Nur 514 - Exam 2023 with verified questions and answers

What are the 5 steps of the nursing process & an example of each? Assessment - Collecting subjective & objective data from the patient Diagnosis -Data is collected & analyzed in order to make a nursing judgment Planning - Nurse decides the best plan while considering data Implementation -Carrying out the plan Evaluation -Determining whether plan was successful & what can be improved Write an example of an initial comprehensive assessment -ongoing/partial assessment - focused assessment & emergent assessment Initial comprehensive: seeing a new patient for the first time at that practice Ongoing/partial: a check up/follow up Emergent: Pt coming into ER w/ gunshot wound Focused: Pt broke arm or is having stomach pains How can the nurse prepare for the assessment? Review pt record Review pt previous & current health status w/ other healthcare professionals Take time to educate themselves about pt diagnosis & tests performed What is a nursing diagnosis? Give an example. Data analyzed and by definition of NANDA "a clinical judgment concerning a human response to health conditions/life processes, or vulnerability for that response by an individual, family, group or community." It serves as a basis for nursing interventions w/ achievable outcomes by nursing staff Example: Pt came back from surgery → "Risk for infection r/t new incision & increased WBC from possible inflammation" What is the health belief model? When would we use it? The health belief model is based on 3 concepts: the existence of sufficient motivation the belief that one is susceptible or vulnerable to a serious problem the belief that change following a health recommendation would be beneficial to the individual at a level of acceptable cost. This model would be used to analyze health promotion and disease prevention. What are some examples of subjective data? Anything patient states Does not involve measured, numeric data Examples: sensations/symptoms, feelings, perceptions, desires, preferences, beliefs, ideas, values, personal information What are the 3 phases of the interview? Define them. Pre Introductory: Review medical record Introductory: Nurse introduces themselves Explain purpose of the interview, what type of questions will be asked, and why they will be taking notes Nurses makes sure pt is comfortable and ensures their privacy Working phase: Nurse listens to patients comments on biographical data, reasons for seeking care, history of present health concern, past health history, family history, review of body systems for current health problems, lifestyle & health practices Nurse & patient together determine pt problem & goal Summary & Closing: Nurse summarizes information obtained during working phase & validates pt problems and goals They discuss possible plans to resolve the problem Nurse asks if there are any other questions or concerns Give examples of nonverbal communication & what to avoid when interviewing a patient Nonverbal communication pertains to anything & everything that is not communicated directly using your voice to speak Examples: silence, stands (hands folded over chest), body language (standing vs. sitting, too much eye contact vs. not enough) Nurse interviewer should avoid silence & having an aggressive stance/body language, maintain an appropriate amount of eye contact Give examples of verbal communication tactics Open ended questions Close ended questions Laundry listing Giving options: "is pain sharp, radiating, pulsing, etc." Rephrasing the question Well-placed phrases Inferring Providing information What are some examples of cultural - emotional & age related considerations when conducting an assessment? Example: Assessment on Indian girl No male presence in the room, even if it is her father Have mom there for emotional support For age, do not ask any questions related to personal matters in front of her mom Age related example: hearing abilities of pt. Cultural example: space b/w you and pt. What mnemonic is used to explore pt symptoms? What does each letter in the mnemonic stand for? COLDSPA Character: describe the signs/symptoms (feeling, appearance, smell, sound taste) Onset: when did it begin? Location: where is it? Where does it radiate? Other locations? Duration: how long does it last? Is it continuous or intermittent? Severity: how bad is the pain (0-10)? Pattern: what relieves it? What worsens it? Associated factors: other symptoms that may be related to the main symptom? What kind of information is explored when you review the lifestyle & health practice of the patient? Description of a typical day (AM to PM) Nutrition & weight management 24 hr dietary intake (foods & fluids) Who purchases & prepares meals? Activities on a typical day Exercise patterns & habits Sleep & rest patterns Use of medications and other substances (caffeine, nicotine, alcohol, recreational drugs) Self concept Self care responsibilities Social activities for fun & relaxation Relationships w/ family, significant others, pets Values, religious affiliation, spirituality Past, current, & future plans for education Type of work, level of job