome criteria (patient goals) and nursing interventions.
32. Standing orders, or protocols, establish guidelines for treating a specific disease or set of symptoms.
33. In assessing a patient’s heart, the nurse normally finds the point of maximal impulse at the fifth intercostal space, near the
apex.
34. The S1 heard on auscultation is caused by closure of the mitral and tricuspid valves.
35. To maintain package sterility, the nurse should open a wrapper’s top flap away from the body, open each side flap by
touching only the outer part of the wrapper, and open the final flap by grasping the turned-down corner and pulling it toward
the body.
36. The nurse shouldn’t dry a patient’s ear canal or remove wax with a cotton-tipped applicator because it may force cerumen
against the tympanic membrane.
37. A patient’s identification bracelet should remain in place until the patient has been discharged from the health care facility
and has left the premises.
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38. The Controlled Substances Act designated five categories, or schedules, that classify controlled drugs according to their
abuse potential.
39. Schedule I drugs, such as heroin, have a high abuse potential and have no currently accepted medical use in the United
States.
40. Schedule II drugs, such as morphine, opium, and meperidine (Demerol), have a high abuse potential, but currently have
accepted medical uses. Their use may lead to physical or psychological dependence.
41. Schedule III drugs, such as paregoric and butabarbital (Butisol), have a lower abuse potential than Schedule I or II drugs.
Abuse of Schedule III drugs may lead to moderate or low physical or psychological dependence, or both.
42. Schedule IV drugs, such as chloral hydrate, have a low abuse potential compared with Schedule III drugs.
43. Schedule V drugs, such as cough syrups that contain codeine, have the lowest abuse potential of the controlled substances.
44. Activities of daily living are actions that the patient must perform every day to provide self-care and to interact with society.
45. Testing of the six cardinal fields of gaze evaluates the function of all extraocular muscles and cranial nerves III, IV, and VI.
46. The six types of heart murmurs are graded from 1 to 6. A grade 6 heart murmur can be heard with the stethoscope slightly
raised from the chest.
47. The most important goal to include in a care plan is the patient’s goal.
48. Fruits are high in fiber and low in protein, and should be omitted from a low-residue diet.
49. The nurse should use an objective scale to assess and quantify pain. Postoperative pain varies greatly among individuals.
50. Postmortem care includes cleaning and preparing the deceased patient for family viewing, arranging transportation to the
morgue or funeral home, and determining the disposition of belongings.
51. The nurse should provide honest answers to the patient’s questions.
52. Milk shouldn’t be included in a clear liquid diet.
53. When caring for an infant, a child, or a confused patient, consistency in nursing personnel is paramount.
54. The hypothalamus secretes vasopressin and oxytocin, which are stored in the pituitary gland.
55. The three membranes that enclose the brain and spinal cord are the dura mater, pia mater, and arachnoid.
56. A nasogastric tube is used to remove fluid and gas from the small intestine preoperatively or postoperatively.
57. Psychologists, physical therapists, and chiropractors aren’t authorized to write prescriptions for drugs.
58. The area around a stoma is cleaned with mild soap and water.
59. Vegetables have a high fiber content.
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60. The nurse should use a tuberculin syringe to administer a subcutaneous injection of less than 1 ml.
61. For adults, subcutaneous injections require a 25G 5/8″ to 1″ needle; for infants, children, elderly, or very thin patients, they
require a 25G to 27G ½” needle.
62. Before administering a drug, the nurse should identify the patient by checking the identification band and asking the patient
to state his name.
63. To clean the skin before an injection, the nurse uses a sterile alcohol swab to wipe from the center of the site outward in a
circular motion.
64. The nurse should inject heparin deep into subcutaneous tissue at a 90-degree angle (perpendicular to the skin) to prevent
skin irritation.
65. If blood is aspirated into the syringe before an I.M. injection, the nurse should withdraw the needle, prepare another
syringe, and repeat the procedure.
66. The nurse shouldn’t cut the patient’s hair without written consent from the patient or an appropriate relative.
67. If bleeding occurs after an injection, the nurse should apply pressure until the bleeding stops. If bruising occurs, the nurse
should monitor the site for an enlarging hematoma.
68. When providing hair and scalp care, the nurse should begin combing at the end of the hair and work toward the head.
69. The frequency of patient hair care depends on the length and texture of the hair, the duration of hospitalization, and the
patient’s condition.
70. Proper function of a hearing aid requires careful handling during insertion and removal, regular cleaning of the ear piece to
prevent wax buildup, and prompt replacement of dead batteries.
71. The hearing aid that’s marked with a blue dot is for the left ear; the one with a red dot is for the right ear.
72. A hearing aid shouldn’t be exposed to heat or humidity and shouldn’t be immersed in water.
73. The nurse should instruct the patient to avoid using hair spray while wearing a hearing aid.
74. The five branches of pharmacology are pharmacokinetics, pharmacodynamics, pharmacotherapeutics, toxicology, and
pharmacognosy.
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75. The nurse should remove heel protectors every 8 hours to inspect the foot for signs of skin breakdown.
76. Heat is applied to promote vasodilation, which reduces pain caused by inflammation.
77. A sutured surgical incision is an example of healing by first intention (healing directly, without granulation).
78. Healing by secondary intention (healing by granulation) is closure of the wound when granulation tissue fills the defect and
allows reepithelialization to occur, beginning at the wound edges and continuing to the center, until the entire wound is
covered.
