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LPN Mod 1-Assessment tbm

Terms in this set (89)

A nurse is assessing a postoperative client. Which information should the nurse document as subjective data?
A. Vital signs.
B. Client's descriptions of pain.
C. Electrocardiograms (ECGs).
D. Laboratory test results.
B. Client's descriptions of pain.
Subjective data come directly from the client and are usually recorded as direct quotations that reflect his opinions or feelings about a situation. Vital signs, laboratory test results, and ECGs are examples of objective data. Remembering
To evaluate a client's reason for seeking care, a nurse performs deep palpation. What is the nurse assessing?
A. Hydration.
B. Skin turgor.
C. Temperature.
D. Organs.
D. Organs.
The purpose of deep palpation, in which the nurse indents the client's skin approximately 1½" (3.8 cm), is to assess underlying organs and structures, such as the kidneys and spleen. The nurse can assess skin turgor, hydration, and temperature by using light touch or light palpation. Understand.
A nurse prepares to assess a client who has just been admitted to the health care facility. During assessment, the nurse performs which activity?
A. Collects data.
B. Formulates nursing diagnoses.
C. Develops a care plan.
D. Writes client outcomes.
A. Collects data.
During the assessment step of the nursing process, the nurse collects relevant data from various sources. She formulates nursing diagnoses during the nursing diagnosis step and develops a care plan and writes appropriate client outcomes during the planning step. Remember
During assessment, a nurse auscultates for a client's breath sounds. Auscultation provides which type of data?
A. Objective.
B. Secondary source.
C. Subjective.
D. Medical.
A. Objective. Physical examination techniques such as auscultation provide objective data, which reflect findings without interpretation. The client and his family report subjective data to the nurse. The family and members of the health care team provide secondary source information. The nurse obtains medical data from the physician and medical record. Remember
A client is admitted to the preoperative clinic for a breast biopsy. Which information would the nurse enter into the medical record as objective data?
A. Client states, "I am worried about the results."
B. Left breast is tender to touch.
C. Anxiety level of client is rated at 7 out of 10.
D. Blood pressure 130/90 mm Hg; pulse 100 bpm; respirations 14 breaths/min
D. Bp, Pulse, Resp.
Objective data is information that the nurse observes or collects by observation. The other options fall into the subjective data category of information. Apply
A 70-year-old client tells the nurse during an assessment interview that food does not seem to be very interesting, and eating is difficult. The nurse conducts the physical examination and focuses on:
A. Weight and abdominal examination.
B. Urinary habits and hearing acuity.
C. Joint mobility.
D. Lung and heart sounds.
A. Weight and abdominal examination.
During the physical examination, the nurse will verify statements the client made during the history by assessing weight, bowel sounds, and habits. Lung and heart sounds will not reflect an eating problem. Joint mobility might indicate the client's exercise habits. Urinary habits and hearing acuity are not part of a dietary assessment. Understanding
The nurse is preparing to assess a 2-week-old infant who is sleeping in the parent's arms. The nurse decides that it would be best to:
A. Undress the top half of the infant.
B. Weigh the infant first.
C. Auscultate the lungs and heart sounds first.
D. Test the infant's hearing first.
C. Auscultate the lungs and heart sounds first.
Most infants who are disturbed from sleep will cry, which will increase respiration's and heart rate and make it impossible to listen to the heart and lung sounds. If the child is sleeping or quiet, it is best to auscultate first. Undressing the child may cause the child to cry. Weight can be done whether the child is crying or not. If the child is a normal newborn, testing the hearing is not necessary. Analysis
An older client is in the clinic for assessment. The nurse notes that the client walks with a shuffling gait, smells odorous, and has wrinkled clothes, while the accompanying family member is well groomed. The nurse plans to assess the client for:
