NR 302: Health Assessment - Exam 1
alert - ANS-awake or readily aroused, oriented, fully aware of external and internal stimuli and
responds appropriately
apical - ANS-apex (apical pulse is taken at 5th intercostal) ALWAYS count apical heart rate for
ONE full minute
auscultation - ANS-to listen; evaluation of sounds; use stethoscope
base of fingers or ulnar surface of hand (palpation) - ANS-best for vibration
bradypnea - ANS-Slow regular respirations less than 10/min
clarification - ANS-use this when the person's word choice is ambiguous or confusing ("Tell me
what you mean by 'tired blood'")
Clinical Judgement - ANS-Identify problems and make decisions using the nursing process;
ability to solve problems is based on level of experience
coma - ANS-completely unconscious, no response to pain or to any external or internal stimuli;
light coma has some reflexes; deep coma has no motor response
comprehensive assessment - ANS-done when the person is first admitted or first arrives
confrontation - ANS-you have observed a certain action, feeling, or statement and you now
focus the person's attention on it; give honest feedback about what you see or feel
diurnal rhythm - ANS-a daily cycle of a peak and a trough occurs: the BP climbs to a high in late
afternoon or early evening and then declines to an early morning low
doppler technique - ANS-enhances pulse and BP measurement
pitch is higher when distance is small (close distance);
pitch is lower when distance increases (farther)
dorsa of hands and fingers (palpation) - ANS-best for determining TEMPERATURE because the
skin here is thinner than on palms
empathy - ANS-recognizes a feeling and puts it into words; names the feeling and allows the
expression of it ("This must be hard for you")
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