- awareness of risks for heart disease, cancer, diabetes, stroke
Light Palpation vs Deep Palpation - ** VERIFIED ANSWERS **✔✔Light Palpation: Less than 1 cm
(0.4 inch)
Deep Palpation: 4 cm (1.6 inch) for abdominal organs / masses
,General Survey - ** VERIFIED ANSWERS **✔✔A written summary of the impression of the client's
overall health. The nurse gathers this information from the first encounter with the client and
continues to make observations throughout the assessment process.
a) Physical appearance
b) Body structure
c) Mobility
d) Behavior
e) Vital signs
Nursing Process Framework Order - ** VERIFIED ANSWERS **✔✔assessment, analysis/data
collection, planning, implementation, evaluation
Assessment/Data collection - ** VERIFIED ANSWERS **✔✔Involves the systematic collection of
information about clients' present health status to identify needs and additional data to collect based
on findings.
Subjective Data - ** VERIFIED ANSWERS **✔✔What the client tells the nurse. Ex: "my shoulder is
really sore."
Objective Data - ** VERIFIED ANSWERS **✔✔Data the nurse obtains through observation and
examination. Ex: Client grimaces when attempting to brush their hair with the left arm
Analysis/Data Collection - ** VERIFIED ANSWERS **✔✔Nurses use critical thinking skills to
identify clients health statuses or problems, interpret/monitor the collection database, reach an
appropriate nursing judgement about health status and provide nursing care
Planning - ** VERIFIED ANSWERS **✔✔Nurses must establish priorities and optimal outcomes of
care they can readily measure and evaluate.
Implementation - ** VERIFIED ANSWERS **✔✔Nurses base the care they provide on assessment
data, analyses, and the plan of care they developed in the previous steps of the nursing process.
, Evaluation - ** VERIFIED ANSWERS **✔✔Nurses' evaluate clients responses to nursing
interventions and form a clinical judgement about the extent to which clients have met the goals and
outcomes.
Sources of Data for Collection and Assessment - ** VERIFIED ANSWERS **✔✔Observation,
interviews with clients and families, medical history, comprehensive / focused physical assessment,
etc.
Critical Thinking and the Nursing Process - ** VERIFIED ANSWERS **✔✔Assessment / Data
Collection: Collect information about a clients present health to identify needs and to identify
additional data to collect based on findings.
Differentiate between irrelevant and relevant data
Organize, categorize and validate data
Interpret assessment data and draw conclusion
Identify clusters and cues
Recognize actual problems
Identify goals and outcomes for client care
Determine accuracy of theories and understanding of teachings
Oral Hygiene - ** VERIFIED ANSWERS **✔✔Helps decrease the risk of infection for clients living
in long term facilities, especially from the transmission of pathogens that cause pneumonia.
Other populations who require meticulous oral hygiene: Those who are seriously ill, injured,
unconscious, dehydrated, or have an altered mental health status or limited upper body mobility.
Foot Care - ** VERIFIED ANSWERS **✔✔Foot care prevents skin breakdown, pain and infection.
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