79. Keloid formation is an abnormality in healing that’s characterized by overgrowth of scar tissue at the wound site.
80. The nurse should administer procaine penicillin by deep I.M. injection in the upper outer portion of the buttocks in the adult
or in the midlateral thigh in the child. The nurse shouldn’t massage the injection site.
81. An ascending colostomy drains fluid feces. A descending colostomy drains solid fecal matter.
82. A folded towel (scrotal bridge) can provide scrotal support for the patient with scrotal edema caused by vasectomy,
epididymitis, or orchitis.
83. When giving an injection to a patient who has a bleeding disorder, the nurse should use a small-gauge needle and apply
pressure to the site for 5 minutes after the injection.
84. Platelets are the smallest and most fragile formed element of the blood and are essential for coagulation.
85. To insert a nasogastric tube, the nurse instructs the patient to tilt the head back slightly and then inserts the tube. When the
nurse feels the tube curving at the pharynx, the nurse should tell the patient to tilt the head forward to close the trachea and
open the esophagus by swallowing. (Sips of water can facilitate this action.)
86. Families with loved ones in intensive care units report that their four most important needs are to have their questions
answered honestly, to be assured that the best possible care is being provided, to know the patient’s prognosis, and to feel that
there is hope of recovery.
87. Double-bind communication occurs when the verbal message contradicts the nonverbal message and the receiver is unsure
of which message to respond to.
88. A nonjudgmental attitude displayed by a nurse shows that she neither approves nor disapproves of the patient.
89. Target symptoms are those that the patient finds most distressing.
90. A patient should be advised to take aspirin on an empty stomach, with a full glass of water, and should avoid acidic foods
such as coffee, citrus fruits, and cola.
91. For every patient problem, there is a nursing diagnosis; for every nursing diagnosis, there is a goal; and for every goal, there
are interventions designed to make the goal a reality. The keys to answering examination questions correctly are identifying the
problem presented, formulating a goal for the problem, and selecting the intervention from the choices provided that will
enable the patient to reach that goal.
92. Fidelity means loyalty and can be shown as a commitment to the profession of nursing and to the patient.
93. Administering an I.M. injection against the patient’s will and without legal authority is battery.
94. An example of a third-party payer is an insurance company.
95. The formula for calculating the drops per minute for an I.V. infusion is as follows: (volume to be infused × drip factor) ÷ time
in minutes = drops/minute
96. On-call medication should be given within 5 minutes of the call.
97. Usually, the best method to determine a patient’s cultural or spiritual needs is to ask him.
98. An incident report or unusual occurrence report isn’t part of a patient’s record, but is an in-house document that’s used for
the purpose of correcting the problem.
99. Critical pathways are a multidisciplinary guideline for patient care.
100. When prioritizing nursing diagnoses, the following hierarchy should be used: Problems associated with the airway, those
concerning breathing, and those related to circulation.
101. The two nursing diagnoses that have the highest priority that the nurse can assign are Ineffective airway clearance and
Ineffective breathing pattern.
102. A subjective sign that a sitz bath has been effective is the patient’s expression of decreased pain or discomfort.
103. For the nursing diagnosis Deficient diversional activity to be valid, the patient must state that he’s “bored,” that he has
“nothing to do,” or words to that effect.
104. The most appropriate nursing diagnosis for an individual who doesn’t speak English is Impaired verbal communication
related to inability to speak dominant language (English).
105. The family of a patient who has been diagnosed as hearing impaired should be instructed to face the individual when they
speak to him.
106. Before instilling medication into the ear of a patient who is up to age 3, the nurse should pull the pinna down and back to
straighten the eustachian tube.
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107. To prevent injury to the cornea when administering eyedrops, the nurse should waste the first drop and instill the drug in
the lower conjunctival sac.
108. After administering eye ointment, the nurse should twist the medication tube to detach the ointment.
109. When the nurse removes gloves and a mask, she should remove the gloves first. They are soiled and are likely to contain
pathogens.
110. Crutches should be placed 6″ (15.2 cm) in front of the patient and 6″ to the side to form a tripod arrangement.
111. Listening is the most effective communication technique.
112. Before teaching any procedure to a patient, the nurse must assess the patient’s current knowledge and willingness to learn.
113. Process recording is a method of evaluating one’s communication effectiveness.
114. When feeding an elderly patient, the nurse should limit high-carbohydrate foods because of the risk of glucose intolerance.
115. When feeding an elderly patient, essential foods should be given first.
116. Passive range of motion maintains joint mobility. Resistive exercises increase muscle mass.
117. Isometric exercises are performed on an extremity that’s in a cast.
118. A back rub is an example of the gate-control theory of pain.
119. Anything that’s located below the waist is considered unsterile; a sterile field becomes unsterile when it comes in contact
with any unsterile item; a sterile field must be monitored continuously; and a border of 1″ (2.5 cm) around a sterile field is
considered unsterile.
120. A “shift to the left” is evident when the number of immature cells (bands) in the blood increases to fight an infection.
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121. A “shift to the right” is evident when the number of mature cells in the blood increases, as seen in advanced liver disease
and pernicious anemia.
122. Before administering preoperative medication, the nurse should ensure that an informed consent form has been signed
and attached to the patient’s record.
123. A nurse should spend no more than 30 minutes per 8-hour shift providing care to a patient who has a radiation implant.
124. A nurse shouldn’t be assigned to care for more than one patient who has a radiation implant.
125. Long-handled forceps and a lead-lined container should be available in the room of a patient who has a radiation implant.
126. Usually, patients who have the same infection and are in strict isolation can share a room.
127. Diseases that require strict isolation include chickenpox, diphtheria, and viral hemorrhagic fevers such as Marburg disease.
