NR i304 iFinal iWorksheet
Questions:
1. Define isubjective iand iobjective idata. iGive ithree iexamples iof ieach iand istate iif ithe ifindings iare
idocumented iin ithe ihistory ior iphysical iexamination ifindings.
• Subjective iData iwhat ithe iperson isays iabout ihimself ior iherself iduring ithe iphysical
iexamination; isymptom iis ia isubjective isensations ithat ithe iperson iis ifeeling;
o Examples: iitching, ipain, ifeelings iof iworry, inausea, idepression, ifatigue, ianxiety,
loneliness, ietc.
• Objective iData iwhat ithe iyou ias ithe ihealth iprofessional iobserve iby iinspecting,
ipercussing, ipalpating, iand iauscultating iduring ithe iphysical iexamination; ia isign iis ian
iobjective iabnormality ithat iyou ias ithe iexaminer icould idetect ion iphysical iexamination ior
iin ilaboratory ireports; iobservable iand imeasurable;
o Examples: iblood ipressure, idiscoloration iof ithe iskin, iskin imoisture, ivomiting,
itemperature, iweight, ibleeding, iblood icell icount, ietc.
2. List ifive iactions ia inurse ishould itake iwhen iassessing ia ipatient iwith ia ipotentially icritical
ihemodynamic istate. iPut iyour iactions iin ipriority iorder iof i1-5.
• Hemodynamic iState iinstable iblood ipressure, iwhich ican ilead ito iinadequate iarterial
iblood iflow ito iorgans; iheart ifailure.
• Priority iActions: imain igoals ifor inurse iare ito ievaluate ithe icardiac iand icirculatory ifunction,
as iwell ias ithe iresponse ito iany iinterventions.
ii.
3. What idoes ithe ipriority isetting iABC imean? iHow idoes ithe inurse iuse ithis imnemonic iin ipatient
iassessment? iIf ia ipatient ihas ia islow ior irapid irespiratory irate, iis iairway ithe iprimary iconcern?
• A: iairway.
• B: ibreathing.
• C: icirculation.
4. What iis iHIPAA? iDescribe ione isituation iwhen ithe inurse imust iadhere ito iHIPAA.
• Health iInsurance iPortability iand iAccountability iAct iof i1996 i(HIPAA) ilaws ito iimprove
iefficiency iin ihealth icare idelivery iby istandardizing ielectronic idata iinterchange iand
iprotection iof iconfidentiality iand isecurity iof ihealth idata iby isetting iand ienforcing
istandards; icomposed iof i4 iparts ithat ihave irules, iwhich iinclude: istandards ifor ielectronic
itransactions, iunique iidentifiers istandards, ithe isecurity irule, iand ithe iprivacy irule.
o Example: iif ipatient iisn’t iable ito igive iconsent ia ispouse, irelative, ior ia iclose ifriend
ican i(but, ithe inurse imust idocument iit); i2 inurses iassigned ito ithe isame ipatient ican
italk iabout ithe ipatient’s imedical idiagnosis iin ithe ipatients iprivate iroom; ia inurse ican
igive iinformation iabout ia ipatient iover ithe iphone iif ithe ipatient igives ipermission ito
ido iso ito ithat iperson; inurses ican iperform iresearch ias ilong ias ipatient iconfidentiality
iis imaintained iat iall itimes;
5. Describe ithe iprocess iof itaking ia ipulse. iWhat iis ia inormal ipulse? iWhat iare iqualities iof ia inormal
ipulse? iWhat iis ithe ifirst iaction ia inurse ishould itake iwhen ithe ipulse iis inot ias iexpected?
• Normal iPulse i2+ ibilaterally iforce; i60-100 ibeats iper iminute; i50-95 ibeats iper iminute iin
ihealthy iindividuals.
1
, 2
o Qualities iof iA iNormal iPulse irhythm ishould ibe iregular, ieven itempo;
isymmetrical i2+ ibilateral iforce;
• Process iof iTaking iA iPulse iusing ithe ipads iof iyour i1st i3 ifingers, ipalpate ithe iradial ipulse i@
ithe iflexor iaspect iof ithe iwrist ilaterally ialong ithe iradius ibone; iif irhythm iis iregular, icountithe
i# iof ibeats iin i30 iseconds iand imultiply iby i2; iif iit’s iirregular ithan icount ifor ia ifull iminute;
• 1ST iAction iif iPulse iIs iNot iExpected
6. What iis idehydration? iList ithree isubjective iand ithree iobjective ifindings iof idehydration. iList ithe
iexpected ivital isigns iof ia ipatient iwho iis idehydrated.
