NSE 103 Final Exam
what is subjective data? data the patient tells you
what are symptoms? something the client feels
what are signs? observable findings
what is objective data what you observe and can measure
determination about a client's health status
what is clinical judgement?
deciding their capacity to engage in care and whether action should be taken or not
what is clinical reasoning? the thinking process by which a nurse reaches a clinical judgement
what is clinical deterioration? a worsening clinical state related to physiological decompensation
what are priorities of care? what actions are most important to take first, and which can follow
self-actualization
esteem
what are the levels of maslow's hierachy of
social
needs from top to bottom
security
physiological
what are the levels of priority of care? first, second, third
what is first level priority of care? problems that reflect critical findings & require urgent action
problems that may lead to clinical deterioration / may become life threatening
what is second level priority of care?
requires prompt action
, problems that are not acute in nature
what is third level priority of care?
not urgent & can wait until the client is stable
effective
ineffective
what are the four types of interventions?
unrelated
contraindicated
primary survey
focussed
what are the types of health assessments?
assessment head to
toe assessment
complete health assessment
what are the components of a primary ABCDE (Airway, breathing, circulation, disability and exposure)
survey?
what does D stand for in ABCDE (primary disability - level of consciousness, speech, pain
survey)? what does it mean?
what does E stand for in ABCDE (primary exposure - temperature, skin integrity, ability to transfer, wounds, etc
survey)? what does it mean?
what is a focussed assessment? specific to a health concern / reason for seeking care
assesses several body systems & provides an overview of the client's current health
what is a head to toe assessment?
status
what does a cephalocaudal approach head to toe
mean?
what is a complete health assessment? subjective & objective assessment of all body systems; comprehensive
alert & oriented
confused & disoriented
what are the five levels of consciousness? lethargic
obtunded
unconscious
what does lethargic mean (level of slow to arouse to stimuli or questions, sleepy
consciousness)?
what does obtunded mean (level of significant impairment to level of consciousness; without stimuli they immediately
consciousness)? return to sleep
by asking them about:
how do you assess someone's level of place
orientation? time
person
self
, strategies that enable people/communities to increase control over & improve their
what is health promotion?
health
behavioural
what are the three types of
relational
health promotion?
structural
what is behavioural health promotion? focus on lifestyles & behaviours on an individual level
what is relational health promotion? emphasizes social change at the relational level
what is structural health promotion? addresses policies & practices that affect health at a broader community level
what is hyperthermia? elevated body temperature
what is hypothermia? low body temperature
what factors may cause hyperthermia? internal (fever caused by infection) or external (exposure to heat)
tympanic
oral
what are the five ways temperature can
axillary
be taken?
rectal
dermal
how are temperatures usually taken in rectal
pediatric populations?
for children, what age are rectal usually children under two, but over 30 days
thermometers used?
what may happen if you take the rectal tearing
temperature of a newborn (>30 days) with a
rectal thermometer?
what is a dermal thermometer? non-contact infrared thermometers
what must you assess before taking an oral whether the client has consumed any hot or cold liquids reccently
temperature?
what is the normal temperature range for an 36.5-37.5 C
adult?
what is the normal temperature range for an slightly lower than younger adults
older adult?
what is the normal temperature range for 35.5-37.7 C
infants & young children?
diurnal rhythm (can also decrease)
exercise
what factors may influence temperature?
stress &
(increase)
anxiety
menstrual cycle
pregnancy
, what is hypoexmia? low oxygen in the blood
pulse oximetry device (can be put on fingers, toes, earlobes or forehead)
what are the two ways oxygen saturation is
measured?
arterial line
what is an arterial line? catheter line inserted into an artery to measure O2 saturation
what are normal oxygen saturation levels? 97-100%
older adults tend to have_____levels of lower
oxygen saturation
in a hospital setting, oxygen 92-100%
saturation levels of% are generally
acceptable, unless the client is a ______ child
what is inspection? purposeful & systematic observation of the client
what is palpation? using your hands / fingers to assess the client based on your sensation of touch
temperature
moisture
texture
palpation can provide information on:
thickness
pain
etc
tapping on the body to elicit sounds, then determining if those sounds are
what is percussion?
appropriate
air-filled
percussion sounds can indicate if an area is: fluid-filled
dense
resonance
hyperresonance
what are the five percussion sounds? tympany
dullness
flatness
what is ressonance? (percussion) low-pitched, hollow sound with a moderate duration
what is hyperressonance? (percussion) low-pitched, booming sound, longer duration
what is tympany? (percussion) high-pitched, longer duration, sounds like a drum
what does tympany indicate? fluid-filled
what is dullness? (percussion) quiet thud, high-pitched, short duration
what does dullness indicate? dense tissues
what is auscultation? listening to the body through a stethoscope
what is pulse? a pressure wave that expands & recoils the artery when the heart contracts
what is stroke volume? the volume of blood the heart pumps per contraction
what is the normal heart rate of an adult? 60-100
what is subjective data? data the patient tells you
what are symptoms? something the client feels
what are signs? observable findings
what is objective data what you observe and can measure
determination about a client's health status
what is clinical judgement?