128. For the patient who abides by Jewish custom, milk and meat shouldn’t be served at the same meal.
129. Whether the patient can perform a procedure (psychomotor domain of learning) is a better indicator of the effectiveness
of patient teaching than whether the patient can simply state the steps involved in the procedure (cognitive domain of
learning).
130. According to Erik Erikson, developmental stages are trust versus mistrust (birth to 18 months), autonomy versus shame and
doubt (18 months to age 3), initiative versus guilt (ages 3 to 5), industry versus inferiority (ages 5 to 12), identity versus identity
diffusion (ages 12 to 18), intimacy versus isolation (ages 18 to 25), generativity versus stagnation (ages 25 to 60), and ego
integrity versus despair (older than age 60).
131. When communicating with a hearing impaired patient, the nurse should face him.
132. An appropriate nursing intervention for the spouse of a patient who has a serious incapacitating disease is to help him to
mobilize a support system.
133. Hyperpyrexia is extreme elevation in temperature above 106° F (41.1° C).
134. Milk is high in sodium and low in iron.
135. When a patient expresses concern about a health-related issue, before addressing the concern, the nurse should assess the
patient’s level of knowledge.
136. The most effective way to reduce a fever is to administer an antipyretic, which lowers the temperature set point.
137. When a patient is ill, it’s essential for the members of his family to maintain communication about his health needs.
138. Ethnocentrism is the universal belief that one’s way of life is superior to others.
139. When a nurse is communicating with a patient through an interpreter, the nurse should speak to the patient and the
interpreter.
140. In accordance with the “hot-cold” system used by some Mexicans, Puerto Ricans, and other Hispanic and Latino groups,
most foods, beverages, herbs, and drugs are described as “cold.”
141. Prejudice is a hostile attitude toward individuals of a particular group.
142. Discrimination is preferential treatment of individuals of a particular group. It’s usually discussed in a negative sense.
143. Increased gastric motility interferes with the absorption of oral drugs.
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144. The three phases of the therapeutic relationship are orientation, working, and termination.
145. Patients often exhibit resistive and challenging behaviors in the orientation phase of the therapeutic relationship.
146. Abdominal assessment is performed in the following order: inspection, auscultation, percussion & palpation.
147. When measuring blood pressure in a neonate, the nurse should select a cuff that’s no less than one-half and no more than
two-thirds the length of the extremity that’s used.
148. When administering a drug by Z-track, the nurse shouldn’t use the same needle that was used to draw the drug into the
syringe because doing so could stain the skin.
149. Sites for intradermal injection include the inner arm, the upper chest, and on the back, under the scapula.
150. When evaluating whether an answer on an examination is correct, the nurse should consider whether the action that’s
described promotes autonomy (independence), safety, self-esteem, and a sense of belonging.
151. When answering a question on the NCLEX examination, the student should consider the cue (the stimulus for a thought)
and the inference (the thought) to determine whether the inference is correct. When in doubt, the nurse should select an
answer that indicates the need for further information to eliminate ambiguity. For example, the patient complains of chest pain
(the stimulus for the thought) and the nurse infers that the patient is having cardiac pain (the thought). In this case, the nurse
hasn’t confirmed whether the pain is cardiac. It would be more appropriate to make further assessments.
152. Veracity is truth and is an essential component of a therapeutic relationship between a health care provider and his
patient.
153. Beneficence is the duty to do no harm and the duty to do good. There’s an obligation in patient care to do no harm and an
equal obligation to assist the patient.
154. Nonmaleficence is the duty to do no harm.
155. Frye’s ABCDE cascade provides a framework for prioritizing care by identifying the most important treatment concerns.
156. A = Airway. This category includes everything that affects a patent airway, including a foreign object, fluid from an upper
respiratory infection, and edema from trauma or an allergic reaction.
157. B = Breathing. This category includes everything that affects the breathing pattern, including hyperventilation or
hypoventilation and abnormal breathing patterns, such as Korsakoff’s, Biot’s, or Cheyne-Stokes respiration.
158. C = Circulation. This category includes everything that affects the circulation, including fluid and electrolyte disturbances
and disease processes that affect cardiac output.
159. D = Disease processes. If the patient has no problem with the airway, breathing, or circulation, then the nurse should
evaluate the disease processes, giving priority to the disease process that poses the greatest immediate risk. For example, if a
patient has terminal cancer and hypoglycemia, hypoglycemia is a more immediate concern.
160. E = Everything else. This category includes such issues as writing an incident report and completing the patient chart. When
evaluating needs, this category is never the highest priority.
161. When answering a question on an NCLEX examination, the basic rule is “assess before action.” The student should evaluate
each possible answer carefully. Usually, several answers reflect the implementation phase of nursing and one or two reflect the
assessment phase. In this case, the best choice is an assessment response unless a specific course of action is clearly indicated.
162. Rule utilitarianism is known as the “greatest good for the greatest number of people” theory.
163. Egalitarian theory emphasizes that equal access to goods and services must be provided to the less fortunate by an affluent
society.
164. Active euthanasia is actively helping a person to die.
165. Brain death is irreversible cessation of all brain function.
166. Passive euthanasia is stopping the therapy that’s sustaining life.
167. A third-party payer is an insurance company.
168. Utilization review is performed to determine whether the care provided to a patient was appropriate and cost-effective.