satisfaction, work stressors Finances Stressors in life, coping strategies Residency, type of environment, neighborhood Environmental risks What are some examples of objective data? Presence of a wound Vital signs Ht/wt General appearance Level of consciousness Anything the nurse can see with their own eyes What are the 4 physical exam techniques that you must do in order? Inspection Palpation Percussion Auscultation Always inspect before touching pt so you don't change appearance of the skin What are the different types of palpation and when you would use them? Types of palpation Light: place hand lightly on surface, very little or no depression, feel using circular motion Use for pulses, tenderness, skin texture, temperature, moisture Moderate Depress skin 1-2 cm w/ hand Use circular motion Use for feeling easily palpable body organs and masses Can note size, consistency, mobility of structures Deep Place dominant hand on skin, nondominant hand on top to apply pressure Depress b/t 2.5-5 cm Used for feeling very deep organs or structures covered by thick muscle Bimanual palpation Use 2 hands, place one on each side of body Use one hand to apply pressure, other hand to feel structure Use for noting size, shape, consistency, mobility of structures Used in OB settings often (breast & uterus exams) Why do we use percussion? Eliciting pain Determining location, size & shape Determining density Detecting abnormal masses Eliciting reflexes What are standard precautions during an exam? Standard precautions during an exam include hand hygiene, PPE such as gloves, gowns, masks, goggles, and face shields (this depends on the type of exam p. 33), patient placement, patient care equipment and instruments/devices, care of the environment, linen, and safe injection practices What are methods of validating your data? Asking client additional questions for clarification Ask another healthcare provider to concur data Confirming data with a repeat assessment Examine subjective and objective discrepancies What is the HITECH act? What are the abbreviations used for medical records that are kept electronically? Encourages use of health information technology (EHR) What does SBAR stand for? When and why would you use it? Situation Background Assessment Recommendation Used to communicate assessment data, improves quality & safety outcomes when used by health team members to communicate or hand off client information (ex. report to next shift), decreases errors What is step one of analyzing data? Give an example of an identified strength and abnormal finding of both an objective and subjective piece of data: -Identifying strengths and abnormal findings. -The nurse should compare data with reference standards. -The nurse should know basic risk factors based on data obtained (i.e. gender, age, genetics) - Example of strength in subjective: Pt. reports she sleeps well, 8 hours per night with no interruptions. -Example of abnormal in subjective: Pt. reports skipping meals -Example of strength in objective: BP in normal range -Example of abnormal finding in objective: BP out of normal range What is step 2 of analyzing data? Give an example? -Cluster data. Group both abnormal cues and strength cues. "Parking lot" Example: Client may have a nonproductive cough w/ labored respirations at a rate of 24 per minute, however you have gathered no data on the status of breath sounds. Assess client breath sounds to formulate appropriate nursing diagnosis/ collaborative problems. What is step 3 of analyzing data? Give an example? Draw inferences Requires nurse to document inferences about each cue cluster Consider nursing diagnosis, collaborative problem, and referrals Ex. diabetic pt is having difficulty understanding a diabetic diet so the nurse refers the patient to a dietitian What is step 4 of analyzing data? Give an example? Propose possible nursing diagnoses wellness/health promotion - the pt and support system has motivation to increase well being and enhance health behaviors Risk diagnosis - pt doesn't have a problem but is vulnerable to developing it Actual diagnosis is current problem What is step 6 of analyzing data? Give an example? Check for defining characteristics Ex. making sure related factors are present in patient to confirm or deny diagnosis What is step 6 of analyzing data? Give an example? Step 6: confirm or rule out diagnosis If cue cluster doesn't meet diagnosis, rule it out Diagnosis should be verified with client and other HC professionals caring for the client Consult w/ family members, significant others, other HC professionals What is step 7 of analyzing data? Give an example? Documenting conclusions Document all your observations and data that supports diagnosis , collaboration problems, referrals and nursing diagnoses. What is the difference between actual - risk for - health promotion - collaborative and medical diagnosis? Actual: is actually happening to the patient Risk for: could potentially happen if we don't intervene Health promotion: intervene/educate to improve pt health outcomes after discharge Collaborative: referral to external providers Medical diagnosis: done by physician or