NUR 2092 Health Assessment Exam #1 COMPLETE SOLUTIONS FOR

NUR 2092 Health Assessment Exam #1 COMPLETE SOLUTIONS FOR NUR2092 Health Assessment Exam #1 COMPLETE SOLUTIONS Steps of the Nursing Process Correct Answer: Assessment - gather data Diagnosis - problem Outcome Identification - goals, what we want to happen, expect to happen Planning - treatment plan, intervention Implementation - doing the plan Evaluation - Was it successful, meet the goals Define Subjective Data Correct Answer: What patient says about himself or herself during history taking symptoms Define Objective Data Correct Answer: Observed when inspecting, percussing, palpating, and auscultating patient during physical examination signs Factors of Diagnosis Correct Answer: -Cluster of data that seem to be associated in some way. -Validate data, confirm accuracy -Look for gaps in your information -Interpret data and identify problems -Document the diagnosis Factors of Outcome Identification Correct Answer: -Identify expected outcomes related to patient individualization -Ensure outcomes have the SMART components -Specify short-term and long-term goal measurement criteria What does SMART stand for? Correct Answer: Specific, Measurable, Attainable, Realistic, Timely Factors of Planning Correct Answer: -Establish priorities based on meeting patients care goals -Develop outcomes and set time frames for meeting outcomes -Identify relevant interventions and utilize interdisciplinary health care team members for the patient -Document plan of care Factors of Evaluation Correct Answer: -Refer to outcomes -Evaluate patient's condition and compare actual outcomes to expected outcomes -If reached outcome: does something need to be done -If NOT reached: identify reasons for not achieving -Modify plan if needed -Document in plan of care Evidence-Based Decision Making factors Correct Answer: -Best evidence from clinical review of research literature -The providers clinical expertise -Patient's preference and values -Physical examination and assessment of patient Focused Database Correct Answer: Problem-centered Used for a limited or short-term problem Smaller scope and more targeted than the complete database Complete Database Correct Answer: Includes a complete health history and full physical examination Yielding the first diagnosis Steps in Priority Problem Levels Correct Answer: 1. First-level priority: emergent, life threatening, immediate 2. Second- level: next in urgency, requires attention to prevent further deterioration 3. Third-Level: important to patient's health, but can be addressed after urgent problems What are the two parts to Communicating? Correct Answer: 1. Sending 2. Receiving In communication what are the two types in "sending"? Correct Answer: 1. Verbal: words/tone 2. Nonverbal: less conscious In communication, what does "receiving" mean? Correct Answer: Interpretation based on past experiences, culture, and self concept Physical and emotional state Communication does what with a patient? Correct Answer: -Builds a relationship -Builds rapport Key to Communication Correct Answer: Is the receiver getting the message the way it was intended? Active listening Types of questions in Therapeutic Communication Correct Answer: Open-ended: narrative answers, feelings and opinions, develops rapport Close-ended: yes/no questions, used for specific information, limits rapport In Therapeutic Communication, what are the types of responses focused on the client's frame of reference? Correct Answer: CLARIFICATION (rephrase) FACILITATION (nodding, Hmm,hmm) SILENCE (when to use) SUMMARIZE (summarize what pt stated) EMPATHY (likening to others, comfort, "I understand") In Therapeutic Communication, what are the types barriers? Correct Answer: AVOIDANCE LANGUAGE (using other words) CHANGING THE SUBJECT DISTANCING (walking to the door, avoid eye contact) BLAMING (if you didn't smoke...) FALSE REASSURANCE (you'll be fine) FAILURE TO LISTEN GIVING ADVICE Barriers in Communication include: Correct Answer: - lack of interest - physical barriers - patient's inability to hear you - safety - physiological barriers - language/use of medical jargon, or speaking above someone's educational level Substance Abuse Assessment Correct Answer: - Tolerance: carries from person to person - Watch for withdrawal symptoms - Dependence - Addiction Dependence vs Addiction Correct Answer: -Dependence: can be weeded off -Addiction: destructive