Clinical tip:1 Nurse practice act - ANSWER legal scope of practice (what you can
legally assess and diagnose)
How did you obtain consent to perform an assessment and patient rights? -
ANSWER Be okay with them saying no and
Comparing behaviour with developmental stage - ANSWER acting as they should
at their age
How do you gather equipment and what determines what you need? - ANSWER
per assessment/ basics
What would you find in a normal abdomen assessment? - ANSWER bowel sounds
5-30 per/min
What do you find in an abnormal assessment? - ANSWER No present bowel
sounds after 5 minutes of listening
What is the correct technique when assessing an abdomen? - ANSWER Inspection,
Auscultation, Percussion, Palpation
What are some major organs you would find in each of the four quadrants? -
ANSWER RUQ: Liver, Gallbladder LUQ: Spleen, pancreas, stomach RLQ:
Appendix, LLQ: Bowels
What is PERRLA? - ANSWER pupils equal, round, reactive to light and
accommodation. Using penlight outer to inner eye
In a head to toe assessment what areas would you perform last? - ANSWER Lower
extremities or areas with pain.
How do you use a doppler? - ANSWER fingertip size of gel, place probe on gel
mound, move probe around, wipe off with tissue, clean probe how manufactuer
says, mark spot, document findings
, How/Who would require an emergent assessment? - ANSWER Someone in a life
threatening situation (cardiac arrest) ABC's (airway, breathing, circulation) Used to
determine status of patients
What is the nursing process? - ANSWER Assessment, diagnosis, planning,
implementation, evaluation
What is the nursing assessment phase? - ANSWER subjective data, objective data,
validation of data, documentation of data
Difference between comprehensive and focused assessment? - ANSWER
Comprehensive- health history and physical exam. Focused thorough assessment in
specific problem
what are examples of subjective data? - ANSWER name, age, personal health
history family history
What are examples of objective data? - ANSWER measurements, physical
characteristics, body functions, behavior
What is the difference between history of present illness, and review of systems -
ANSWER HPI: COLDSPA, several aspects of health problem, how a specific
problem is explained from pt
ROS: each body system is addressed client asks specific ?'s to elicit further details
documenting health status
What are risk factors? - ANSWER Things that are linked to an increase in your
chance of contracting a disease
E.g. smoking, obesity, drinking, exposure to radiation
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