other provider What is the SBIRT tool? When would you use it? Why? SBIRT (Screening, Brief Intervention, and Referral to Treatment) is a quick assessment tool used to examine and approach unhealthy drug and alcohol use. It would be used in a situation where a substance abuse disorder is not present, but the individual may have unhealthy behaviors. It aims to encourage the individual to make healthy decisions. What is the CAGE assessment? When would you use it and why? The CAGE assessment is a screening tool used when providers suspect that tps are experiencing possible issues related to alcohol or alcoholism. This screening tool is uncomfortable but can be useful in recognizing potential reliance on alcohol and can be used preventatively to get the pt support to prevent further problems. C: Have you ever tried to cut back on your use? A: Have you ever been annoyed/angered when questioned about your sue? G: Have you ever felt guilty about your use? E: Have you ever had an eye opener to get started in the morning? What are some cultural considerations when asking about lifestyle and health practices? Religion can affect the way people perceive troubles, it often can help relieve anxiety of it There is a link b/t socioeconomic factors, HIV risk, depression, substance abuse, violence and Latina health disparities Some cultures encourage care of parents and others encourage independence Seeking help may be seen as weakness What are some differences between a patient with dementia and normal age-related changes? What is the SLUMS assessment? Pt with dementia may ask the same question repeatedly, repeat the same story over and over, forget how to perform daily tasks, get lost in familiar surroundings, forget to maintain hygiene, and rely on someone else to answer questions or make decisions for them SLUMS is a tool to assess mental status of older adults to determine if dementia might be present It asks questions about orientations, identification of familiar objects, and simple cognitive tasks What is the SAD assessment? When and why is it used? The SAD PERSONS scale is used to assess suicide risk in patients. Each category that relates to the patient would score them a point. The categories that are looked at are: (men automatically get 1 pt since they follow through/ suicide more often than women) age (20,45), depression, previous attempt of suicide, alcohol abuse, rational thinking loss, lacking social support, organized plan of suicide, no spouse, availability of lethal means & sickness What is the PHQ-9? Why and when is it used? PHQ-9 is a screening tool used for depression after the use of PHQ-2. It allows further assess to the access to the client that indicates depression on the PHQ-2 tool. What are abnormal findings for level of consciousness (LOC)? Lethargy: opens eyes, answer questions, falls back asleep Obtunded: opens eyes to loud voice, responds slowly with confusion, and seems unaware of environment Coma: remains unresponsive to all stimuli, eye stay closed Stupor: awakens to vigorous shake/painful stimuli, but returns to unresponsive sleep What are abnormal findings of voice and speech problems? Lethargy: opens eyes, answers questions, falls back asleep Obtunded: opens eyes to loud voice, responds slowly with confusion, and seems unaware of environment. Coma: remains unresponsive to all stimuli, eyes stay closed. Stupor awakens to vigorous shake/painful stimuli, but returns to unresponsive sleep. What is the Glasgow coma scale? What is a normal score? Abnormal? The glasgow coma scale measures one's response to stimuli. A client who scores 10 or lower needs emergency attention. A client with a score of 7 or lower is in a coma. What are some potential health promotion diagnoses? Young adult: readiness for enhanced knowledge, readiness for self-health management, readiness for enhanced relationships, readiness for enhanced parenting Middle aged adult: Readiness of enhanced knowledge, readiness for enhanced self health management, readiness for enhanced family processes, readiness for enhanced coping, readiness for enhanced family coping, readiness for enhanced community coping Older adult: Readiness for enhanced knowledge, readiness for enhanced self-health management, readiness for enhanced relationships, readiness for enhanced religiosity What are potential risk diagnoses? The client does not currently have the problem but is vulnerable to developing it Ex. poor nutrition, immobility causing impaired skin integrity, incontinence Young adult: Risk for disturbed personal identity, self violence, isolation, ineffective relationships, impaired parenting, impaired attachment, post-trauma syndrome, loneliness, situational low self-esteem, suicide Middle-aged adult: Risk for disturbed personal identity, loneliness, low self-esteem, caregiver role strain, post-trauma syndrome, spiritual distress, grieving, suicide What are potential actual diagnoses? Determined depending on individuals levels of assessed development. Nursing diagnosis can be labeled as primarily "psychosocial" (the client is currently experiencing the stated problem or has a dysfunctional pattern Ex. impaired