169. A value cohort is a group of people who experienced an out-of-the-ordinary event that shaped their values.
170. Voluntary euthanasia is actively helping a patient to die at the patient’s request.
171. Bananas, citrus fruits, and potatoes are good sources of potassium.
172. Good sources of magnesium include fish, nuts, and grains.
173. Beef, oysters, shrimp, scallops, spinach, beets, and greens are good sources of iron.
174. Intrathecal injection is administering a drug through the spine.
175. When a patient asks a question or makes a statement that’s emotionally charged, the nurse should respond to the emotion
behind the statement or question rather than to what’s being said or asked.
176. The steps of the trajectory-nursing model are as follows:
177. Step 1: Identifying the trajectory phase
178. Step 2: Identifying the problems and establishing goals
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179. Step 3: Establishing a plan to meet the goals
180. Step 4: Identifying factors that facilitate or hinder attainment of the goals
181. Step 5: Implementing interventions
182. Step 6: Evaluating the effectiveness of the interventions
183. A Hindu patient is likely to request a vegetarian diet.
184. Pain threshold, or pain sensation, is the initial point at which a patient feels pain.
185. The difference between acute pain and chronic pain is its duration.
186. Referred pain is pain that’s felt at a site other than its origin.
187. Alleviating pain by performing a back massage is consistent with the gate control theory.
188. Romberg’s test is a test for balance or gait.
189. Pain seems more intense at night because the patient isn’t distracted by daily activities.
190. Older patients commonly don’t report pain because of fear of treatment, lifestyle changes, or dependency.
191. No pork or pork products are allowed in a Muslim diet.
192. Two goals of Healthy People 2010 are:
193. Help individuals of all ages to increase the quality of life and the number of years of optimal health
194. Eliminate health disparities among different segments of the population.
195. A community nurse is serving as a patient’s advocate if she tells a malnourished patient to go to a meal program at a local
park.
196. If a patient isn’t following his treatment plan, the nurse should first ask why.
197. Falls are the leading cause of injury in elderly people.
198. Primary prevention is true prevention. Examples are immunizations, weight control, and smoking cessation.
199. Secondary prevention is early detection. Examples include purified protein derivative (PPD), breast self-examination,
testicular self-examination, and chest X-ray.
200. Tertiary prevention is treatment to prevent long-term complications.
201. A patient indicates that he’s coming to terms with having a chronic disease when he says, “I’m never going to get any
better.”
202. On noticing religious artifacts and literature on a patient’s night stand, a culturally aware nurse would ask the patient the
meaning of the items.
203. A Mexican patient may request the intervention of a curandero, or faith healer, who involves the family in healing the
patient.
204. In an infant, the normal hemoglobin value is 12 g/dl.
205. The nitrogen balance estimates the difference between the intake and use of protein.
206. Most of the absorption of water occurs in the large intestine.
207. Most nutrients are absorbed in the small intestine.
208. When assessing a patient’s eating habits, the nurse should ask, “What have you eaten in the last 24 hours?”
209. A vegan diet should include an abundant supply of fiber.
210. A hypotonic enema softens the feces, distends the colon, and stimulates peristalsis.
211. First-morning urine provides the best sample to measure glucose, ketone, pH, and specific gravity values.
212. To induce sleep, the first step is to minimize environmental stimuli.
213. Before moving a patient, the nurse should assess the patient’s physical abilities and ability to understand instructions as
well as the amount of strength required to move the patient.
214. To lose 1 lb (0.5 kg) in 1 week, the patient must decrease his weekly intake by 3,500 calories (approximately 500 calories
daily). To lose 2 lb (1 kg) in 1 week, the patient must decrease his weekly caloric intake by 7,000 calories (approximately 1,000
calories daily).
215. To avoid shearing force injury, a patient who is completely immobile is lifted on a sheet.
216. To insert a catheter from the nose through the trachea for suction, the nurse should ask the patient to swallow.
217. Vitamin C is needed for collagen production.
218. Only the patient can describe his pain accurately.
219. Cutaneous stimulation creates the release of endorphins that block the transmission of pain stimuli.
220. Patient-controlled analgesia is a safe method to relieve acute pain caused by surgical incision, traumatic injury, labor and
delivery, or cancer.
221. An Asian American or European American typically places distance between himself and others when communicating.
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222. The patient who believes in a scientific, or biomedical, approach to health is likely to expect a drug, treatment, or surgery
to cure illness.
223. Chronic illnesses occur in very young as well as middle-aged and very old people.
224. The trajectory framework for chronic illness states that preferences about daily life activities affect treatment decisions.
225. Exacerbations of chronic disease usually cause the patient to seek treatment and may lead to hospitalization.
226. School health programs provide cost-effective health care for low-income families and those who have no health insurance.
227. Collegiality is the promotion of collaboration, development, and interdependence among members of a profession.
228. A change agent is an individual who recognizes a need for change or is selected to make a change within an established
entity, such as a hospital.
229. The patients’ bill of rights was introduced by the American Hospital Association.
230. Abandonment is premature termination of treatment without the patient’s permission and without appropriate relief of
symptoms.
231. Values clarification is a process that individuals use to prioritize their personal values.
232. Distributive justice is a principle that promotes equal treatment for all.
233. Milk and milk products, poultry, grains, and fish are good sources of phosphate.
234. The best way to prevent falls at night in an oriented, but restless, elderly patient is to raise the side rails.
235. By the end of the orientation phase, the patient should begin to trust the nurse.
236. Falls in the elderly are likely to be caused by poor vision.
237. Barriers to communication include language deficits, sensory deficits, cognitive impairments, structural deficits, and
paralysis.
