2024 PCCN ASSESSMENT OF
PROGRESSIVE CARE PATIENTS
AND THEIR FAMILIES CHAPTER
1EXAM WITH ANSWERS
Why is assessment of acutely ill patients and their families essential? -
CORRECT-ANSWERSinformation obtained identifies immediate and future
needs so a plan of care can be initiated
Traditional approaches to Patient Assessment include: - CORRECT-ANSWERS-
include a complete evaluation of patient history
- comprehensive physical exam of all body systems
What FOUR factors are used to evaluate the nutritional status of a patient? -
CORRECT-ANSWERS-weight
-muscle tone
-condition of oral mucosa
-lab values (serum albumin; transferrin)
AUSCULTATION of the abdomen includes: - CORRECT-ANSWERS-bowel
sounds in all four quadrants
-characteristics and frequency
-adventitious sounds (friction rubs, bruits, hums)
How are BOWEL SOUNDS auscultated? - CORRECT-ANSWERS-clockwise
fashion in all four quadrants
-note frequency
-presence/absence of sounds
What are the FOUR ratings for bowel sounds? - CORRECT-ANSWERS-absent
-hypoactive
-normal
-hyperactive
Before noting ABSENT bowel sounds, a quadrant should be auscultated for
how long? - CORRECT-ANSWERS-60 - 90 seconds
PALPATION of the abdomen helps determine: - CORRECT-ANSWERS-areas of
fluid
,-rigidity
-tenderness
-pain
-guarding (rebound tenderness)
Why do you auscultate BEFORE palpation? - CORRECT-ANSWERS-palpation
may change frequency and character of the
peristaltic sounds
In a patient with GI drainage tubes, OBSERVE: - CORRECT-ANSWERS-location
-function
-characteristics of drainage
-validate proper placement
-ensure patency
-drainage/leakage around tubes
INSPECT emesis and stool for: - CORRECT-ANSWERS-occult blood
INSPECT ostomies for: - CORRECT-ANSWERS-location
-color of stoma
-peristomal skin condition
-type of drainage
Identify common DIAGNOSTIC tests pertinent to the hematologic system: -
CORRECT-ANSWERS-evaluation of RBC's
-coagulation studies
Diminished RBC's may affect: - CORRECT-ANSWERS-oxygen-carrying
capacity of the blood
Identify common S/Sx of anemia (diminished RBC's): - CORRECT-ANSWERS-
pallor
-cyanosis
-light-headedness
-tachypnea
-tachycardia
Insufficient clotting factors are evidenced by: - CORRECT-ANSWERS-bruising
-oozing from puncture sites/mucous membranes
-overt bleeding
Identify common DIAGNOSTIC tests pertinent to the immunologic system: -
CORRECT-ANSWERS-white blood cells (WBC's)
-differential counts
, List additional things that can be indicative of underlying infection? -
CORRECT-ANSWERS-puncture sites/mucous membranes for oozing drainage
-inflamed/reddened areas
-spiking or persistent low grade temp
INSPECTING the skin involves: - CORRECT-ANSWERS-head-to-toe, A - P, &
between skin folds skin integrity
-color, temp, turgor
-rashes, striae, discoloration, scars, lesions
-abrasions, pressure ulcers, wounds
-note size, depth, presence/absence of drainage
Name factors that can affect communication: - CORRECT-ANSWERS-culture
-developmental stage
-physical condition
-stress
-perception
-neurocognitive deficits
-emotional state
-language skills
What non-verbal clues can provide important information about the patient?