behaviors with what you are doing Substance Abuse withdrawal symptoms: Correct Answer: - nausea/vomiting - tremor - paroxysmal sweats - anxiety - visual disturbances - headache - disorientation Alcohol Use assessment Correct Answer: - quick assessment: frequency use of alcohol, tobacco, prescription drug for nonmusical use, illicit drugs - AUDIT: Alcohol Use Disorders Identification Test - CAGE: Cut down, Annoyed, Guilty, Eye-opener CAGE questionnaire Correct Answer: Have you ever felt you should Cut down on your drinking? Have people Annoyed you by criticizing your drinking? Have you ever felt bad or Guilty about your drinking? Have you ever had a drink first thing in the morning to steady your nerves (Eye-opener)? Domestic Violence Assessment includes: Correct Answer: - need to ask every client needs to be assessed for the risk/evidence of abuse - use own words in nonjudgemental way - Abuse Assessment Screen - Walker's Cycle of Violence: tolerance, explosion, honeymoon Assessment of Intimate Partner Violence (IPV) Correct Answer: - HITS: hurt, insult, threaten, scream - 1-5 points: never to frequently - 10 or more: indicate IPV When should you report for Domestic Violence cases Correct Answer: children/elder adult- not required Warning signs of Human Trafficking include: Correct Answer: - injuries/signs of physical abuse - malnourished - disoriented - lack of identification - few personal belongings - avoids eye contact - minor appearing in relationship with older person - works long hours, lives in work environment - fearful, anxious, submissive - fearful of law enforcement - cannot freely contact friends/family Human Trafficking Screening factors: Correct Answer: - best to speak to client alone: try not to raise suspicions - treat each case as unique - assume victim is at risk of harm - do NOT start with sensitive questions - determine need for interpreter When Should You Do If You Suspect a Patient is a Human Trafficking Victim? Correct Answer: - Call 911 first then call the Human Trafficking Center - victim will need assistance with shelter, medical care, and legal - ICE has a Victim Assistance Program The General Survey Process: Correct Answer: 1. begin with first contact 2. general impressions of client (age, sex, LOC, skin color, facial features) 3. physical appearance (facial expression, speech, dress, hygiene 4. body structure (stature, nutrition, symmetry, posture, position, body build) 5. body movement (gait, ROM, assistive devices, involuntary movements) 6. emotional/mental status and behavior (mood/affect, speech, appropriate behavior for setting) Two primary components of Health History are: Correct Answer: 1. Health History - Subjective date 2. Physical Assessment - Objective data Components of Comprehensive Body System Health History: Correct Answer: - biographic data - reason for seeking care - present health status - past medical history - family history - personal and psychological history - review of body systems Biographic data includes: Correct Answer: name, address, birth date, gender, marital status, ethnic group, occupation, primary language, and source of info/reliability Reason for seeking care is commonly known as Correct Answer: the "chief complaint" this is in the patients words and ask what symptoms they are having Cause of Illness: Biomedical Correct Answer: diseases caused by bacteria, viruses involves scientific theories Cause of Illness: Magicoreligious Correct Answer: Illness caused by supernatural forces May use folk remedies Voodoo, Witchcraft, Faith-healing Cause of Illness: Naturalistic Correct Answer: Illness caused by loss of natural balance Yin/Yang flow of energy Mini-Cog Assessment Correct Answer: Four unrelated word test Repeat at 5 min, 10 min and 30 min Testing for Dementia and Alzheimer's Short-term memory dysfunction What does PQRSTU stand for? Correct Answer: Palliative(provocative), quality, radiate, severity, time, understanding Components of Past Health History Correct Answer: Child illnesses Accidents/injuries Operations/hospital stays Serious /chronic illnesses Obstetric history Immunizations Allergies Current medications Last examination date Components of Social History Correct Answer: Where do they live? Are they safe? Do they have clean water, heat, air-conditioning? Do they work, do they feel safe? Do they exercise? Review of Symptoms components Correct Answer: Be specific gives an opportunity to re-ask