skin integrity: reddened area on hip Young adult: Anxiety, disturbed body image, parental role conflict, ineffective coping, dysfunctional family, fear, ineffective health maintenance, deficient knowledge, sedentary lifestyle, moral distress, imbalanced nutrition, impaired parenting, posttrauma syndrome, risk-prone health behavior, ineffective role performance, chronic low self esteem, sexual dysfunction, sleep deprivation, social isolation, spiritual distress Middle-aged adult: Anxiety, disturbed body image, caregiver role strain, decisional conflict, parental role conflict, defensive coping, deficient knowledge, compromised family coping, fear, anticipatory grieving, moral distress, imbalanced nutrition, posttrauma syndrome, sexual dysfunction, sleep deprivation, social isolation, spiritual distress Older adult: Anxiety, disturbed body image, decisional conflict, ineffective community coping, deficient diversional activity, fear, impaired home maintenance, interrupted family processes, hopelessness, impaired physical mobility, moral distress, imbalance nutrition, powerlessness, relocation stress syndrome, disturbed sleep pattern, social isolation, spiritual distress, impaired religiosity What are the routes to measure temperature? What are the normal and abnormal values? Oral: 96.6-99.5 Axillary: 95.6-98.5 Temporal 97.4-100.3 Rectal: 97.4-100.3 What are the locations to take pulse rate? What are the normal and abnormal values? Radial, carotid, brachial Normal: 60 - 100 BPM 60 = bradycardia 100 = tachycardia How do you measure respiration? What are the normal and abnormal values? What are considerations for older adults? Measure: 1 full rise and fall of chest/abdomen Normal: 12-20 Bradypnea 12 Tachypnea 20 Elderly normal: 15-22 What are the Korotkoff sounds and why are they important? Phase 1: first appearance of faint, clear, repetitive tapping sounds Number on pressure gauge at which you hear the first sound is systolic pressure Phase 2: Muffled or swishing, softer and longer than phase 1 Intermittent murmur, may temporarily subside Phase 3: Return of distinct, crisp, and louder sounds Phase 4: Sounds that are muffled, less distinct, and softer (blowing quality) Phase 5: All sounds disappear completely Diastolic measurement is last sound heard before period of continuous silent Korotkoff sounds are important b/c they are what allow nurses and physicians to obtain the accurate measurement when checking a patient's blood pressure What are the classifications in blood pressure ranges? Normal: 120/80 Hypotension: 90/60 Prehypertension: 120-139/80-89 Hypertension stage 1: 140-159/90-99 Hypertension stage 2: 160-179/100-109 What are recommendations for follow-up based on initial blood pressure? Normal: recheck in 2 years Prehypertension: recheck in 1 year Stage 1 hypertension: confirm within 2 months Stage 2 hypertension: evaluate or refer to source of care within 1 month (higher pressures evaluate and treat immediately or within 1 week → 180/110 mmHg) A nurse measures a client's BP at 174/103 mmHg. The nurse recognizes this as what classification of BP measurement? Stage 2 hypertension A nurse is assessing the respiratory rate of an elderly client. Which of the following findings in breaths per minute would indicate a normal respiratory rate in this client? 11 18* 23 12 Normal range for elderly → 15-22 A nurse is preparing to assess a client's vital signs. In which order should the nurse assess them? Temp-pulse-RR-BP What are some physiologic responses to pain? Anxiety, fear, hopelessness, sleeplessness, thoughts of suicide, focus on pain, reports of pain, cries & moans, frowns and facial grimaces, decrease in cognitive function, mental confusion, altered temperament, high somatization, dilated pupils, increased HR, peripheral, systemic & coronary vascular resistance and blood pressure What are the 3 classifications of pain? Nociceptive Neuropathic Inflammatory How can we explain the duration and etiology of pain? Ex: Acute pain. Etc. Acute pain: Typically associated with a recent injury or has a sudden onset Chronic nonmalignant pain Typically due to a specific cause or injury and has remained constant for more than 6 months Cancer pain Associated with the compression of peripheral nerves or meninges or from damage following surgery, chemotherapy, radiation or tumor growth and infiltration Intractable pain Pain that is described as having a high resistance to pain relief What are the seven dimensions of pain? Physical Sensory Behavioral Sociocultural Cognitive Affective spiritual What are some developmental and cultural considerations when assessing pain? When assessing pain for infants, children, or people w/ cognitive impairment, there is a hierarchy of ways to try to find out information about a person's pain Self report: best option but not always can be used Search for potential causes of pain If the pt has had surgery, if they have a wound that could be painful, if they have a catheter, etc. Observe pt behavior Use a pain scale, but this may not be always accurate Surrogate reporting of pain and behavior/activity changes Ask a family member or caregiver if they have noticed