- CORRECT-ANSWERS-body gestures
-facial expressions
-eye movements
-involuntary movements
-changes in HR,BP and RR
Name the TWO ways anxiety is exhausting. - CORRECT-ANSWERS-
physhologically
-physiologically
Progressive care clinicians must balance: - CORRECT-ANSWERS-need to
gather data
-prioritizing and providing care
Collection of assessment data is obtained in: - CORRECT-ANSWERS-phased
or staged manner
-consistent with pt care priorities
What is the crucial element to developing competence in assessing
progressive care patients? - CORRECT-ANSWERS-consistent and systematic
approach
PROGRESSIVE CARE PATIENTS
AND THEIR FAMILIES CHAPTER
1EXAM WITH ANSWERS
Why is assessment of acutely ill patients and their families essential? -
CORRECT-ANSWERSinformation obtained identifies immediate and future
needs so a plan of care can be initiated
Traditional approaches to Patient Assessment include: - CORRECT-ANSWERS-
include a complete evaluation of patient history
- comprehensive physical exam of all body systems
What FOUR factors are used to evaluate the nutritional status of a patient? -
CORRECT-ANSWERS-weight
-muscle tone
-condition of oral mucosa
-lab values (serum albumin; transferrin)
AUSCULTATION of the abdomen includes: - CORRECT-ANSWERS-bowel
sounds in all four quadrants
-characteristics and frequency
-adventitious sounds (friction rubs, bruits, hums)
How are BOWEL SOUNDS auscultated? - CORRECT-ANSWERS-clockwise
fashion in all four quadrants
-note frequency
-presence/absence of sounds
What are the FOUR ratings for bowel sounds? - CORRECT-ANSWERS-absent
-hypoactive
-normal
-hyperactive
Before noting ABSENT bowel sounds, a quadrant should be auscultated for
how long? - CORRECT-ANSWERS-60 - 90 seconds
PALPATION of the abdomen helps determine: - CORRECT-ANSWERS-areas of
fluid
,-rigidity
-tenderness
-pain
-guarding (rebound tenderness)
Why do you auscultate BEFORE palpation? - CORRECT-ANSWERS-palpation
may change frequency and character of the
peristaltic sounds
In a patient with GI drainage tubes, OBSERVE: - CORRECT-ANSWERS-location
-function
-characteristics of drainage
-validate proper placement
-ensure patency
-drainage/leakage around tubes
INSPECT emesis and stool for: - CORRECT-ANSWERS-occult blood
INSPECT ostomies for: - CORRECT-ANSWERS-location
-color of stoma
-peristomal skin condition
-type of drainage
Identify common DIAGNOSTIC tests pertinent to the hematologic system: -
CORRECT-ANSWERS-evaluation of RBC's
-coagulation studies
Diminished RBC's may affect: - CORRECT-ANSWERS-oxygen-carrying
capacity of the blood
Identify common S/Sx of anemia (diminished RBC's): - CORRECT-ANSWERS-
pallor
-cyanosis
-light-headedness
-tachypnea
-tachycardia
Insufficient clotting factors are evidenced by: - CORRECT-ANSWERS-bruising
-oozing from puncture sites/mucous membranes
-overt bleeding
Identify common DIAGNOSTIC tests pertinent to the immunologic system: -
CORRECT-ANSWERS-white blood cells (WBC's)
-differential counts
, List additional things that can be indicative of underlying infection? -
CORRECT-ANSWERS-puncture sites/mucous membranes for oozing drainage
-inflamed/reddened areas
-spiking or persistent low grade temp
INSPECTING the skin involves: - CORRECT-ANSWERS-head-to-toe, A - P, &
between skin folds skin integrity
-color, temp, turgor
-rashes, striae, discoloration, scars, lesions
-abrasions, pressure ulcers, wounds
-note size, depth, presence/absence of drainage
Name factors that can affect communication: - CORRECT-ANSWERS-culture
-developmental stage
-physical condition
-stress
-perception
-neurocognitive deficits
-emotional state
-language skills
What non-verbal clues can provide important information about the patient?
- CORRECT-ANSWERS-body gestures
-facial expressions
-eye movements
-involuntary movements
-changes in HR,BP and RR
Name the TWO ways anxiety is exhausting. - CORRECT-ANSWERS-
physhologically
-physiologically
Progressive care clinicians must balance: - CORRECT-ANSWERS-need to
gather data
-prioritizing and providing care
Collection of assessment data is obtained in: - CORRECT-ANSWERS-phased
or staged manner
-consistent with pt care priorities
What is the crucial element to developing competence in assessing
progressive care patients? - CORRECT-ANSWERS-consistent and systematic
approach
