NR 304 Final Worksheet Q and A

Questions:
Define subjective and objective data. Give three examples of each and state if the findings are documented in the history or physical examination findings.
Subjective Data what the person says about himself or herself during the physical examination; symptom is a subjective sensations that the person is feeling;
Examples: itching, pain, feelings of worry, nausea, depression, fatigue, anxiety, loneliness, etc.
Objective Data what the you as the health professional observe by inspecting, percussing, palpating, and auscultating during the physical examination; a sign is an objective abnormality that you as the examiner could detect on physical examination or in laboratory reports; observable and measurable;
Examples: blood pressure, discoloration of the skin, skin moisture, vomiting, temperature, weight, bleeding, blood cell count, etc.

List five actions a nurse should take when assessing a patient with a potentially critical hemodynamic state. Put your actions in priority order of 1-5.
Hemodynamic State instable blood pressure, which can lead to inadequate arterial blood flow to organs; heart failure.
Priority Actions: main goals for nurse are to evaluate the cardiac and circulatory function, as well as the response to any interventions. 

What does the priority setting ABC mean? How does the nurse use this mnemonic in patient assessment? If a patient has a slow or rapid respiratory rate, is airway the primary concern?
A: airway.
B: breathing.
C: circulation.

What is HIPAA? Describe one situation when the nurse must adhere to HIPAA.
Health Insurance Portability and Accountability Act of 1996 (HIPAA) laws to improve efficiency in health care delivery by standardizing electronic data interchange and protection of confidentiality and security of health data by setting and enforcing standards; composed of 4 parts that have rules, which include: standards for electronic transactions, unique identifiers standards, the security rule, and the privacy rule. 
Example: if patient isn’t able to give consent a spouse, relative, or a close friend can (but, the nurse must document it); 2 nurses assigned to the same patient can talk about the patient’s medical diagnosis in the patients private room; a nurse can give information about a patient over the phone if the patient gives permission to do so to that person; nurses can perform research as long as patient confidentiality is maintained at all times; 

Describe the process of taking a pulse. What is a normal pulse? What are qualities of a normal pulse? What is the first action a nurse should take when the pulse is not as expected?
Normal Pulse 2+ bilaterally force; 60-100 beats per minute; 50-95 beats per minute in healthy individuals.
Qualities of A Normal Pulse rhythm should be regular, even tempo; symmetrical 2+ bilateral force;
Process of Taking A Pulse using the pads of your 1st 3 fingers, palpate the radial pulse @ the flexor aspect of the wrist laterally along the radius bone; if rhythm is regular, count the # of beats in 30 seconds and multiply by 2; if it’s irregular than count for a full minute; 
1ST Action if Pulse Is Not Expected

What is dehydration? List three subjective and three objective findings of dehydration. List the expected vital signs of a patient who is dehydrated. 
Dehydration osmolar fluid loss of water, with no loss of electrolytes. 
Subjective Findings:  thirst, dizziness, syncope, confusion, weakness, fatigue, nausea, 
Objective Findings: dry, furrowed tongue, vomiting, weight loss, oliguria ( output of urine), distended bladder, sunken eyes, diminished capillary refill, diaphoresis, cool clammy skin, flattened neck veins,  urine specific gravity,  osmolality,  blood urea nitrogen (BUN),  electrolytes,  glucose,  serum sodium. 
Expected Vital Signs of Dehydrations tachycardia, weak, thread pulse; hypotension, orthostatic hypotension,  central venous pressure; tachypnea ( respirations), hypoxia; hyperthermia