Nursing is a profession within the health care sector focused on the care of individuals, families, and communities so they may attain, maintain, or recover optimal health and quality of life.
Nursing is just not about taking care of the patients in recovery beds by feeding them and administering medication, there is much more to it. This nursing assessment will help you as a nurse to better understand different nursing concepts.
Is a step by step linear process
Is a multidimensional thinking process
Is not required when making sound diagnostic reasoning and clinical judgement
Does not grow
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Complete Database
Episodic Database
Follow-Up Database
Emergency Database
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Is the inequalities in heath that are unnecessary and avoidable and differences that are considered unfair and unjust.
Is a generic term used to designate differences, variations, and disparities in the health status of individual and groups.
Health inequality and health inequity are the same
Example include the higher incidence of deaths in the prime of life for women in Canada compared with men, largely due to breast and other cancers
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Have you ever had pain in the eye?
From a scale of 1 to 10, 1 being the weakest and 10 being the strongest, how much would you rate your pain?
Is it okay if I touch you?
How have you been getting along?
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Providing false assurance or reassurance
Giving unwanted advice
Using professional Jargon
Interrupting
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Make sure you speak louder
Make sure to exaggerate your lip movement for better understanding
Find an interpreter or speak slowly
Make sure you do not use hand gestures because this can invade their personal space
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Provocative or palliative, quality or quantity, region or radiation, severity scale, timing, and understanding patient's perception
Past health, quality of health, requirement of health, standard of health, Teaching of health, and understanding of health
Palpating, questioning, reasoning, signaling, teaching, and understanding
None of the above
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May be of genetic significance for the data collection
May tell a clients prolonged contact with any communicable disease
May indicate effect of a family members illness on the client
All of the above
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Instrumental activities of daily living
Activities that patient needs full assistance in performing
Activities of daily living
Activities that patient needs no assistance in performing
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Subjective data
Objective data
Data clustering
Data analysis and interpreting
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Other health care provider may document for you
Do not generalize or form judgements through written communication
Do not be descriptive. Time is wasted on documentation for writing everything seen, heard, felt or smelled.
It is okay not to record assessment during your next shift
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Collecting
Interpreting
Clustering
Labelling
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A dead stop of sound, absolute dullness, very short duration and can be heard over bones
A muffled thud, short in duration, and can be heard over the liver
Clear and hollow sound, moderate in duration and can be heard over normal lung tissue
Musical and drumlike, sustained longest duration, and can be heard over stomach
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Using a large cuff for thin clients
Taking blood pressure when the client wakes up
Asking client to support own arm
If failing to record measurement, take it again right away
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Age, gender, ethnocultural background and weight
Amount of stress, weight, exercise and emotions
Physical appearance, body structure, behaviour and mobility
Rate, rhythm, force and elasticity
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Systolic pressure
Diastolic pressure
Pulse pressure
Mean arterial pressure
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Nociceptive pain, acute pain
Nociceptive pain, persistent pain
Neuropathic pain, acute pain
Neuropathic, persistent pain
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Pain should be considered a normal part of aging
Older adults will often deny having pain for fear of dependency
Pain in neonates and infants cannot be assessed
Psychological changes that take place that may indicate the presence of pain includes sweating, increase blood pressure and heart rate, vomiting and nausea
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The short-form McGill pain questionnaire
The brief pain inventory
Numeric rating scale
Descriptor scale
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Perception, transmission, transduction, modulation
Transmission, perception, modulation, transduction
Transduction, transmission, perception, modulation
Transduction, modulation, perception, transmission
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Ms. E who had prior suicide attempt and is now in a rehabilitation centre
Mr. F jokingly tells his friend that he was wants to shoot himself with his fathers pistol because there is so much to deal with in life. The next day Mr. F had ran away from home and left his family a letter saying he is giving up
Mr. G who is recovering from a traumatic brain injury from a car crash that has killed his wife