238. The three elements that are necessary for a fire are heat, oxygen, and combustible material.
239. Sebaceous glands lubricate the skin.
240. To check for petechiae in a dark-skinned patient, the nurse should assess the oral mucosa.
241. To put on a sterile glove, the nurse should pick up the first glove at the folded border and adjust the fingers when both
gloves are on.
242. To increase patient comfort, the nurse should let the alcohol dry before giving an intramuscular injection.
243. Treatment for a stage 1 ulcer on the heels includes heel protectors.
244. Seventh-Day Adventists are usually vegetarians.
245. Endorphins are morphine-like substances that produce a feeling of well-being.
246. Pain tolerance is the maximum amount and duration of pain that an individual is willing to endure.
Physical Assessment
Integument
Skin: The client’s skin is uniform in color, unblemished and no presence of any foul odor. He has a good skin turgor and skin’s
temperature is within normal limit.
Hair: The hair of the client is thick, silky hair is evenly distributed and has a variable amount of body hair. There are also no signs
of infection and infestation observed.
Nails: The client has a light brown nails and has the shape of convex curve. It is smooth and is intact with the epidermis. When
nails pressed between the fingers (Blanch Test), the nails return to usual color in less than 4 seconds.
Head
Head: The head of the client is rounded; normocephalic and symmetrical.
Skull: There are no nodules or masses and depressions when palpated.
Face: The face of the client appeared smooth and has uniform consistency and with no presence of nodules or masses.
Eyes and Vision
Eyebrows: Hair is evenly distributed. The client’s eyebrows are symmetrically aligned and showed equal movement when asked
to raise and lower eyebrows.
Eyelashes: Eyelashes appeared to be equally distributed and curled slightly outward.
Eyelids: There were no presence of discharges, no discoloration and lids close symmetrically with involuntary blinks
approximately 15-20 times per minute.
Eyes
The Bulbar conjunctiva appeared transparent with few capillaries evident.
The sclera appeared white.
The palpebral conjunctiva appeared shiny, smooth and pink.
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There is no edema or tearing of the lacrimal gland.
Cornea is transparent, smooth and shiny and the details of the iris are visible. The client blinks when the cornea was touched.
The pupils of the eyes are black and equal in size. The iris is flat and round. PERRLA (pupils equally round respond to light
accommodation), illuminated and non-illuminated pupils constricts. Pupils constrict when looking at near object and dilate at
far object. Pupils converge when object is moved towards the nose.
When assessing the peripheral visual field, the client can see objects in the periphery when looking straight ahead.
When testing for the Extraocular Muscle, both eyes of the client coordinately moved in unison with parallel alignment.
The client was able to read the newsprint held at a distance of 14 inches.
Ears and Hearing
Ears: The Auricles are symmetrical and has the same color with his facial skin. The auricles are aligned with the outer canthus of
eye. When palpating for the texture, the auricles are mobile, firm and not tender. The pinna recoils when folded. During the
assessment of Watch tick test, the client was able to hear ticking in both ears.
Nose and Sinus
Nose: The nose appeared symmetric, straight and uniform in color. There was no presence of discharge or flaring. When lightly
palpated, there were no tenderness and lesions
Mouth
The lips of the client are uniformly pink; moist, symmetric and have a smooth texture. The client was able to purse his lips when
asked to whistle.
Teeth and Gums: There are no discoloration of the enamels, no retraction of gums, pinkish in color of gums
The buccal mucosa of the client appeared as uniformly pink; moist, soft, glistening and with elastic texture.
The tongue of the client is centrally positioned. It is pink in color, moist and slightly rough. There is a presence of thin whitish
coating.
The smooth palates are light pink and smooth while the hard palate has a more irregular texture.
The uvula of the client is positioned in the midline of the soft palate.
Neck
The neck muscles are equal in size. The client showed coordinated, smooth head movement with no discomfort.
The lymph nodes of the client are not palpable.
The trachea is placed in the midline of the neck.
The thyroid gland is not visible on inspection and the glands ascend during swallowing but are not visible.
Thorax, Lungs, and Abdomen
Lungs / Chest: The chest wall is intact with no tenderness and masses. There’s a full and symmetric expansion and the thumbs
separate 2-3 cm during deep inspiration when assessing for the respiratory excursion. The client manifested quiet, rhythmic and
effortless respirations.
The spine is vertically aligned. The right and left shoulders and hips are of the same height.
Heart: There were no visible pulsations on the aortic and pulmonic areas. There is no presence of heaves or lifts.
Abdomen: The abdomen of the client has an unblemished skin and is uniform in color. The abdomen has a symmetric contour.
There were symmetric movements caused associated with client’s respiration.
The jugular veins are not visible.
When nails pressed between the fingers (Blanch Test), the nails return to usual color in less than 4 seconds.
Extremities
The extremities are symmetrical in size and length.
Muscles: The muscles are not palpable with the absence of tremors. They are normally firm and showed smooth, coordinated
movements.
Bones: There were no presence of bone deformities, tenderness and swelling.
Joints: There were no swelling, tenderness and joints move smoothly.
Performing a Comprehensive Health Assessment
A comprehensive health assessment includes:
● A complete medical history, A general survey, A complete physical assessment
The medical history and the general survey were previously detailed. In this section, you will review the components of the
complete physical assessment.
Vital Signs
The pulse, blood pressure, bodily temperature and respiratory rate are measured and documented.