deciding their capacity to engage in care and whether action should be taken or not
what is clinical reasoning? the thinking process by which a nurse reaches a clinical judgement
what is clinical deterioration? a worsening clinical state related to physiological decompensation
what are priorities of care? what actions are most important to take first, and which can follow
self-actualization
esteem
what are the levels of maslow's hierachy of
social
needs from top to bottom
security
physiological
what are the levels of priority of care? first, second, third
what is first level priority of care? problems that reflect critical findings & require urgent action
problems that may lead to clinical deterioration / may become life threatening
what is second level priority of care?
requires prompt action
, problems that are not acute in nature
what is third level priority of care?
not urgent & can wait until the client is stable
effective
ineffective
what are the four types of interventions?
unrelated
contraindicated
primary survey
focussed
what are the types of health assessments?
assessment head to
toe assessment
complete health assessment
what are the components of a primary ABCDE (Airway, breathing, circulation, disability and exposure)
survey?
what does D stand for in ABCDE (primary disability - level of consciousness, speech, pain
survey)? what does it mean?
what does E stand for in ABCDE (primary exposure - temperature, skin integrity, ability to transfer, wounds, etc
survey)? what does it mean?
what is a focussed assessment? specific to a health concern / reason for seeking care
assesses several body systems & provides an overview of the client's current health
what is a head to toe assessment?
status
what does a cephalocaudal approach head to toe
mean?
what is a complete health assessment? subjective & objective assessment of all body systems; comprehensive
alert & oriented
confused & disoriented
what are the five levels of consciousness? lethargic
obtunded
unconscious
what does lethargic mean (level of slow to arouse to stimuli or questions, sleepy
consciousness)?
what does obtunded mean (level of significant impairment to level of consciousness; without stimuli they immediately
consciousness)? return to sleep
by asking them about:
how do you assess someone's level of place
orientation? time
person
self
, strategies that enable people/communities to increase control over & improve their
what is health promotion?
health
behavioural
what are the three types of
relational
health promotion?
structural
what is behavioural health promotion? focus on lifestyles & behaviours on an individual level
what is relational health promotion? emphasizes social change at the relational level
what is structural health promotion? addresses policies & practices that affect health at a broader community level
what is hyperthermia? elevated body temperature
what is hypothermia? low body temperature
what factors may cause hyperthermia? internal (fever caused by infection) or external (exposure to heat)
tympanic
oral
what are the five ways temperature can
axillary
be taken?
rectal
dermal
how are temperatures usually taken in rectal
pediatric populations?
for children, what age are rectal usually children under two, but over 30 days
thermometers used?
what may happen if you take the rectal tearing
temperature of a newborn (>30 days) with a
rectal thermometer?
what is a dermal thermometer? non-contact infrared thermometers
what must you assess before taking an oral whether the client has consumed any hot or cold liquids reccently
temperature?
what is the normal temperature range for an 36.5-37.5 C
adult?
what is the normal temperature range for an slightly lower than younger adults
older adult?
what is the normal temperature range for 35.5-37.7 C
infants & young children?
diurnal rhythm (can also decrease)
exercise
what factors may influence temperature?
stress &
(increase)
anxiety
menstrual cycle
pregnancy
, what is hypoexmia? low oxygen in the blood
pulse oximetry device (can be put on fingers, toes, earlobes or forehead)
what are the two ways oxygen saturation is
measured?
arterial line
what is an arterial line? catheter line inserted into an artery to measure O2 saturation
what are normal oxygen saturation levels? 97-100%
older adults tend to have_____levels of lower
oxygen saturation
in a hospital setting, oxygen 92-100%
saturation levels of% are generally
acceptable, unless the client is a ______ child
what is inspection? purposeful & systematic observation of the client
what is palpation? using your hands / fingers to assess the client based on your sensation of touch
temperature
moisture
texture
palpation can provide information on:
thickness
pain
etc
tapping on the body to elicit sounds, then determining if those sounds are
what is percussion?
appropriate
air-filled
percussion sounds can indicate if an area is: fluid-filled
dense
resonance
hyperresonance
what are the five percussion sounds? tympany
dullness
flatness
what is ressonance? (percussion) low-pitched, hollow sound with a moderate duration
what is hyperressonance? (percussion) low-pitched, booming sound, longer duration
what is tympany? (percussion) high-pitched, longer duration, sounds like a drum
what does tympany indicate? fluid-filled
what is dullness? (percussion) quiet thud, high-pitched, short duration
what does dullness indicate? dense tissues
what is auscultation? listening to the body through a stethoscope
what is pulse? a pressure wave that expands & recoils the artery when the heart contracts
what is stroke volume? the volume of blood the heart pumps per contraction
what is the normal heart rate of an adult? 60-100