differences in the patients attitude or if they seem like they have been in pain This method can have discrepancies Attempt an analgesic trial The nurse will have to see if any changes occur in the patients self-report after this trial Cultural: Some cultures see pain differently than others Some may believe pain = weakness, so they may be stoic Other cultures can see pain as normal → may not accept pain meds b/c just part of life & not a clinical problem Don't make any assumptions, even if you have had patients before of similar cultural background, each patient is treated independently, do not stereotype Using COLDSPA what questions do you use to assess pain? C - character: can you describe your pain? What does it feel like? O - onset: when did the pain start? L - location: where does it hurt, does it radiate, does it occur anywhere else? D - duration: how long does the pain last when it occurs? How often? S - severity: could you rate your pain on a scale of 1-10? P - pattern: what relieves it? What worsens it? A - associate factors: does it stop you from doing daily activities? What other symptoms are there? What are abnormal physical assessment findings indicating a patient may be in pain? Dilated pupils Increased HR Mental confusion Decreased intestinal motility Increased epinephrine & ADH Decreased urinary output → fluid retention Increased blood pressure Hyperglycemia Muscle spasms What is intimate partner violence? What special considerations should be taken when assessing for IPV? What are the signs of IPV? IPV = "physical, sexual or psychological harm by a current/former partner or spouse." Ex. sexual assault, progressive isolation, stalking, deprivation, intimidation, reproductive coercion Most common → sexual violence & stalking Special considerations: as a society we focus on women as the victim, but males can be too 1/7 men have experienced violence by their partner Signs: both men and women suffer from similar S/S which include chronic pain, headaches, insomnia, PTSD, psychological/physical/mental health problems What are the phases in the cycle of violence? Tension building phase: first sign criticism, abuser makes unrealistic demands, when expectations are not met, criticism/ridicule escalates into shoving/slapping Acute batting stage: maybe triggered by something minor but results in violence lasting up to 24 hours Honey moon phase: period of reconciliation, begins after the abuser uses period of pattern and then is loving and promises not to do it again What should you ask the client when you are assessing for a safety plan? If you ever have to leave, do you have a safe place where you will go? Have you gathered all of your: cash, SSN cards, birth certificates, driver's license, rent & utility receipts, bank account numbers, insurance policy numbers, marriage license, jewelry, important phone numbers, copy of protection order? Have you made a code word with your friends, family, children? Will they know how to call police & get you help? Do you have a bag packed, hidden, yet easily accessible to grab quickly? Have you removed any weapons from the home? Have you told your neighbors about the abuse? Can you ask them to call the police when they hear a disturbance? What are some of the considerations related to older adults you should be aware of when assessing the skin to determine if abuse has occured? Skin in older patients is much more fragile Bruise easier Skin tears easier Ask right questions to determine if it is common aging process vs. abuse What are some of the cultural considerations you should be aware of when assessing the skin to determine if abuse has occurred? Some cultures may have different practices or habits that effect the skin in a way that may appear harmful or similar to abuse (for example, coining in some Eastern cultures) so it is important to understand the cultural background and ask the right questions to determine if abuse is present What are some of the considerations for interviewing a child for abuse? Do not bribe child statements/answers should come naturally Children who have been abused/malnourished may appear much younger than actual age Children may be cognitively behind what is considered normal for their age What is the HITS assessment tool? When do we use it? Frequency of IPV Hurt, Insult, Threaten, Scream What are some of the signs of human trafficking? Individual not free to leave/come as they wish Is in commercial sex industry and has a pimp/manager Under 18 and is providing commercial sex acts unpaid/paid very little or for trips Works excessively long or unusual hours Not allowed breaks Owes a large debt Was recruited through false promises High security measures in the work/living locations Is fearful, anxious, depressed, submissive, tense, nervous, paranoid, fearful/anxious around law enforcement Avoids eye contact Lacks healthcare Appears malnourished Shows signs of physical and/or sexual abuse Has few/no personal possessions Is not in control of their own money Is not in control of IDs Not allowed to speak for themselves Claims of just visiting or unable to claim where they live Lack of knowledge of whereabouts Loss