Assessment of the Thorax
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Inspection: The anterior and posterior thorax is inspected for size, symmetry, shape and for the presence of any skin lesions
and/or misalignment of the spine; chest movements are observed for the normal movement of the diaphragm during
respirations.
Palpation: The posterior thorax is assessed for respiratory excursion and fremitus.
Percussion: For normal and abnormal sounds over the thorax
Assessment of the Lungs
Auscultation: The assessment of normal and adventitious breath sounds.
Percussion: For normal and abnormal sounds. Normal breath sounds like vesicular breath sounds, bronchial breath sounds,
bronchovesicular breath sounds are auscultated and assessed in the same manner that adventitious breath sounds like rales,
wheezes, friction rubs, rhonchi, and abnormal bronchophony, egophony, and whispered pectoriloquy are auscultated, assessed
and documented.
Assessment of the Cardiovascular System
Inspection: Pulsations indicating the possibility of an aortic aneurysm
Auscultation: Listening to systolic heart sounds like the normal S1 heart sound and abnormal clicks, the diastolic heart sounds of
S2, S3, S4, diastolic knocks and mitral valve sounds, all of which are abnormal with the exception of S2 which can be normal
among clients less than 40 years of age.
Assessment of the Peripheral Vascular System
Inspection: The extremities are inspected for any abnormal color and any signs of poor perfusion to the extremities, particularly
the lower extremities. While the client is in a supine position, the nurse also assesses the jugular veins for any bulging pulsations
or distention.
Auscultation: The nurse assesses the carotids for the presence of any abnormal bruits.
Palpation: The peripheral veins are gently touched to determine the temperature of the skin, the presence of any tenderness
and swelling.
The peripheral vein pulses are also palpated bilaterally to determine regularity, number of beats, volume and bilateral equality
in terms of these characteristics.
Assessment of the Musculoskeletal System
Inspection: The major muscles of the body are inspected by the nurse to determine their size, and strength, and the presence of
any tremors, contractures, muscular weakness and/or paralysis. All joints are assessed for their full range of motion. The areas
around the bones and the major muscle groups are also inspected to determine any areas of deformity, swelling and/or
tenderness.
Palpation: The muscles are palpated to determine the presence of any spasticity, flaccidity, pain, tenderness, and tremors.
Assessment of the Neurological System
Of all of the bodily systems that are assessed by the registered nurse, the neurological system is perhaps the most extensive and
complex.
Some of the terms and terminology relating to the neurological system and neurological system disorders that you should be
familiar with include those below.
Acalculia: Acalculia is the client's loss of ability to perform relatively simple mathematical calculations like addition and
subtraction.
Agnosia: Agnosia is defined as the loss of a client's ability to recognize and identify familiar objects using the senses despite the
fact that the senses are intact and normally functioning. The different types of agnosia, as based on each of the five senses, are
auditory agnosia, visual agnosia, gustatory agnosia, olfactory agnosia, and tactile agnosia.
Agraphia: Agraphia, simply defined, is the Inability of the client to write. Agraphia is one of the four hallmark symptoms of
Gerstmann's syndrome. The other symptoms of Gerstmann's syndrome are acalculia, finger agnosia, and an inability to
differentiate between right and left.
Alexia: Alexia, which is a type of receptive aphasia, occurs when the client is unable to process, understand and read the written
word. This neurological disorder is also referred to as word blindness and optical alexia.
Anhedonia: Anhedonia is a loss of interest in life experiences and life itself as the result of the neurological deficit.
Anomia: Anomia is a lack of ability of the client to name a familiar object or item.
Anosagnosia: Anosagnosia is characterized with the client's inability to perceive and have an awareness of an affected body part
such as a paralyzed or missing leg. Anosagnosia is closely similar to hemineglect and hemiattention
Anosdiaphoria: Anosdiaphoria is an indifference to one's illness and disability
Aphasia: Aphasia includes expressive aphasia and receptive aphasia. Expressive aphasia is characterized by the client's inability
to express their feelings and wishes to others with the spoken word; and receptive aphasia is the client's inability to understand
the spoken words of others.
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Asomatognosi: Asomatognosia is the inability of the client to recognize one or more of their own bodily parts.
Astereognosia: Astereognosia is the client's inability to differentiate among different textures with their sense of touch and also
the inability of the client to identify a familiar object, like a button, with their tactile sensation.
Asymbolia: Asymbolia is the loss of the client's inability to respond to pain even though they have the sensory function to feel
and perceive the pain. Asymbolia is also referred to as pain dissociation and pain asymbolia.
Autotopagnosia: Autotopagnosia is the inability of the client to locate their own body parts, the body parts of another person,
or the body parts of a medical model.
Balint's syndrome: Balint's syndrome includes ocular apraxia, optic ataxia and simultanagnosia, which consist of impaired visual
scanning, visusopatial ability and attention.
Boston Diagnostic Aphasia Examination: The Boston Diagnostic Aphasia Examination is a standardized comprehensive
assessment tool that assess and measures the client's degree of aphasia in terms of the client's perceptions, processing of these
perceptions and responses to these perceptions while using problem solving and comprehension skills.
Broca's aphasia: Broca's aphasia entails the client's lack of ability to form and express words even though the client's level of
comprehension is intact.
Color agnosia: Color agnosia reflects the client's lack of ability to recognize and name different colors.
Conduction aphasia: Conduction aphasia is the client's lack of ability to repeat phrases and/or write brief dictated passages
despite the fact that the client has intact speech abilities, comprehension abilities, and the ability to name familiar objects.
Constructional apraxia: Constructional apraxia is the inability of the client to draw and copy simple shapes on paper.
