Exam 1: NR302 / NR 302 (New 2026/2027 Update) Health Assessment I |Review with Questions and Answers| 100% Correct | A Grade -Chamberlain

Exam 1: NR302 / NR 302 (New 2026/2027 Update) Health Assessment I |Review with Questions and Answers| 100% Correct | A Grade -Chamberlain Q. The Nurse is interviewing their patient. The nurse states "Can you tell me exactly what you feel when you are having difficulty catching your breath?" Which of the following communication techniques is the nurse utilizing? A) Attending to cues B) Paraphrasing C) Focusing D) Summarazing ANSWER C) Focusing Q. The nurse is obtaining a family health history when the client reports that a grandparent has type 1 diabetes. Where can the nurse document this information? A) Present health/ illness B) Family Genogram C) Past Medical History D) Health Belief Model ANSWER B) Family Genogram Q. The Nurse is interviewing a patient with acute pain. Which of the following actions by the nurse should be preformed first? A) Attempt to reduce the pain and complete the interview later B) Interview the family to get the information needed C) Document why the interview could not be completed at this time D) Proceed very quickly with the interview ANSWER A) Attempt to reduce the pain and complete the interview later Q. The nurse is interviewing her patient. The nurse says to the client "It sounds like you do not like your new job because it is more stressful than you anticipated." Which of the following types of communication is the nurse utilizing? A) Questioning B) Paraphrasing C) Attending D) Listening ANSWER B) Paraphrasing Q. In an interview, the nurse may find it necessary to take notes to aid his or her memory later. Which statement is true regarding note-taking? A) Note-taking may impede the nurse's observation of the patient's nonverbal behaviors. B) Note-taking allows the patient to continue at his or her own pace as the nurse records what is said. C) Note-taking allows the nurse to shift attention away from the patient, resulting in an increased comfort level. D) Note-taking allows the nurse to break eye contact with the patient, which may increase his or her level of comfort. ANSWER A) Note-taking may impede the nurse's observation of the patient's nonverbal behaviors. Page: 31 Some use of history forms and note-taking may be unavoidable. But be aware that note-taking during the interview has disadvantages. It breaks eye contact too often, and it shifts attention away from the patient, which diminishes his or her sense of importance. It also may interrupt the patient's narrative flow, and it impedes the observation of the patient's nonverbal behavior. Q. During an interview, the nurse states, "You mentioned shortness of breath. Tell me more about that." Which verbal skill is used with this statement? A) Reflection B) Facilitation C) Direct question D) Open-ended question D) Open-ended question ANSWER Page: 32 The open-ended question asks for narrative information. It states the topic to be discussed but only in general terms. The nurse should use it to begin the interview, to introduce a new section of questions, and whenever the person introduces a new topic. Q. A nurse is taking complete health histories on all of the patients attending a wellness workshop. On the history form, one of the written questions asks, "You don't smoke, drink, or take drugs, do you?" This question is an example of: A) talking too much. B) using confrontation. C) using biased or leading questions. D) using blunt language to deal with distasteful topics. ANSWER C) using biased or leading questions. Page: 36 This is an example of using leading or biased questions. Asking, "You don't smoke, do you?" implies that one answer is "better" than another. If the person wants to please someone, he or she is either forced to answer in a way corresponding to their implied values or is made to feel guilty when admitting the other answer. Q. During an interview, a parent of a hospitalized child is sitting in an open position. As the interviewer begins to discuss his son's treatment, however, he suddenly crosses his arms against his chest and crosses his legs. This would suggest that the parent is: A) just changing positions. B) more comfortable in this position. C) tired and needs a break from the interview. D) uncomfortable talking about his son's treatment. ANSWER D) uncomfortable talking about his son's treatment. Page: 37 Note the person's position. An open position with the extension of large muscle groups shows relaxation, physical comfort, and a willingness to share information. A closed position with the arms and legs crossed tends to look defensive and anxious. Note any change in posture. If a person in a relaxed position suddenly tenses, it suggests possible discomfort with the new topic. Q. The nurse is interviewing a patient who has a hearing impairment. What techniques would be most beneficial in communicating with this patient? A) Determine the communication method he prefers. B) Avoid using facial and hand gestures because most hearing-impaired people find this degrading. C) Request a sign language interpreter before meeting with him to help facilitate the communication. D) Speak loudly and with exaggerated facial movement when talking with him because this helps with lip reading. ANSWER A) Determine the communication method he prefers. Pages: 40-41 The nurse should ask the deaf person the preferred way to communicate—by signing, lip reading, or writing. If the person prefers lip reading, then the nurse should be sure to face him or her squarely and have good lighting on the nurse's face. The nurse should not exaggerate lip movements because this distorts words. Similarly, shouting distorts the reception of a hearing aid the person may wear. The nurse should speak slowly and should supplement his or her voice with appropriate hand gestures or pantomime. Q. The nurse is performing a health interview on a patient who has a language barrier, and no interpreter is available. Which is the best example of an appropriate question for the nurse to ask in this situation? A) "Do you take medicine?" B) "Do you sterilize the bottles?" C) "Do you have nausea and vomiting?" D) "You have been taking your medicine, haven't you?" ANSWER A) "Do you take medicine?" Page: 46 In a situation where there is a