A. Possible elder abuse.
B. Nutritional habits.
C. Parkinson's disease.
D. Activity level.
A. Possible elder abuse.
The client's appearance could mean depression, inability to perform activities of daily living, or possible elder abuse. The nurse would consider elder abuse in this case because the family member appears to be well groomed. Nutritional habits would not account for the client's appearance. Activity level does not explain the smell and wrinkled clothes. There is no particular reason to suspect Parkinson's in the client's appearance. Analysis
The nurse has completed an initial assessment on a client who is newly diagnosed with type 2 diabetes mellitus. During teaching about the ordered treatments, the nurse will most likely tell the client:
A. "If you do not follow the treatment regimen, you will get much worse."
B. "We will need you to come back in 3 months."
C. "You can gradually initiate the dietary changes."
D. "You can wait to start an exercise program."
B. "We will need you to come back in 3 months."
After the problems of the initial assessment have been addressed with the client, the nurse explains that ongoing assessments will be needed to determine the effectiveness of care. Suggesting that the client will get worse by not following the plan is a threat and is never appropriate. Dietary changes and an exercise program need to be implemented immediately. Understanding
A nurse is obtaining the health history of a client whose background differs from her own. To develop culturally acceptable strategies for nursing care, the nurse should assess which client factor?
A. Tradition and ethnic factors.
B. Financial resources.
C. Community involvement.
D. Marital status.
A. Tradition and ethnic factors.
Assessing the client's tradition and ethnic factors helps the nurse identify behaviors she should take into account when planning his care. Although the nurse also must consider the client's marital status, financial resources, and community involvement when planning care and rehabilitation, these factors have little relevance when she is formulating culturally acceptable strategies for nursing care. Apply
A mother brings her 8-month-old son to the pediatrician's office. When the nurse approaches to measure the child's vital signs, he clings to the mother tightly and starts to cry. The mother says, "He used to smile at everyone. I don't know why he's acting this way." The nurse begins teaching the mother about growth and development by stating:
A. "Your baby's having a temper tantrum, which is common at his age."
B. "Children who behave that way are developing shy personalities."
C. "Your baby's behavior indicates stranger anxiety, which is common at his age."
D. "Children at his age begin to fear pain."
C. "your baby's behavior indicates stranger anxiety, which is common at his age."
Stranger anxiety, common in infants aged 6 to 8 months, may cause the child to cry, cling to the caregiver, and turn away from strangers. Typically, it occurs when the child starts to differentiate familiar and unfamiliar people. The child's behavior doesn't necessarily indicate shyness. According to Piaget, fear of pain characterizes the operational stage of development in school-aged children, not infants. Temper tantrums are typical in toddlers who are trying to assert their independence. During a temper tantrum, children may kick, scream, hold their breath, or throw themselves onto the floor rather than cling to a parent. Apply
A nurse is caring for an adolescent who underwent surgery for a perforated appendix. When caring for this adolescent, the nurse should keep in mind that the main life-stage task for an adolescent is to:
A. Plan for the future.
B. Develop an identity and independence.
C. Resolve conflict with parents.
D. Develop trust.
B. Develop an identity and independence.
An adolescent strives for a sense of independence and identity. During this time, conflicts are heightened, not resolved. Trust begins to develop during infancy and matures during the course of development. Adolescents rarely finalize plans for the future; this normally happens later in adulthood. Analyze
A nurse is providing injury-prevention education to the parents of a school-aged child. The parents admit that they keep a gun in their home. Which of the nurse's statements is most appropriate?
A. "Store ammunition in the same locked area as the gun."
B. "Your child should attend a community gun-safety program."
C. "Remind your child that only a parent may touch the gun."
D. "The gun should be stored unloaded in a locked cabinet."
D. "The gun should be stored unloaded in a locked cabinet."
The nurse should instruct the parents to keep the gun unloaded in a locked cabinet and ammunition elsewhere. Just keeping the gun out of the child's sight isn't sufficient; the child might be able to locate the gun. It's inappropriate to refer a school-aged child to a gun-safety program. The parents shouldn't keep the gun on hand with the understanding that the child won't touch it. Apply
A client, age 75, is admitted to the hospital. Because of the client's age, the nurse should modify the assessment by:
