Samenvattingen, Aantekeningen en Examens

The nurse is preparing to teach a client how to safely ambulate with crutches following surgery. Which principle of teaching and learning is most important? -the client knows not to have their axillae rest on the crutch pads to reduce the risk of injury -Ensure the client understands the proper height of the crutches -Gather all materials and plan the teaching presentation -Identify an appropriate time to provide the instruction when the client is alert and prepared to learn Identify an appr...

What are the types of assessments? Initial comprehensive Ongoing Focused Emergency Normal BP 120/80 Normal HR 60-100 bpm Normal RR 10-20 bpm, usually 1:4 with HR Normal SpO2 >97% Normal oral temperature 96-99.5F (35.8-37.3C) Normal axillary temperature 1 degree Celsius lower than oral Normal TM temperature 0.3-0.6 degrees Celsius higher than oral Normal rectal temperature 1 degree Celsius higher than oral Equipment for nutritional status exam skin-fold calipers, ...

FIXED and non movalbe nodes are _________. Malignant, tender and non movable Heart goes from ___ ICS to the ___ ICS 2nd ICS (base) to the 5th ICS (apex) Pericardium Outer, double walled, sac w/ Fluid Myocardium middle muscle layer, muscle=contraction Endocardium inner, thin layer AV valves include the _________ valves & the ________ valves. Tricuspid (R) valves & the Bicuspid (L) valves. T/F The AV Valves are the Entrance ventricles. TRUE, SL=exit & AV=entrance T/F The Sem...

A nurse is preparing to asses a client who is new to the clinic. When beginning the collection of the client database, which of the following actions should the nurse prioritize? Establish a trusting relationship A nurse is interpreting and validating information from an older adult client who has been experiencing a functional decline. The nurse is in which phase of the interview? Working A 71-year-old woman has been admitted to the hospital for a vaginal hysterectomy, and the nurse is co...

A client who had a Roux-en-Y bypass procedure for morbid obesity ate a chocolate chip cookie after a meal. After ingestion of the cookie, the client reported cramping pains, dizziness, and palpitation. After having a bowel movement, the symptoms resolved. What should the nurse educate the client about regarding this event? a. Gastric outlet obstruction b. Dumping syndrome c. Bile reflux d. Celiac disease b. dumping syndrom Dumping syndrome is an unpleasant set of vasomotor and GI sympto...

Self report What is the most reliable indicator of a patient's experience of pain? Location? Onset? Timing? Type? Associated Symptoms? Alleviating factors? Radiation? Precipitating event? LOTTAARP Besides the client's rating of the intensity of the pain, what other things should the nurse ask? using diagnostic reasoning skills to interpret data accurately. What is data analysis? It involves critical thinking Why is data analysis difficult? thinking in a rational, self-di...

How do you assess distant visual acuity? Have patient stand 20 ft away from Snellen or E chart and ask to read each line aloud What does 20/20 vision mean? it means that a client can distinguish what a person with normal vision can distinguish from 20 ft away What is an abnormal finding associated with visual acuity? Myopia -- impaired far vision 2nd number will be higher 20/200 indicates legally blind How do you assess near visual acuity? Have patient hold vision chart 14" from...

In which clients would you expect to see gynecomastia? Males during puberty. Can also be seen in males with hormonal imbalance, drug abuse, cirrhosis, leukemia, and thyrotoxicosis Objective signs of breast cancer Prominent/asymmetric venous pattern Pue d'orange skin Retracted nipple Dimpling Restricted movement of breast tissue Thickening of breast tissue Pain Discharge Large/irregular, hard, fixed nodules Normal variations in breast findings nodes palpated:none or 1-2 Nipple dis...

What is the purpose of a comprehensive exam? Collection of subjective and objective data Created when a patient enters a health care system Serves as baseline data for comparison later What is the purpose of a partial, or on-going exam? Mini-overview of body systems and holistic health patterns Occurs only after baseline/comprehensive database has been established Used during follow-up visits What is the purpose of a focused exam? consists of a thorough assessment, but only co...

pment for What are the types of assessments? - Correct Answer Initial comprehensive Ongoing Focused Emergency Normal BP - Correct Answer 120/80 Normal HR - Correct Answer 60-100 bpm Normal RR - Correct Answer 10-20 bpm, usually 1:4 with HR Normal SpO2 - Correct Answer >97% Normal oral temperature - Correct Answer 96-99.5F (35.8-37.3C) Normal axillary temperature - Correct Answer 1 degree Celsius lower than oral Normal TM temperature - Correct Answer 0.3-0.6 degrees Cel...