NUR 2092 Exam 1 Health Assessment Verified Guide 2023/2024

1. What are the steps in the Nursing Process? a. Assessment- collection of data from multiple sources (physical exam, health history, review records) b. Diagnosis- cluster data that seems to be associated, validate info, look for gaps in info, interpret data and identify problems c. Outcome identification- Identify expected outcomes set a SMART goal d. Planning- establish priorities, document plan of care, set time frames for meeting goals e. Implementation- provide teaching and health promotion, use evidence based interventions f. Evaluation- evaluate individuals condition and compare actual outcomes to expected outcomes, and possibly modify plan 2. What is subjective Data? a. What the patient says about him or herself. 3. What is objective Data? a. What we observe when inspecting and assessing the patient 4. What is a SMART goal? a. Specific b. Measurable c. Attainable d. Relevant e. Time-Bound 5. What is evidence based clinical decision making? a. Review of research and literature, providers clinical expertise, patients preferences and values 6. What are the two parts to communicating? a. Sending- verbal and nonverbal b. Receiving- interpretation based on past experiences, culture, and self-concept; physical and emotional state. 7. What is the key with communication? a. Is the receiver receiving the information the way you want it to come across? 8. How do you prepare for an interview? a. Privacy b. No interuptions c. Physical environment i. Temperature ii. Noise level iii. Light level iv. Distance (4-5 ft) v. No distractions vi. Seating d. Limit note taking 9. What is a closed ended question? a. A question that allows only a yes or no answer. 10. When is a closed ended question used? a. To gain specific information 11. What is an opened ended question? a. A question that allows for a narrative answer. 12. When is an opened ended question used? a. To hear the pts feelings and opinions b. To develop rapport 13. What is a facilitation response? a. Mm-hmm, uh-huh 14. What does a silence response do? a. Allow time to think 15. What is a reflection response? a. “It’s hard to get up in the morning” “You have difficulty getting the day started” 16. What is an empathy response? a. “I can’t do anything for myself anymore.” “It must be difficult not being independent, losing control” 17. What are some barriers to communication? a. Lack of interest b. Physical barriers like a curtain, door, computer, pain, room temp. c. Hearing deficit d. Safety e. Psychological barriers- embarrassment, disbelief, anger, fear, grief, fatigue f. Language barrier g. Medical jargon 18. What are the types of pain and causes? a. Nociceptive Pain i. Usually acute ii. Starts outside the nervous system iii. From actual potential damages such as fracture or surgery iv. Responsive to anti-inflammatories and opiates b. Neuropathic Pain i. Abnormal processing from injury to nerve fibers or central nervous system ii. Chronic iii. Pt normally feels numbness, tingling, shooting, burning, or phantom pain iv. Poorly responsive to pain meds c. Referred Pain i. Felt at a site different from the organ affected ii. Spinal nerve and brain can not differentiate d. Phantom Pain i. Brain still getting messages ii. Pain where a limb used to exist e. Acute Pain i. Short term ii. Tissue damage iii. Self protective mechanism iv. Mild- moderate pain= sympathetic nervous system response v. Severe Pain= parasympathetic nervous system response f. Chronic Pain i. Over 6 months ii. Adaptive response iii. Does not stop when injury heals iv. Abnormal processing of pain fibers from peripheral and central sites g. Breakthrough Pain i. Starts again or worsens before next scheduled medication dose 19. What are behaviors of someone in acute pain? a. Guarding b. Grimacing c. Restlessness d. Moaning e. Stillness f. Diaphoresis g. Change in Vitals 20. What are behaviors of someone in chronic pain? a. Bracing b. Rubbing c. Diminished activity d. Change in appetite e. Adaption f. Often little indication g. Self distraction 21. How to assess a patient for substance abuse? a. Tolerance b. Dependence vs addiction c. Know withdrawal symptoms i. Nausea/vomiting ii. Tremor iii. Paroxysmal sweats iv. Anxiety v. Headache vi. Disorientation 22. How to use CAGE for alcohol assessment? a. Cut down drinking b. Annoyed by people criticizing your drinking c. Guilty feeling about drinking d. Eye opener (had a drink first thing in the morning to help nerve) 23. Who should be assessed for risk of abuse? a. Everyone 24. How would you attempt to assess a patient for abuse? a. Get them alone b. Ask in non-judgmental way 25. What are some signs of abuse? a. Frequent bladder infection b. Chronic pelvic pain c. STI’s d. Anxiety and Depression e. Signs of PTSD 26. What to do if you think a patient is a victim of abuse? a. Report it b. Call 911 if necessary