A. Shortening it due to possible client fatigue.
B. Addressing the client by his first name.
C. Speaking loudly and slowly.
D. Allowing extra time for the assessment.
D. Allowing extra time for the assessment.
When assessing an elderly client, the nurse should allow extra time to compensate for aging-related physiologic changes, address the client respectfully rather than by his first name, and give simple instructions. Speaking in a loud voice is demeaning and assumes that the client has difficulty hearing, which may not be the case. Apply
The nurse is preparing to conduct an assessment of the rectum for a 68-year-old female client. The nurse asks the client:
A. To assume the lithotomy position.
B. To sit on the edge of the table.
C. If side-lying would be easier.
D. If skipping this assessment would be best.
C. If side-lying would be easier.
The lithotomy position may be difficult for the older client, so the nurse explores with the client the position that would be best for both the client and nurse, such as side-lying. Sitting on the edge of the bed would not allow the nurse access to the rectum. Skipping the assessment is not an option. Apply
In a care conference, the social worker is asking if a psychosocial assessment has been completed. Which areas would the nurse report on as part of this assessment?
A. General survey results, eating habits, and ability to perform activities of daily living.
B. Health habits, family relationships, affect, and thought patterns.
C. Rest and sleep patterns, activity and exercise patterns, and coping and stress tolerance.
D. Breathing patterns, circulation patterns, and responses to hospitalization.
B. Health habits, family relationships, affect, and thought patterns.
A psychosocial assessment involves assessment of health habits, family relationships, emotional responses, and thought patterns. These areas are important to assess to determine how the client is coping with illness. It is also important to identify the support systems of the client. Each of the other choices includes physical assessment factors, not just psychosocial factors. Apply
Which of the following is usually unrelated to a nursing physical assessment?
A. Hygiene and grooming.
B. Balance and strength.
C. Blood and urine values.
D. Posture and gait.
C. Blood and urine values.
Ordering and assessing urine and blood values are not in the independent practice of nursing. These assessments are dependent or interdependent functions of the nurse and are covered by specific orders or standing orders. Assessing posture and gait, balance and strength, and hygiene and grooming are within the scope of nursing practice. Analyze.
The nurse is assessing an older adult's skin. The assessment will involve inspecting the skin for color, pigmentation, and vascularity. The critical component in the nurse's assessment is noting the:
A. Skin turgor.
B. Changes from the normal expected findings.
C. Similarities from one side to the other.
D. Appearance of age-related wrinkles.
B. Changes from the normal expected findings.
Noting changes from the normal expected findings is the most important component when assessing an older client's integumentary system. Comparing one extremity with the contralateral extremity (i.e., comparing one side with the other) is an important assessment step; however, the most important component is noting changes from an expected normal baseline. Noting wrinkles related to age is not of much consequence unless the client is admitted for cosmetic surgery to reduce the appearance of age-related wrinkling. Noting skin turgor is an assessment of fluid status, not an assessment of the integumentary system. Analyze
When assessing a dark-skinned client for cyanosis, what should the nurse examine?
A. The client's oral mucous membranes.
B. The client's nail beds.
C. The inner aspects of the client's wrists.
D. The client's retinas.
A. The client's oral mucous membranes.
In dark-skinned clients, cyanosis can best be detected by examining the conjunctiva, lips, and oral mucous membranes. Examining the retinas, nail beds, or inner aspects of the wrists is not an appropriate assessment for determining cyanosis in any client. The nailbeds may indicate cyanosis, but the best place to assess is the oral mucous membranes. Analyze
In light-skinned patients, cyanosis presents as a dark bluish tint to the skin and mucous membranes (which reflects the bluish tint of unoxygenated hemoglobin). But in dark-skinned patients, cyanosis may present as gray or whitish (not bluish) skin around the mouth, and the conjunctivae may appear gray or bluish.
