Fundamentals Of Nursing NCLEX Quiz 10

Inspection begins immediately as the nurse meets the patient. as she observes the patient’s appearance and behavior. Observational data are not intrusive to the patient. When performing assessment techniques involving physical touch. the behavior. posture. demeanor. and responses might be altered. Palpation. percussion. and auscultation should be performed in that order. except when performing an abdominal assessment. During abdominal assessment. auscultation should be performed before palpation and percussion to prevent altering bowel sounds.

If the patient is able. the nurse should have the patient sit upright to obtain vital signs in order to allow the nurse to easily access the anterior and posterior chest for auscultation of heart and breath sounds. It allows for full lung expansion and is the preferred position for measuring blood pressure. Additionally. patients might be more comfortable and feel less vulnerable when sitting upright (rather than lying down on the back) and can have direct eye contact with the examiner. However. other positions can be suitable when the patient’s physical condition restricts the comfort or ability of the patient to sit upright.

The nurse is performing a focused physical assessment. which is done to obtain data about an identified problem. in this case shortness of breath. An ongoing assessment is performed as needed. after the initial data are collected. preferably with each patient contact. A comprehensive physical assessment includes an interview and a complete examination of each body system. A psychosocial assessment examines both psychological and social factors affecting the patient. The nurse conducting a psychosocial assessment would gather information about stressors. lifestyle. emotional health. social influences. coping patterns. communication. and personal responses to health and illness. to name a few aspects.

If a patient is unable to sit up. the nurse should place him lying flat on his back. with the head of the bed elevated. Dorsal recumbent position is used for abdominal assessment if the patient has abdominal or pelvic pain. The patient in dorsal recumbent is on his back with knees flexed and soles of feet flat on the bed. Lithotomy position is used for female pelvic examination. It is similar to dorsal recumbent position. except that the patient’s legs are well separated and thighs are acutely flexed. Feet are usually placed in stirrups. Fold sheet or bath blanket crosswise over thighs and legs so that genital area is easily exposed. Keep patient covered as much as possible. The patient in Sim’s position is on left side with right knee flexed against abdomen and left knee slightly flexed. Left arm is behind body; right arm is placed comfortably. Sims’ position is used to examine the rectal area. In semi-Fowler’s position. the patient is supine with the head of the bed elevated and legs slightly elevated.

The bell of the stethoscope should be used to hear low-pitched sounds. such as murmurs. bruits. and jugular hums. The diaphragm should be used to hear high-pitched sounds that normally occur in the heart. lungs. and abdomen.

The nurse should modify his examination by demonstrating equipment before using it to examine a school-age child. The nurse should make sure parents are not present during the physical examination of an adolescent. but they usually help younger children feel more secure. The nurse should allow a preschooler to help with the examination when possible. but not usually a school-age child. Toddlers are often fearful of invasive procedures. so those should be performed last in this age group. It is best to perform invasive procedures last for all age groups; therefore. this does not represent a modification.

For adults. BMI should range between 20 and 25; BMI less than 20 is considered underweight; BMI 25 to 29.9 is overweight; and BMI greater than 30 is considered obese.

Sims’ position is typically used to examine the rectal area. However. the position should be avoided if the patient has undergone hip replacement surgery The patient with a hip replacement can assume the supine. dorsal recumbent. or semi-Fowler’s positions without causing harm to the joint. Supine position is lying on the back facing upward. The patient in dorsal recumbent is on his back with knees flexed and soles of feet flat on the bed. In semi-Fowler’s position. the patient is supine with the head of the bed elevated and legs slightly elevated.

Nursing models produce a holistic database that is useful in identifying nursing rather than medical diagnoses. Body systems and head-to-toe are not nursing models. and they are not holistic; they focus on identifying physiological needs or disease. Maslow’s hierarchy is not a nursing model. but it is holistic. so it is acceptable for identifying nursing diagnoses. Gordon’s functional health patterns are a nursing model.

The nurse recorded a vague generality: “he has had a good night.” The nurse did not use the patient’s exact words. but she did not quote the patient at all. so that is not one of her errors. The nurse used the “waffle” word. “seems” worried instead of documenting what the patient said or did to lead her to that conclusion. The nurse recorded these inferences: worried and had a good night.