questions now that they are comfortable evaluate health promotion practices Factors that affect Nutritional Status Correct Answer: physiologic psychologic developmental cultural economic factors Assessing Nutritional Status methods Correct Answer: 24 hour recall food diary - most comprehensive food frequency typical food intake direct observation- % of food eaten Best Screening Tool for Dietary Intake Correct Answer: 24 hour recall method Nutritional assessment includes Correct Answer: Anthropometric measurements swallowing assessment lab tests Define mental status Correct Answer: Client's level of cognitive and emotional functioning a state of well being Delirium Correct Answer: Acute confusional change or loss of consciousness and perceptual disturbance that may accompany acute illness; usually resolves when underlying cause is treated Dementia Correct Answer: Gradual progressive process, causing decreased cognitive function even though the person is fully conscious and awake; not reversible Components of Mental Health Survey (ABCT) Correct Answer: Appearance Behavior Cognition Thought Process Primary, secondary, tertiary prevention Correct Answer: 1. Primary prevention-- aims to prevent disease BEFORE it occurs. (ex. seat belts, smoking education) 2. Secondary prevention-- aims to REDUCE impact of a disease or injury. (ex. screening for things early). 3. Tertiary prevention-- Aims to soften the impact of an ongoing illness or injury that has lasting effects. Help manage long term problems. (ex. cardiac rehabilitation programs). How does the data base vary according to clinical setting? Correct Answer: It could be complete, focused or problem-centered, follow-up, or emergency (quick assessment to provide immediate care) 4 assessment techniques Correct Answer: Inspection Pulsation Percussion Auscultation Nociceptive pain Correct Answer: Triggered by events outside the nervous system from actual trauma or tissue damage Acute Responsive to opiates/anti-inflamatories Neuropathic Pain Correct Answer: Abnormal processiing from injury to nerve fiber or CNS chronic Poorly responsive to pain medications Pain assessment tools Correct Answer: Numeric rating scales Wong baker FACES FLACC (under 3 years old) CRIES (pre term infants) PAINAD (dementia) Phantom Pain Correct Answer: Pain that feels like it is coming from a body part that has been amputated. Breakthrough Pain Correct Answer: Severe pain that erupts while a patient is already medicated with long-acting painkiller Referred Pain Correct Answer: Felt at a particular site but originates from another location. Both sites are innervated by the same spinal nerve, and it is difficult for the brain to differentiate the point of origin. For example, left arm pain for heart attack. Chronic Pain Behaviors Correct Answer: Bracing, Rubbing, Diminished activity, Change in appetite, Adaptation, Often little indication, Self distribution Acute Pain Behaviors Correct Answer: Grimacing or other facial expressions Bracing or holding injured area Rocking Changes in activity Limping Culture Correct Answer: Customs, beliefs and attitudes that distinguishes one group of people from another. Transmited through language, material objects, ritual, institutions and art, from one generation to the next Ethnicity Correct Answer: Relating to races or large groups of people who have the same customs, religion, origin and culture Acculturation Correct Answer: adapting to and acquiring another culture Assimilation Correct Answer: minority group takes on culture of the dominant culture two way process Biculturalism Correct Answer: divided loyalty identifies with two cultures Ethnocentrism Correct Answer: Belief in the superiority of one's belief or way on life Race Correct Answer: identification of individuals or groups by shared genetics heritage and biological or physical characteristics Material vs. Nonmaterial Correct Answer: material: things you can touch non material: verbal, non verbal language, beliefs, customs, social structures Cultural Competence methods Correct Answer: know self, understand own heritage know the cultures in your area avoid stereotyping be aware of your biases/prejudices learn new communication skills Palpation Correct Answer: process of using one's hands to examine the body Inspection Correct Answer: visual examination of the body during palpation, the dorsal surface of the hand detects: Correct Answer: Temperature most