Waist circumference is an indicator of:
A. Abdominal fat content.
B. Percentage of body fat.
C. Body mass index.
D. Ratio of body fat to muscle mass.
A. Abdominal fat content.
Waist circumference is an indicator of abdominal fat content. Fat stored in abdomen increases the risk for type II diabetes and cardiovascular disease. Remember
The nurse is assessing a client's nutritional status before surgery. Which observation would indicate poor nutrition in a 5-foot 7-inch (170 cm) female client who is 21 years of age?
A. Weight of 128 lb (58.1 kg).
B. Dull expression.
C. Poor posture.
D. Brittle nails.
D. Brittle nails.
Brittle nails indicate poor nutrition. Poor posture indicates that the client does not stand up straight and use her muscles to support herself. A dull expression reflects the client's affect and emotional status. The client's weight of 128 lb (58.1 kg) is within normal range. Analyze
A client of Hispanic descent is prescribed a low-fat diet. The client tells the nurse, "I am going to have a hard time giving up my favorite family recipes." Which food should the nurse recommend that is low in fat?
A. Salsa.
B. Refried beans.
C. Grilled steak.
D. Pasta.
A. Salsa.
Salsa contains tomatoes, onions, and peppers, all of which are low in fat and may be part of a Hispanic diet. Pasta contains carbohydrates, not fat. Beef can have a high fat content compared to meat such as chicken or fish. Refried beans are fried and should be avoided on a low-fat diet. Analyze.
Calorie and nutrient requirements during adolescence:
A. Are lower than during childhood.
B. Are higher than during adulthood due to growth and development.
C. Peak early and then fall until adulthood is reached.
D. Cannot be generalized because variations exist.
B. Are higher than during adulthood due to growth and development.
Larger than during adulthood due to growth and development (growth spurts). The caloric and nutrient needs do increase but when during adolescents they occur is variable and depends on the timing and duration of growth spurts. Girls experience growth spurts between 10-11 years of age and peak at 12. Boys begin the growth spurt at 12 and peak at 14. Stature growth ceases at a median age of approximately 21. Nutritional needs increase later for boys than for girls. Looking at the questions, what happens with caloric and nutrient needs, they will be increasing because of the growth and development changes that happen during these growth spurts. There is no set time for this to happen in adolescents, it can be variable from teen to teen and gender. It does not necessarily peak early and then decrease. Some teens could have a peak later in adolescence, not necessarily early. Even though there are variations to when the growth spurts are going to occur, it will happen and thus during adolescence caloric and nutrient requirements should be increased in anticipation.
The nurse knows her instructions about vitamin B12 are effective when the older client verbalizes, she will:
A. Consume more meat.
B. Drink more milk.
C. Eat vitamin B12-fortified cereal.
D. Consume more fruits and vegetables.
C. Vitamin B12 cereal.
Most older adults may not be able to absorb natural vitamin B12 from foods. Older adults do not need more vitamin B12 than younger adults, but their ability to absorb the natural form of B12 from food may be impaired. Adults over the age of 50 years are urged to consume the RDA for vitamin B12 from fortified food or supplements to ensure adequacy. Understand
Is the nurse's role in nutrition is to call the dietitian?
No, the nurse is in an ideal position to provide nutrition information to patients and their families since he or she is the one with the greatest client contact.
Do vitamins provide energy?
No, vitamins are needed to release energy from carbohydrates, protein, and fat but are not a source of energy.
Nurses must use critical thinking in their day-to-day practice, especially in circumstances surrounding client care and wise use of resources. In which of the following situations would critical thinking be most beneficial?
A. Assisting an orthopedic client with the proper use of crutches.
B. Administering IV push medications to critically ill clients.
C. Teaching new parents about car seat safety.
D. Educating a home health client about treatment options.
D. Educating a home health client about treatment options.
Nurses who utilize good critical-thinking skills are able to think and act in areas where there are neither clear answers nor standard procedures. Treatment options, especially for the home health client, can be extensive. There are many points to consider (good and bad) and choosing between treatment options can cause conflict among family members. The nurse in this case must use creativity, analysis based on science, and problem-solving skills—all of which contribute to critical-thinking skills. Administering IV medications (even to critically ill clients), teaching correct use of crutches, and teaching new parents about car seat safety do not require as much reasoning. There are standard procedures to follow and, most of the time, clear answers about the rationale.