of sense of time Inconsistencies in story What are the long-term consequences of child abuse? Psychological Relationships problems Low self esteem Depression Cognitive problems Social problems Fear Inability to trust Behavioral Pregnancy Tasking seual risks Juvenile delinquency Being a criminal as an adult alcohol/drug abuse Physical HTN, obesity, DM, CV disease Poor brain development Learning difficulties Brain injury/head trauma Lung problems, liver disease, chronic disease Societal High cost of child abuse and fatalities ($124 billion/year) Indirect costs: Increased healthcare system use Mental illness, domestic violence, substance abuse Financial issues Absenteeism from work juvenile/crime activity What are some of the theories of violence? Psychopathy Social learning Biologic Family systems Feminist We should probably expand on these What are some signs of emotional abuse in adults? Constant insults or criticism Blaming victim for things that are not their fault Threaten to hurt children or pets Isolation from supporters (family, friends, coworkers) Deprivation Humiliation Stalking & intimidation Manipulation (ex. Threats of suicide) Which observation of a client should cause the nurse to suspect that the client may be physically abused? Wears long sleeves in warm weather* Speech is slow but with good eye contact Coherent and relaxed speech Well-groomed and dressed A client expresses to the nurse visiting her home that her husband has threatened to kill her. The nurse understands that threats of harm and intimidation are which type of abuse? Economic Psychological* Sexual Physical The nurse assesses a client who was physically assaulted by his brother. The nurse learns that the client has been punched and kicked. After marking the area of injury on the body map what score should the nurse document for this abuse? 5 3* 4 1 What are some cultural considerations when performing the physical assessment? In some cultures, female patients prefer a female nurse/physician What are some cultural considerations when assessing the skin- hair- nails? Head and neck? Eyes? Ears? Mouth? Head & neck: In US, traumatic brain injuries are very common Mouth: oral diseases are prevalent in poorer population in developed/developing countries Dental caries, periodontal disease, tooth loss, oral mucosal, oropharyngeal lesions, cancer, HIV & trauma Skin, hair, nails Fair skinned people (especially w/ light eyes and freckles) are higher risk for skin cancer Darker skinned people more at risk for postinflammatory hyperpigmentation, vitiligo, pityriasis alba, dry/ashy skin, dermatosis papulosangria, keloid & keloid-like acne, hair loss (African, Native, Asians, latinos, hispanics) Eyes Looks at visual impairment across the ages (50, more in females) and geography Highly developed countries you see cataracts as leading cause followed by glaucoma, & age-related macular degeneration Ears Genetic causes, complications at birth, certain infectious diseases, chronic ear infections, use of drugs, exposure to excessive noise & aging What should we know about blood transfusions and specific cultures? Jehovah's Witness patients refuse blood transfusions, be aware before administering a blood transfusion even if it could save their life What are some hispanic healing practices? Folk healers hot/cold balance for diet, herbs Amulets Prayers to God Saints & spiritual reparations for sins Avoids "evil eye" caused by jealous/envy What are some native american healing practices? Medicine men or shamans Respect for nature and avoid evil spirits Use masks, herbs, sand paintings & amulets What are some african healing practices? Magico herbalist Hoodoo Traditional healers (old lady, granny or lay midwife) Magical and herbal mix of herbs, roots, and rituals Talismans or amulets What are some asian preventative and healing practices? Herbal medicine instead of western medicine Ayurvedic medicine → spices, special oils (amla oil, mustard oil) Home remedies, prayer Some cultures believe in evil effects for their diseases What are some of the cultural differences of the use of eye contact in different cultures? Americans tend to give good eye contact Eastern countries & native americans tend to look down to show respect African Americans look away when being talked to but give good eye contact when speaking Caucasians & hispanic american females tend to face each other while males and people of other cultures tend to face slightly away from the other speaker How should we respect the SPACE of a patient we are interviewing? What are some cultures who prefer closer space versus those that prefer distance during the interview? Muslim (eastern) culture prefers distance during the interview Most European cultures don't mind closer space Hispanic cultures prefer to interact in a closer space than Americans Germans tend to prefer more privacy than Americans What are some of the things that should be reviewed when assessing a patient's culture? Ethnicity Generational status Education level Religion Previous healthcare experiences occupation/income Belief about time and space Communication needs/preferences Why do nurses need to