Dressing apraxia: Dressing apraxia occurs when the person is not able to appropriately dress oneself because of some
neurological dysfunction.
Dysgraphaesthesia: Dysgraphaesthesia impairs the client's ability to sense and identify a letter or number that is tactily drawn
on the client's palm.
Dysgraphia: Dysgraphia is similar to agraphia; however, dysgraphia is difficulty in terms of writing and agraphia is the client's
complete inability to write.
Environmental agnosia: Environmental agnosia is the lack of ability of the client to recognize familiar places, like the US
Supreme Court, by looking at a photograph of it.
Finger agnosia: Finger agnosia occurs when the person is not able to identify what finger is being touched by the person
performing the neurological assessment.
Geographic agnosia: Geographic agnosia is the lack of ability of the client to recognize familiar counties, like Canada or Mexico,
when viewing a world map.
Gerstmann's Syndrome: Gerstmann's Syndrome consists of dyscalculia or acalculia, finger agnosia, one sided disorientation and
dysgraphia or agraphia.
Hemiasomatognosia: Hemiasomatognosia is the neurological disorder that occurs when the client does not perceive one half of
their body and they act in a manner as if that half of the body does not even exist.
Homonymous hemianopsia: Homonymous hemianopsia occurs when the person has neurological blindness in the same visual
field of both eyes bilaterally.
Ideomotor apraxia: Ideomotor apraxia is a neurological deficit that affects the client's ability to pretend doing simple tasks of
everyday living like brushing one's teeth.
Misoplegia: Misoplegia is a hatred and distaste for an adversely affected limb.
Motor alexia: Motor alexia occurs when the client is not able to comprehend the written word despite the fact that the client
can read it aloud.
Musical alexia: Musical alexia is a client's inability to recognize a familiar tune like "The National Anthem" or "Silent Night".
Movement agnosia: Movement agnosia is a neurological deficit that is characterized with a client's lack of ability to recognize an
object's movement.
Ocular apraxia: Ocular apraxia is the neurological deficit that occurs when the person is no longer able to rapidly move their
eyes to observe a moving object.
Optic ataxia: Optic ataxia is characterized with the client's inability to reach for and grab an object.
Phonagnosia: Phonagnosia is the client's lack of ability to recognize familiar voices such as those of a child or spouse.
Prosopagnosia: Prosopagnosia is a lack of ability to recognize familiar faces, like the face of a spouse or child.
Simultanagnosia: Simultanagnosia is a neurological disorder that occurs when the client is not able to perceive and process the
perception of more than object at a time that is in the client's visual field.
Somatophrenia: Somatophrenia occurs when the client denies the fact that their body parts are not even theirs, but instead,
these body parts belong to another.
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The Two-Point Discrimination Test: This test measures and assesses the client's ability to recognize more than one sensory
perception, such as pain and touch, at one time.
Visual agnosia: Visual agnosia is the client's lack of ability to recognize and attach meaning to familiar objects.
Wechsler Memory Scale IV: Wechsler Memory Scale IV: This measurement tool is a standardized comprehensive method to
assess verbal and visual memory, including immediate memory, delayed memory, auditory memory, visual memory and visual
working memory..
The neurological system is assessed with:
Inspection
Balance, gait, gross motor function, fine motor function and coordination, sensory functioning, temperature sensory
functioning, kinesthetic sensations and tactile sensory motor functioning, as well as all of the cranial nerves are assessed.
Balance is assessed using the relatively simple Romberg test. The Romberg test is the test that law enforcement use to test
people for drunkenness. Gait can be assessed by simply observing the client as they are walking or by coaching the person to
walk heal to toe as the nurse observes the client for their gait.
Gross motor functioning is bilaterally assessed by having the client contract their muscles; and fine motor coordination and
functioning is observed for both the upper and the lower extremities as the client manipulates objects.
Sensory functioning is determined by touching various parts of the body, bilaterally, with a pen or another blunt item while the
client has their eyes closed. The client is prompted to report whether or not they feel the blunt item as the nurse touches the
area. Similarly, a hot and cold object is placed on the skin on various parts of the body to assess temperature sensory
functioning. The client will then report whether they feel heat, cold or nothing at all.
Kinesthetic sensations are assessed to determine the client's ability to perceive and report their bodily positioning without the
help of visual cues.
Tactile sensory functioning is assessed for the client's ability to have stereognosis, extinction, one point discrimination and two
point discrimination. One and two point discrimination relates to the client's ability to feel whether or not they have gotten one
or two pin pricks that the nurse gently applies. Stereognosis is the client's ability to feel and identify a familiar object while their
eyes are closed. For example, the nurse may place a pen, a button or a paper clip in the client's hand to determine whether or
not the client can identify the object without any visual cues. Extinction is the client's ability to identify whether or not they are
being touched by the person doing the assessment with either one or two bilateral touches. For example, the nurse may touch
both knees and then ask the client if they felt one or two touches while the client has their eyes closed.
Reflexes
Reflexes are automatic muscular responses to a stimulus. When reflexes are absent or otherwise altered, it can indicate a
neurological deficit even earlier than other signs and symptoms of the neurological deficit appear.
Reflexes can be described as primitive and long term. Primitive reflexes are normally present at the time of birth and these
reflexes normally disappear as the baby grows older; neurological deficits are suspected when these primitive reflexes remain
beyond the point in time when they are expected to disappear. Reflexes, other than the primitive reflexes remain intact and
active during the entire life span, under normal conditions.
