From Foundations of Nursing by Christensen Kockrow, pages 93 through 120.
Illegal activity
Habits and lifestyle patterns
Fun and pleasure
Rest and recreation
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All members of one cultural group behave in exactly the same manner
As a nurse, it is important to identify and examine our own cultural and ethnic beliefs
Cultural and ethnic diversity have no impact in health care
Patient's response to signs and symptoms are independent of their cultural values
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"I will do it as soon as possible"
"I think the next shift will have to do it"
"After I give the medication"
"Maybe later, when I am done with others"
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Head to toe is systemic while focused concentrates on regional parts
Head to toe is completed when the patient is admitted; focused concentrates on a particular part of a body
Head to toe is done on every shift while focused is done when the person is admitted
Both RN's and LPN's should do head to toe assessments as well as focused assessments
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I will need to determine the etiology of any pathologic symptoms you might have.
Oh nothing, it is just something that we do.
It is a way for us to know how we are going to take care of you later
Maybe you can tell me how you got here.
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Do a focused assessment on the foot first and do the complete physical assessment later
If a complete physical assessment is necessary, it is best to assess any painful areas last.
Focus on the pain and provide comfort before anything else.
Since the patient is a new admit, concentrate on the general physical assesment only
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True
False
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Give patient a warm blanket
Ask if patient wants a glass of water
Offer patient to empty his/her bladder
Provide a small
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Skin, hair, head and neck including eyes, ear, nose and mouth
Chest, back, arm, abdomen
Perineal area, legs and feet
Eyes and ears alone
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Motor function
Range of motion
Level of consiousness
Pupillary response
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Painful sensation
Problem and solution
Pain and safety
Pernicious stimulation
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Motor function
Order of assessment
Level of consciousness
Pupillary response
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Deep tendon reflexes
Proprioception
Cranial nerve assessment
Pupillary reflex
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True
False
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Increase in systolic blood pressure
Bradycardia
Irregular breathing pattern
Widening pulse pressure
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Glasgow Coma Scale
PERRLA
Rhomberg Test
Motor function assessment
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A chair to sit on
Medication
Water
Some snacks
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Enema
Decubitus
Edema
Infection
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Thrill
Crackles
Bruits
Wheezes
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Bruit
Thrill
Crackles
Rhonci
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Kussmaul
Cheyne-stokes
Botte's
Whooping sneeze
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Height
Posture
Weight
Hair loss
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True
False
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Ear piece
Bell
Diaphragm
Tubes
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Use a stethoscope over the clothing of a patient who feels cold
Instruct patient to breathe through his or her mouth quietly and more deeply and slowly than in a usual respiration
Allow a patient with a slight lower back pain to lie supine on bed
Listen to the heart sound at the same time that your are listening to the lung sounds
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True
False
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Pulmonary friction
Pleural friction rub
Pulmonary bruising
Whooping cough
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Spina Bifida
Kyphosis
Lordosis
Scoliosis
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Spina Bifida
Kyphosis
Lordosis
Scoliosis
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Spina Bifida
Kyphosis
Lordosis
Scoliosis
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Closure of the atrioventricular and semilunar valves respectively
Closure of the semilunar and atrioventricular valves respectively
Closure of the atrioventricular and semilunar valves simultaneously
Closure of the atrioventricular valve and opening of the semilunar valve respectively
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Closure of the AV valves and signals the start of systole
Closure of the AV valves and signals the end of systole
Opening of the AV valves and signals the start of systole
Opening of the AV valves and signlas the end of systole
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Apex of the heart
Base of heart
Around the heart
All over the heart
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With the closure of the AV valve and signals the end of systole
With the opening of the AV valve and signals opening of systole
With the opening of the semilunar valves and signals the beginning of systole.
With the closure of the semilunar valves and signals the end of systole
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S1
S2
S3
S4
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Ulnar
Femoral
Brachial
Humoral
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Ischemia
Claudication
Hypoventilation
Atelactesis
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Ischemia
Claudication
Hypoventilation
Atelactesis
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Less than 3 seconds
More than 3 seconds
More than 5 seconds
Around 5 seconds
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Soreness
Pruritus
Flatus
Pain
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Decreased and increased bowel sounds
Loud and quiet bowel sounds
Fetid and scentless bowel sounds
Noisy and loud bowel sounds
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