know about culture? Food choices Ways or prayer, spirituality, healing processes Items each culture possesses to represent their culture or religion Ways of dealing with pain family/community support groups Family structure A nurse begins an interview with a client who is a native american. This nurse should not be surprised to see the client display which type of behavior characteristics of the culture group when responding to questions or engaging conversations with the nurse? Looking down* Interrupting frequently Standing with the face slightly to the side Looking away A nurse provides care for an african american client who experiences anxiety - GI complaints - and a fear of being poisoned or killed. The nurse recognizes this as which culture-bound syndrome? Mal de ojo Susto Rootwork* Empacho What should the nurse do to ensure an effective face-to-face interaction with clients from different cultural backgrounds? Rely on textbooks for info on cultural groups Know that nonverbal communications are common across cultures Develop a cultural habit and build effective relationships* Consider ethnicity as the sole aspect of culture What would be nursing diagnoses found for someone in spiritual distress? Spiritual distress r/t isolation and separation from spiritual support group Risk for spiritual distress r/t isolation and separation from spiritual support group In what ways can spirituality affect a patient's care? Positive impacts of spirituality are represented in holistic nursing-mind, body & spirit NANDA has recognized evidence that spiritual practices have encouraged mental & physical health Meeting a patients spiritual needs can decrease suffering Spiritual pts may utilize their beliefs in coping with illness, pain & life stresses A nurse must perform a non formal spiritual assessment of a client. Which tool would be most appropriate for the nurse to use? Casual conversation Personal interview SPIRIT assessment tool* Open-ended questions S - spiritual belief system P - personal spirituality I - integration with a spiritual community R - rituals and restrictions spirituality requires for healthcare I - implications of spirituality and religion for healthcare T - terminal event planning What is the normal serum albumin level? What would an abnormal level indicate? Normal range: 3.5-5.5 g/dL Abnormally low levels indicate: malnutrition, liver disease or overhydration, high levels suggest dehydration What is a normal hemoglobin A1C? What would abnormal indicate? Normal HBG A1C: 4-6% A1C 6% indicates that the mean glucose level in the blood is 126 indicating the pt has T2DM What two things can you assess to determine patients' hydration changes/status? Change in weight 6-10 lbs/week & skin turgor (including pitting edema) What are orthostatic changes? (orthostatic hypotension?) how would we assess for this? Orthostatic changes = physiological changes that occur when pt stands up Othrostatic hypotension = decrease in blood pressure when standing up S/S of light-headedness, faintness, "wooziness", passing out/syncope, nausea, blurry vision, unable to stand up, dehydration, diuretic/antiHTN meds, and falling What are the ranges for BMI? What does an elevated BMI put a patient at risk for? How do you calculate BMI? BMI 18.5 = underweight 18.5-24.9 = normal 25.0-29.9 = overweight 30 = obese Wt (lbs)/ Ht (inches)^2 x 703 Elevated BMI puts pt at risk for T2DM, HTN, heart disease, certain cancers When assessing the elderly person for nutritional status - what should the nurse note about the muscle tone and mass of the elderly? Muscle tone and mass decrease with aging, loss of subcutaneous fat, making bones & muscles more prominent Fat redistributes w/ aging Fat loss from face & neck redistributes to arms, abdomen & hips What are the warning signs of poor nutrition? Reduced appetite, lack of interest in food & drink, feeling tired all the time, feeling weaker, getting ill often & taking a long tie to recover, wounds taking a long time to heal, poor concentration, feeling cold most of the time, moody or depressed What are some of the educational components a nurse can provide to a patient to prevent or eliminate risks of obesity? Healthy diets, physical activity, drinking water Can use MyPlate as educational tool or refer them to dietitian for dietary needs What is overhydration? Who is most at risk? Overhydration in a healthy person is usually not a problem b/c the body is effective in maintaining a correct fluid balance Clients at risk for overhydration or fluid retention are those w/ kidney, liver, and cardiac diseases in which the fluid mechanisms are impaired What is overnutrition? How is someone defined as obese versus overweight? Overnutrition = form of malnutrition in which the intake of nutrients is oversupplied The amount of nutrients exceeds the amount required for normal growth, development and metabolism Overweight: BMI 25-29.9 Obese: 30-34.9 Extreme obese: 35 What are risk factors of malnutrition? What is malnutrition? Malnutrition: body doesn't get enough nutrients (calories, vitamins, minerals, etc.) Risk factors: lower SES, long work hours + eating fast food, poor food