The primitive reflexes are the:
● Rooting reflex: The infant will turn their head in the direction of the side of the face that is being gently stroked and, then,
the infant will begin a sucking action.
● Sucking reflex: The sucking reflex is demonstrated when the infant performs sucking actions when anything like a nipple or
a finger tip comes in contact with the infant's mouth.
● Tonic neck reflex: The tonic neck reflex, also referred to as the fencing reflex, is demonstrated when the infant's body takes
on the appearance of a fencer's position when the infant's head is turned to the right or to the left.
● Galant or truncal incurvation reflex: This reflex is seen when the infant moves their hips toward the direction of gentle tap
on their back near the spine when the infant is in the prone position.
● Grasp reflex: Newborns grasp fingers and other objects that are placed in their palm. They will also tighten their grasp as
the finger or another object is slowly removed.
● Moro or startle reflex: This reflex normally occurs with a sudden noise such as clapping of hands. The infant will jerk when
the sound is heard. The infant's head and legs will extend and the arms will move upward.
● Step reflex: Newborns will perform walking like movements when the soles of the infant's feet touch a surface such as a
floor. The reflex disappears in about six to eight weeks of age.
● Parachute reflex: The baby extends their arms forward as if to break a fall when a person holds the infant and rotates their
body rapidly.
The other reflexes are the:
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●
Pupil reflex: Pupil reflexes include pupil dilation and pupil accommodation. The "PERLA" mnemonic for pupil reflexes
stands for Pupils Equally Reactive to Light and Accommodation which is a normal finding. The pupil reflexes for their
reactions to light are assessed by using a flash light in a darkened room. Pupils will normally dilate as the light is withdrawn
and they will normally constrict when the light is brought close to the pupils. The pupils are assessed not only for their
reaction to light, they are also assessed in terms of their accommodation. Normally, the pupils will dilate when an object is
moved away from the eye and they will constrict as the object is being brought closer to the eye.
● Plantar reflex: The plantar reflex is elicited when the person performing this assessment strokes the bottom of the foot
and the client's toes curl down. The Babinski sign occurs when the foot goes into dorsiflexion and the great toe curls up;
this sign is an abnormal response to this stimulation and it can indicate the presence of deep vein thrombosis.
● Biceps reflex: This reflex is assessed by placing the thumb on the biceps tendon while the person is in a sitting position and
then tapping the thumb with the Taylor hammer.
● Triceps reflex: This reflex is elicited by tapping the triceps tendon with the Taylor hammer above the elbow while the client
has their hands on their legs when the client is in a sitting position.
● Patellar tendon reflex: This reflex, often referred to as the knee jerk reflex, is elicited by tapping the patellar area with the
Taylor hammer.
● Calcaneal reflex: This reflex, often referred to as the Achilles reflex, is assessed with tapping on the calcaneal reflex on the
ankle with the Taylor hammer.
● Gag reflex: The gag reflex is elicited when the back of the mouth and the posterior tongue is stimulated with a tongue
blade.
● Sneeze reflex: Sneezing occurs to rid the nasal passages of irritants.
● Blinking reflex: This reflex is elicited when the eyes are touched or they are stimulated a sudden bright light or an irritant.
● Cough reflex: Coughing occurs when the airway is stimulated.
● Yawn reflex: Yawning occurs as the result of the body's increased need for oxygen.
All reflexes should be done bilaterally in rapid succession so that all differences between the right and the left reflexes can be
determined and assessed. For example, when the person who is performing these assessments should assess the biceps reflex
of the right arm and then immediately assess the biceps reflex of the left arm so that any differences or inequalities can be
assessed and documented.
Lastly, the nurse assesses the twelve cranial nerves. Some of these twelve cranial nerves are only sensory or motor nerves, and
others have both sensory and motor functions.
Name of the Cranial Nerve, Classification & Function
1. Olfactory Nerve –Sensory -This nerve transmits the sense of smell from the olfactory foramina of the nose.
2. Optic Nerve –Sensory -This cranial nerve transmits the sense of vision from the retina to the brain.
3. Oculomotor Nerve –Motor -The oculomotor nerve controls eye movements, the sphincter of the pupils and the ciliary body
muscles.
4. Trochlear Nerve –Motor -This cranial nerve innervates eye ball movement and the superior oblique muscle of the eyes.
5. Trigeminal Nerve -Motor and Sensory -The trigeminal nerve controls the muscles that are used for chewing food.
6. Abducens Nerve –Motor -This cranial nerve innervates and controls the abduction of the eye using the lateral rectus muscle.
7. Facial Nerve -Motor and Sensory -The facial nerve controls facial movements, some salivary glands and gustatory sensations
from the anterior part of the tongue.
8. Acoustic Nerve –Sensory -This cranial nerve senses and transmits the sense of hearing and it also senses gravity and
maintains balance and equilibrium.
9. Glossopharyngeal Nerve -Motor and Sensory -This nerve gives us the sense of taste from the posterior tongue, and it also
innervates the parotid glands.
10. Vagus Nerve -Motor and Sensory -The vagus nerve controls laryngeal and pharyngeal muscles and damage to this cranial
nerve can lead to swallowing disorders. It also controls the parasympathetic nervous system to the thoracic and abdominal
organs and it controls the resonance of the voice.
11. Spinal Accessory Nerve –Motor -The spinal accessory nerve, in interaction with the vagus nerve, controls the trapezius and
sternocleidomastoid muscles.
12. Hypoglossal Nerve –Motor -The hypoglossal cranial nerve controls the tongue, speech and swallowing.