Maslow's Hierarchy of Needs
1. Physiological needs
2. Safety needs
3. Love and belonging
4. Esteem
5. Self actualization
Passive Vs. Active range of motion
Passive: can move with help
Active: can move without help
How do you grade pulses?
0=Absent/Nonpalpable
+1 Weak/diminished
+2 = Normal
+3= Increased/Strong
+4= Bounding Pulse
Borborygmi
Borborygmi is active intestinal peristalsis which causes rumbling, gurgling, and tinkling abdominal sounds. Auscultation would be the physical assessment method to use to listen for these sounds. Understanding.
Normal BMI range for adults
18.5-24.9
How do you grade muscle strength?
0= 0% of normal strength, complete paralysis
1= 10% of normal strength; no movement, contraction of muscle is palpable or visible.
2= 25% of normal strength; Full muscle movement against gravity with support
3=50% of normal strength; normal movement against gravity
4=75% of normal strength. Full movement against gravity and against minimal resistance
5= 100% of normal strength, full movement against gravity and resistance.
Normal Adult Vital Signs
T 98.6F- 100.4F (36-38C)
P 60-100
R 12-20
O2- 95%-100%
BP >120/80
Percussion
-Striking body surface to elicit sounds or vibration
-Direct or indirect
-Checking for air or fluid
Palpation
Feeling: Usually for organs/growths
(Light or Deep)
Auscultation
Listening with a stethoscope
Adolescent Assessment
-Pubertal growth spurts
-higher caloric intake
-women at risk for eating disorders at this time
-1:1 without parents in room
-Strive for independence and identity
-lack of social interaction may put at risk for suicide
-Vit A, Vit C, Iron and Calcium
Inspection
Looking- Shape, Symmetry, Alignment, Color
Rhythm (Respiratory)
Normal Vs. Abnormal

Cheyene-Strokes breathing= Rhythmic waxing and waning of respirations from deep to shallow to apneic breathing.
Rate
Breath Speed
-Tachypnea- quick, shallow breaths
Bradypnea- Slow. Low respiration rate
Apnea-Cessation of breathing
Depth
Volume
Hyperventilation-Over expansion of lungs, rapid deep breaths
Hypoventilation-Under expanded, Shallow breaths
Normal Elderly Skin Assessment
Dry, thin skin, translucent skin (loss of dermis and subcutaneous fat-making it harder for them to adjust to cold temperatures), thick nails, and sparse distribution of hair (grey)
Dietary considerations: Vit D, B6, B12 and Calcium
Edema (grading scale)
-1+: Mild (2mm)
-2+: Moderate, returns to normal within 15 seconds (4mm)
-3+: Severe, depression takes 15-30 seconds to rebound (6mm)
-4+: Very severe, depression takes >30 seconds to rebound (8mm)
Order of assessment
Inspect, Palpate, Percuss, Auscultate
Order of abdominal assessment
Inspect, auscultate, percuss, palpate
Skin Turgor in Elderly
Inelastic skin turgor is a normal part of aging.
Dehydration causes inelastic skin with tenting
Overhydration causes skin turgor to appear edematous and spongey
Generally normal is dry and firm.
Why is the order of assessment different for abdominal assessments?
Palpating can interfere with bowel sounds.
How long do you listen before you can say bowel sounds are absent?
3-5 minutes
What is a SMART goal?
Specific, Measurable, Attainable, Realistic, Timely
What is a nursing diagnosis Vs. A medical diagnosis?
Nursing= can take independent action to solve (mobility, skin integrity)
Medical= Nursing cannot solve independently
What are the priority frameworks?