• Dehydration iosmolar ifluid iloss iof iwater, iwith ino iloss iof ielectrolytes.
o Subjective i Findings: i i thirst, i dizziness, i syncope, i confusion, i weakness,
i fatigue,inausea,
o Objective iFindings: idry, ifurrowed itongue, ivomiting, iweight iloss, ioliguria i(
ioutput iof iurine), idistended ibladder, isunken ieyes, idiminished icapillary irefill,
idiaphoresis, i cool i clammy i skin, i flattened i neck i veins, i iurine i specific i gravity,
i iosmolality, i iblood iurea initrogen i(BUN), i ielectrolytes, i iglucose, i iserum
isodium.
• Expected iVital iSigns iof iDehydrations itachycardia, iweak, ithread ipulse; ihypotension,
iorthostatic i hypotension, i icentral i venous i pressure; i tachypnea i ( irespirations),
i hypoxia;ihyperthermia
7. How iis ifluid ivolume ideficit irelated ito idehydration? iHow iwould iconcentrations iof isome isolutes
i(solids) ichange iwith idehydration? iWhy?
• Fluid iVolume iin idehydration, iit iis iosmolar ifluid iloss, iin iwhich ithere iis ionly ia iloss iof
iwater iand ithere’s ino iloss iof ielectrolytes.
8. What iis ian iundesirable iresponse iof ithe ibody ito ia ifever?
• It ican ireset ithe ithermostat iof ithe ibrain i@ ia ihigher ilevel, iresulting iin iheat iproduction iand
iconservation.
Why iis ithis iundesirable? iWhat ieffect idoes iit ihave?
• It ican iresult iin ian iincreased iinternal ithermostat, iwhich iwill imean ithat inext itime ithe
itolerance iof ia ifever iwill ibe ihigher iand iresult iin ian iincreased iheat iproduction iand
iincreased iheat iconservation.
9. What iis ithe imost iserious iskin icancer? iWhat iis ione irisk ifactor ifor ithis icancer iand ione iteaching
iitem ito iaddress iwith iyour ipatient? iDescribe ithis imost iserious iskin icancer ibelow.
• Most iSerious iSkin iCancer imelanoma.
o Risk iFactors: ifair iskin, ihistory iof isunburn, iexcessive iUV iexposure, iliving iclosure
ito iequator ior i@ ia ihigher ielevation, ihave imany ior iunusual imoles, ifamily ihistory iof
imelanoma, iweakened iimmune, ietc.
o Teaching iItems iTo iAddress: iprotect iyour iskin, ilimit iyour iexposure ito ithe isun,
iwear ia iheat ior iprotective igear, iwear isunscreen, icheck ian iunusual imoles iand
ialways icheck ion iyour imoles ito ibe iable ito inote iany idifferences, ietc.
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Questions:
1. Define isubjective iand iobjective idata. iGive ithree iexamples iof ieach iand istate iif ithe ifindings iare
idocumented iin ithe ihistory ior iphysical iexamination ifindings.
• Subjective iData iwhat ithe iperson isays iabout ihimself ior iherself iduring ithe iphysical
iexamination; isymptom iis ia isubjective isensations ithat ithe iperson iis ifeeling;
o Examples: iitching, ipain, ifeelings iof iworry, inausea, idepression, ifatigue, ianxiety,
loneliness, ietc.
• Objective iData iwhat ithe iyou ias ithe ihealth iprofessional iobserve iby iinspecting,
ipercussing, ipalpating, iand iauscultating iduring ithe iphysical iexamination; ia isign iis ian
iobjective iabnormality ithat iyou ias ithe iexaminer icould idetect ion iphysical iexamination ior
iin ilaboratory ireports; iobservable iand imeasurable;
o Examples: iblood ipressure, idiscoloration iof ithe iskin, iskin imoisture, ivomiting,
itemperature, iweight, ibleeding, iblood icell icount, ietc.
2. List ifive iactions ia inurse ishould itake iwhen iassessing ia ipatient iwith ia ipotentially icritical
ihemodynamic istate. iPut iyour iactions iin ipriority iorder iof i1-5.
• Hemodynamic iState iinstable iblood ipressure, iwhich ican ilead ito iinadequate iarterial
iblood iflow ito iorgans; iheart ifailure.
• Priority iActions: imain igoals ifor inurse iare ito ievaluate ithe icardiac iand icirculatory ifunction,
as iwell ias ithe iresponse ito iany iinterventions.
ii.
3. What idoes ithe ipriority isetting iABC imean? iHow idoes ithe inurse iuse ithis imnemonic iin ipatient
iassessment? iIf ia ipatient ihas ia islow ior irapid irespiratory irate, iis iairway ithe iprimary iconcern?
• A: iairway.
• B: ibreathing.
• C: icirculation.