Holly, an 8 year old girl is giving away all her toys to the orphanage
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Perception
Orientation
Attention
Consciousness
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Level of Consciousness, speech, mood and affect, and facial expression
Grooming hygiene, dress, body movement, and posture
Attention span, recent memory, and remote memory
Orientation, posture, facial expression, attention span
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Time orientation
Place orientation
Registration of five words
Reading
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Both the dermis and subcutaneous layer
Dermis layer
Epidermis layer
Subcutaneous layer
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Diameter of the mole is 4-5mm big
Elevation of the pigmentation
Borders are smooth
Pigmentation is in a shape of an oval where two halves look the same
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Flexion
Extension
Eversion
Inversion
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Diminishes pulse feeling
Is a unilateral distension of the external jugular veins
Indicates turbulence due to a local vascular cause
Is the condition in which pressure over the carotid sinus leads to a decreased heart rate
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Is palpable, higher and medial to the sternomastoid muscle and unaffected by the position of the person
Is not palpable, pulse drops as person sits, and is lower and more lateral under/behind the sternomastoid muscle
Is palpable, does not vary with respiration and the quality of the pulse is brisk and localized
Is not palpable, is unaffected by position of person and does not vary with respiration
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On the radial side of the wrist
At the base of the neck
On the lateral edge of the ankle
On either the forth or fifth intercostal space
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The swelling of the feet and legs
Changing colour of the facial skin
Needing to pee during the middle of the night
All of the above
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Both lungs are divide into upper, middle, and lower lobes
Each lobes are separated by fissures
The posterior lung is mostly upper lobe
The right lung is narrower than the left lung because the heart bulges to the right
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Resonant
Hyperresonant
Flat
Dull
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Normal breathing sounds of the bronchial should be heard over the bronchi and not the trachea
Normal breathing sound of the lung field should be bronchovesicular
No sounds she be heard over the bronchi
The nurse heard normal breathing sounds
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Inspection
Palpation
Percussion
Auscultation
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A Barrel chest
Scoliosis
A Normal chest
Kyphosis
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Veins are a low pressure system
Veins contain muscle fibers
A and B
None of the above
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Coronal
Sagittal
Lambdoid
None of the above
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Use a gentle circular motion of the finger pads
Use gentle pressure as nodes can get pushed into the muscle
Better to use both hands to compare two sides symmetrically
Do all of the above
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Not proceed any further as pressure could rupture the gland
Listen for presence of bruit which indicates hyperplasia
Notify the physician for further instructions
Administer medication to reduce the size of the thyroid gland
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Supraclavicular node
Deep cervical node
Superficial cervical node
Occipital node
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Are found in pregnant women when their thyroid gland enlarges due to hyperplasia
Are soft spots found in infants skull that allows for the growth of the brain and eventually ossify
Are the name of the facial sags caused from decreased elasticity, decreased subcutaneous fat, and decreased moisture in the skin of aging adult
None of the above
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Of redder nasal mucosa
Of oral mucosa
Of nose bleed
For bacteria and dust to be filtered out
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Maxillary
Ethmoid
Sphenoid and frontal
Maxillary and frontal
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This is an abnormal growth and can cause the client to lose sense of taste
These are symptoms of lesions in the mouth
The inverted V shape helps client with pushing down ingested food
Inverted V shape is not abnormal growth
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1+
2+
3+
4+
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An intact sensory nerve and a functional synapse in the cord
An intact sensory nerve, a functional synapse in the cord and an intact motor nerve fibre
An intact sensory nerve, a functional synapse in the cord, an intact motor nerve fibre, and the neuromuscular junction
An intact sensory nerve, a functional synapse in the cord, an intact motor nerve fibre, the neuromuscular junction and a competent muscle
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The acoustic nerve and its functions are hearing and equilibrium
The hypoglossal nerve and its function is the movement of the tongue
The spinal accessory nerve and its function is movement of trapezius and sternomastoid muscles
The olfactory nerve and its function is smell
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