sensitive body part for temperature During palpation, the ulnar surface is used to detect: Correct Answer: Vibration during palpation, the fingertips detect: Correct Answer: position, texture, size, consistency, masses, fluid, crepitus Percussion evaluates: Correct Answer: size, borders, consistency, tenderness, and extent of fluid direct percussion Correct Answer: involves striking a finger or hand directly against the patient's body Indirect Percussion Correct Answer: requires both hands -- striking finger/hand against other hand placed on patient Proper Use of a Stethoscope Correct Answer: Low sounds- diaphragm High sounds - Bell sphygmomanometer Correct Answer: instrument to measure blood pressure NIBP Correct Answer: Electronic device on BP cuff Normal Pulse Oximetry Level Correct Answer: 95%-100% of oxygen Pulse oximetry Correct Answer: noninvasive method of measuring oxygen in the blood by using a device that attaches to the fingertip Types of thermometers Correct Answer: oral, rectal, axillary, tympanic Influences of Temperature Correct Answer: Menstruation, ovulation, exercise, metabolism, shock, angry or excited, certain drugs and medications Normal temperature range: Correct Answer: 96.4-99.1 F Which thermometer type is least accurate? Correct Answer: Axillary Which thermometer type is most accurate? Correct Answer: Rectal Which thermometer type is least invasive and most accurate? Correct Answer: Temporal Normal heart rate range Correct Answer: 50-95 bpm Types of Heart Rate Locations: Correct Answer: Radial Apical Carotid Brachial Normal Respiratory Rate Correct Answer: 10-20 breaths/min Systolic Correct Answer: Blood pressure in the arteries during contraction of the ventricles. Diastolic Correct Answer: minimum pressure on arteries during ventricle relaxation Normal Blood Pressure Range Correct Answer: Systolic: 90-120 Diastolic: 60-80 Too large of a BP cuff results in: Correct Answer: Falsely low BP Too small of a BP cuff results in: Correct Answer: Falsely high BP What are some patient factors that could cause an inaccurate BP reading? Correct Answer: medication Are they anxious or excited Coffee Legs should be uncrossed Arm relaxed Alcohol Stress smoking Physiologic factors controlling blood pressure Correct Answer: Cardiac output Peripheral vascular resistance Volume of circulating blood Viscosity Elasticity of vessel walls Proper BP Taking Technique Correct Answer: Correct cuff size (80% on arm, 20% flap/overhang) Sitting or lying down Bare arm supported at heart level Palpate the brachial artery Inflate cuff until the artery pulsation is obliterated and then 20 to 30mmHg beyond Deflate cuff slowly but efficiently to listen Dysphagia Correct Answer: Difficulty or discomfort in swallowing Bradypneic Correct Answer: Abnormally slow breathing Depends on number of factors, including age of individual and degree of exertion Tachypneic Correct Answer: Rapid Breathing Indicated by a rate greater than 20 breaths per minute Orthopneic Correct Answer: Difficult or painful breathing except in an erect sitting or standing position Cachectic Correct Answer: Presenting weakness and wasting of body due to severe chronic illness Cyanosis Correct Answer: bluish discoloration of the skin Erythema Correct Answer: superficial reddening of the skin Eupnea Correct Answer: normal, unlabored breathing Hypertrophy Correct Answer: increase in volume of organ or tissue due to enlargement of component cells Hypothermia Correct Answer: abnormally low body temperature Pallor Correct Answer: paleness of the skin Tripod position Correct Answer: An upright position in which the patient leans forward onto two arms stretched forward and thrusts the head and chin forward. Graphy Correct Answer: process of recording Ante Correct Answer: before or forward Mood Correct Answer: prolonged display of feelings, durable Affect Correct Answer: temporary expression of feelings or state of mind Aphasia Correct Answer: inability to express or understand words Dysmenorrhea Correct Answer: painful menstruation Dyspareunia Correct Answer: difficult or painful sexual intercourse Dysuria Correct Answer: painful or difficult urination Nocturia Correct Answer: Waking frequently to urinate Precordial Correct Answer: Situated in front of the heart Retrosternal Correct Answer: behind the breastbone Tinnitus Correct Answer: ringing or buzzing in the ears Parestheisa Correct Answer: Tingling abnormal sensation