-ABC's
-Maslow's Hierarchy of needs
-Nursing Process
When assessing the abdomen, i fyou hear sound in all four quadrants this is:
Normal bowel sounds :)
What is the nursing process?
Assessment/data collection
Diagnosis-Recognize patterns/trends (analysis)
Planning- Establish priorities and goals
Implementation- Nursing interventions
Evaluation- Evaluate client's response to interventions

ADPIE
What are the different types of assessments?
Initial, focused, ongoing, emergent.
We do these to monitor changes in client health.
ABC
Airway, Breathing, Circulation
Capillary Refill
after blanching nail bed, color should return to normal withing <3 secs
longer indicated poor perfusion due to peripheral vasoconstriction
Infant assessment
head circumference
attachment
milestones of development
over/under nutrition (percentiles)
Toddler assessment
playful approach (books/toys)
respirations are visible in abdomen vs. chest
gather nutrition info from last 24 hours
Preschool assessment
Ask about interests (build rapport)
If not reaching milestones may need further screening
observe behavior with caregiver
School age assesment
steady growth
changing body proportions
higher caloric intake, increased appetite
evaluate fine/gross motor control
Lack of hobbies is concern for lack of encouragement in environment
Types of data collected
Objective-can measure/can be validated
Subjective-Can't visualize or validate "client reports..."
Hypertension
High BP
Hypotension
low BP
Manifestations: dizziness, nausea, blurred vision, high pulse, fatigue
Nursing interventions for hypertension
educate client on lifestyle. exercise, stress reduction techniques, low sodium diet, weight loss, antihypertensive meds and when doctor should be notified.
Nursing interventions for hypotension
- Increase fluids
- Place in an upright position unless medically contraindicated
- Evaluate the medications the client is taking
- Instruct the client about the risk for dizziness and falling
- Encourage the client to change positions slowly
- Avoid extremes in temperature
- Stay well hydrated
Tachycardia
Pulse over 100
Bradycardia
Pulse under 60
Fever/hyperthermia
Temp over 38C or 100.4F
Nursing interventions for hyperthermia
Encourage sips of cool fluids
remove excess clothing
antipyretics as ordered to reduce or prevent fever
antibiotics or antivirals if infection is present
place pt. in cool environment
give tepid bath
Tachypnea
Respiratory rate over 20
Bradypnea
Respiratory rate under 12
Oxygen saturation
Estimated amount of oxygen bound to hemoglobin (95-100%)
How can you improve sound if your patient is hairy?
wet down the hair
Rebound tenderness (Blumberg's sign)
Pain with removal of pressure caused by inflammation
Consensual
Pupillary response of pupil to light that enters the opposite eye
PERRLA
pupils are equal, round, and reactive to light and accommodation
Orthostatic blood pressure
Blood pressure is taken when patient is lying,sitting, and standing.
What does hair loss in lower extremities indicate?
poor circulation to extremities
Respiratory symptoms of heart problems
pulmonary edema
Shortness of breath
head of bed up
cough from fluid build up in lungs
Angina
Caused by CAD
Sever chest pain spreading to shoulders arms and neck. Indicated poor blood supply to the heart
How to write a care plan (SOAP)
Specific
Objective
Assessment
Plan
Why do we auscultate in a zig-zag pattern during assessments?
to compare both sides
Roomberg test
Ask client to stand with feet together with arms at both sides and eyes closed. Expected finding is client can stand without swaying for at least 5 seconds.
vocal fremitus
vibration caused by speaking that is palpable
If a patient has a pressure injury what nutrient needs to be replaced?
Protein- helps with tissue repair
What are the energy yielding nutrients?
carbs, fats, proteins
How to assess if someone is Alert and Oriented (A&O) x4
1 Person (name)
2 Place (where are we right now?)
3 Time (date/time)
4 Event (who is the current president?)
Normal Urine output and BM frequency
Urine- 30cc per hour
BM- every 72 hours
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