4. What iis iHIPAA? iDescribe ione isituation iwhen ithe inurse imust iadhere ito iHIPAA.
• Health iInsurance iPortability iand iAccountability iAct iof i1996 i(HIPAA) ilaws ito iimprove
iefficiency iin ihealth icare idelivery iby istandardizing ielectronic idata iinterchange iand
iprotection iof iconfidentiality iand isecurity iof ihealth idata iby isetting iand ienforcing
istandards; icomposed iof i4 iparts ithat ihave irules, iwhich iinclude: istandards ifor ielectronic
itransactions, iunique iidentifiers istandards, ithe isecurity irule, iand ithe iprivacy irule.
o Example: iif ipatient iisn’t iable ito igive iconsent ia ispouse, irelative, ior ia iclose ifriend
ican i(but, ithe inurse imust idocument iit); i2 inurses iassigned ito ithe isame ipatient ican
italk iabout ithe ipatient’s imedical idiagnosis iin ithe ipatients iprivate iroom; ia inurse ican
igive iinformation iabout ia ipatient iover ithe iphone iif ithe ipatient igives ipermission ito
ido iso ito ithat iperson; inurses ican iperform iresearch ias ilong ias ipatient iconfidentiality
iis imaintained iat iall itimes;
5. Describe ithe iprocess iof itaking ia ipulse. iWhat iis ia inormal ipulse? iWhat iare iqualities iof ia inormal
ipulse? iWhat iis ithe ifirst iaction ia inurse ishould itake iwhen ithe ipulse iis inot ias iexpected?
• Normal iPulse i2+ ibilaterally iforce; i60-100 ibeats iper iminute; i50-95 ibeats iper iminute iin
ihealthy iindividuals.
1
, 2
o Qualities iof iA iNormal iPulse irhythm ishould ibe iregular, ieven itempo;
isymmetrical i2+ ibilateral iforce;
• Process iof iTaking iA iPulse iusing ithe ipads iof iyour i1st i3 ifingers, ipalpate ithe iradial ipulse i@
ithe iflexor iaspect iof ithe iwrist ilaterally ialong ithe iradius ibone; iif irhythm iis iregular, icountithe
i# iof ibeats iin i30 iseconds iand imultiply iby i2; iif iit’s iirregular ithan icount ifor ia ifull iminute;
• 1ST iAction iif iPulse iIs iNot iExpected
6. What iis idehydration? iList ithree isubjective iand ithree iobjective ifindings iof idehydration. iList ithe
iexpected ivital isigns iof ia ipatient iwho iis idehydrated.
• Dehydration iosmolar ifluid iloss iof iwater, iwith ino iloss iof ielectrolytes.
o Subjective i Findings: i i thirst, i dizziness, i syncope, i confusion, i weakness,
i fatigue,inausea,
o Objective iFindings: idry, ifurrowed itongue, ivomiting, iweight iloss, ioliguria i(
ioutput iof iurine), idistended ibladder, isunken ieyes, idiminished icapillary irefill,
idiaphoresis, i cool i clammy i skin, i flattened i neck i veins, i iurine i specific i gravity,
i iosmolality, i iblood iurea initrogen i(BUN), i ielectrolytes, i iglucose, i iserum
isodium.
• Expected iVital iSigns iof iDehydrations itachycardia, iweak, ithread ipulse; ihypotension,
iorthostatic i hypotension, i icentral i venous i pressure; i tachypnea i ( irespirations),
i hypoxia;ihyperthermia
7. How iis ifluid ivolume ideficit irelated ito idehydration? iHow iwould iconcentrations iof isome isolutes
i(solids) ichange iwith idehydration? iWhy?
• Fluid iVolume iin idehydration, iit iis iosmolar ifluid iloss, iin iwhich ithere iis ionly ia iloss iof
iwater iand ithere’s ino iloss iof ielectrolytes.
8. What iis ian iundesirable iresponse iof ithe ibody ito ia ifever?
• It ican ireset ithe ithermostat iof ithe ibrain i@ ia ihigher ilevel, iresulting iin iheat iproduction iand
iconservation.
Why iis ithis iundesirable? iWhat ieffect idoes iit ihave?
• It ican iresult iin ian iincreased iinternal ithermostat, iwhich iwill imean ithat inext itime ithe
itolerance iof ia ifever iwill ibe ihigher iand iresult iin ian iincreased iheat iproduction iand
iincreased iheat iconservation.
9. What iis ithe imost iserious iskin icancer? iWhat iis ione irisk ifactor ifor ithis icancer iand ione iteaching
iitem ito iaddress iwith iyour ipatient? iDescribe ithis imost iserious iskin icancer ibelow.
• Most iSerious iSkin iCancer imelanoma.
o Risk iFactors: ifair iskin, ihistory iof isunburn, iexcessive iUV iexposure, iliving iclosure
ito iequator ior i@ ia ihigher ielevation, ihave imany ior iunusual imoles, ifamily ihistory iof
imelanoma, iweakened iimmune, ietc.
o Teaching iItems iTo iAddress: iprotect iyour iskin, ilimit iyour iexposure ito ithe isun,
iwear ia iheat ior iprotective igear, iwear isunscreen, icheck ian iunusual imoles iand
ialways icheck ion iyour imoles ito ibe iable ito inote iany idifferences, ietc.
2