choices, chronic dieting, chronic diseases that affect our nutrient absorption (ex. Crohns), dental issues (i.e. no teeth or dentures), depression and limited access to food (b/c can't shop, cook, feed themselves), psychiatric disorders like anorexia or bulimia, depression or dementia where they may not eat enough, illness/trauma that may interfere w/ ability to take in enough nutrition What are the signs and symptoms of anaphylactic shock related to food allergies? Response include obstructive swelling of lips, tongue or throat, dysphagia, cyanosis, dyspnea, hypotension, feeling faint, confused, weak, passing out, loss of consciousness, chest pain, weak/thready pulse, sense of impending doom What are some factors that influence hydration? Taking diuretic medications Impaired thirst mechanisms High fevers Inability to access adequate fluids, especially water Exposure to excessively high environmental temperatures Excess intake of alcohol or other diuretic fluids A nurse begins a comprehensive physical exam on a client and notes the client has a large amount of adipose tissue around the waistline. The nurse recognizes that this client should be assessed for an increased risk of which diseases? Select all that apply? Pancreatitis Liver disease Hypertension* Stroke* Colon cancer T2DM* How can a nurse best assess dietary habits? Ask about how much food is eaten at an average meal Obtain a 24-hour dietary recall of all foods and fluids consumed* Obtain a ht and wt & calculate a BMI Assess for the presence of any chronic disease process When performing a nutritional assessment on a client a nurse observes that the client has a red & beefy tongue. The nurse recognizes this finding as a deficiency of which essential nutrient? Niacin Iodine Vitamin B* Thiamine What is culture? Culture is a shared system of values, beliefs, and learned patterns of behavior. What is spirituality? Name some characteristics? A search for meaning and purpose in life, which seeks to understand life's ultimate questions in relation to the sacred. Characteristics: Informal, non-organized, self-reflective, may involve spiritual experiences, subjective-as in difficult to consistently measure (ex: daily spiritual experiences, spiritual well-being, etc.) What is religion? Name some characteristics? Rituals, practices & experiences involving a search for the sacred (ex: God) that are shared w/in a group. What is stereotyping? Give an example. Generalization of All members of a particular culture expecting group members to hold the same beliefs and behave the same way. Ex: "He's so old, he won't remember anything you tell him" What is ethnocentrism? Give an example. The perception that one's worldview is the only acceptable truth, and that one's beliefs, values, and sanctioned behaviors are superior to all others. (ex: Americans lol) What is enculturation? Give an example. Through socialization, enculturation is the process where people learn and accept values, norms and roles of a culture. (ex: learning local argot from a specific area of a country) What is assimilation? Give an example. The gradual adoption and incorporation of characteristics of prevailing culture. A person that moves from their native country to a new one and takes on the ways of the new culture. What is acculturation? Give an example Learning process where immigrants assume characteristics of that culture. What is school violence and bullying? Give an example. Unwanted aggressive behavior among school aged children that involves a real or perceived power imbalance that is either repeated or a single event. (ex: is teasing, name-calling, spreading rumors, hitting, cyber bullying) What is a hate crime? Give an example. Any crime that is done because of your race, gender or gender identity, sexxual orientation, color, ethnicity/place of origin, disability or religion. (ex: Vandalizing a restaurant because it is owned by someone who is Muslim) Define elder abuse and give an example? Intentional act of failure to act that causes harm to older adults. (ex: stealing or misusing money/possessions, coercing them to sign documents, physical harm) What is the definition of intimate partner violence? Intimate partner violence is physical violence, sexual violence, stalking, or psychological harm by a current or former partner or spouse. (ex: Spouse using verbal threats towards significant others) What is the definition of physical abuse? Give an example Pushing, shoving, slapping, kicking, choking, punching and burning, any type of physical damage to the victim, could involve holding, tying or other methods of restraints. Intimate Partner Violence is a good example of this. What is the definition of sexual abuse? Sexual abuse involves forcing the victim to perform sexual acts against his or her will, pursuing sexual activity after victim say NO, use of a violence during sex, and using weapons vaginally, orally or anally. Human trafficking is a good example or RAPE. What are the definitions of economic abuse? Give an example. Economic abuse is the improper exploration of another person's personal assets, properties, or funds. Seen a lot in elderly abuse and IPV.