language barrier and no interpreter available, use simple words avoiding medical jargon. Avoid using contractions and pronouns. Use nouns repeatedly and discuss one topic at a time. Q. A female patient does not speak English well, and the nurse needs to choose an interpreter. Which of the following would be the most appropriate choice? A) A trained interpreter B) A male family member C) A female family member D) A volunteer college student from the foreign language studies department ANSWER A) A trained interpreter Page: 46 whenever possible, the nurse should use a trained interpreter, preferably one who knows medical terminology. In general, an older, more mature interpreter is preferred to a younger, less experienced one, and the same gender is preferred when possible. Q. The nurse is conducting an interview. Which of these statements is true regarding open-ended questions? Select all that apply. A) They elicit cold facts. B) They allow for self-expression. C) They build and enhance rapport. D) They leave interactions neutral. E) They call for short one- to two-word answers. F) They are used when narrative information is needed. ANSWER B) They allow for self-expression. C) They build and enhance rapport. F) They are used when narrative information Page: 32 Open-ended questions allow for self-expression, build rapport, and obtain narrative information. These features enhance communication during an interview. The other statements are appropriate for closed or direct questions. Q. The nurse is conducting an interview in an outpatient clinic and is using a computer to record data. Which is the best use of the computer in this situation? Select all that apply. A) Collect the patient's data in a direct, face-to-face manner. B) Enter all the data as the patient states it. C) Ask the patient to wait as the nurse enters data. D) Type the data into the computer after the narrative is fully explored. E) Allow the patient to see the monitor during typing. ANSWER A) Collect the patient's data in a direct, face-to-face manner. D) Type the data into the computer after the narrative is fully explored. E) Allow the patient to see the monitor during typing. Page: 32 The use of a computer can become a barrier. The nurse should begin the interview as usual by greeting the patient, establishing rapport, and collecting the patient's narrative story in a direct face-to-face manner. Only after the narrative is fully explored should the nurse type data into the computer. When typing, the nurse should position the monitor so that the patient can see it. Q. During an assessment, the nurse notices that a patient is handling a small charm that is tied to a leather strip around his neck. Which action by the nurse is appropriate? A) Ask the patient about the item and its significance. B) Ask the patient to lock the item with other valuables in the hospital's safe. C) Tell the patient that a family member should take valuables home. D) No action is necessary. ANSWER A) Ask the patient about the item and its significance. Page: 21 The nurse should inquire about the amulet's meaning. Amulets, such as charms, are often seen as an important means of protection from "evil spirits" by some cultures. Q. In the majority culture of America, coughing, sweating, and diarrhea are symptoms of an illness. For some individuals of Mexican-American origin, however, these symptoms are a normal part of living. The nurse recognizes that this is true, probably because Mexican-Americans: A) have less efficient immune systems and are often ill. B) consider these symptoms a part of normal living, not symptoms of ill health. C) come from Mexico and coughing is normal and healthy there. D) are usually in a lower socioeconomic group and are more likely to be sick. ANSWER B) consider these symptoms a part of normal living, not symptoms of ill health. Page: 27 The nurse needs to identify the meaning of health to the patient, remembering that concepts are derived, in part, from the way in which members of the cultural group define health. Q. Among many Asians there is a belief in the yin/yang theory, rooted in the ancient Chinese philosophy of Tao. The nurse recognizes which statement that most accurately reflects "health" in an Asian with this belief? A) A person is able to work and produce. B) A person is happy, stable, and feels good. C) All aspects of the person are in perfect balance. D) A person is able to care for others and function socially. ANSWER C) All aspects of the person are in perfect balance. Page: 21 Many Asians believe in the yin/yang theory, in which health is believed to exist when all aspects of the person are in perfect balance. The other statements do not describe this theory. An individual who takes the magicoreligious perspective of illness and disease is likely to believe that his or her illness was caused by: A) germs and viruses. B) supernatural forces. C) eating imbalanced foods. D) an imbalance within his or her spiritual nature. B) supernatural forces. Page: 21 The basic premise of the magicoreligious perspective is that the world is seen as an arena in which supernatural forces dominate. The fate of the world and those in it depends on the actions of supernatural forces for good or evil. The other answers do not reflect the magicoreligious perspective. If an American Indian has come to the clinic to seek help with regulating her diabetes, the nurse can expect that she: A) will comply with the treatment prescribed. B) has obviously given up her beliefs in naturalistic causes of disease. C) may also be seeking the assistance of a shaman or medicine man. D) will need extra help in dealing with her illness and may be experiencing a crisis of faith. C) may also be seeking the assistance of a shaman or medicine man. Page: 23 When self-treatment is unsuccessful, the individual may turn to the lay or folk healing systems, to spiritual or religious healing, or to scientific biomedicine. In addition to seeking help from a biomedical or scientific health care provider, patients may also seek help from folk or religious healers. An elderly Mexican-American woman with traditional beliefs has been admitted to an inpatient care unit. A culturally-sensitive nurse would: A) contact the hospital administrator about the best course of action. B) automatically get a curandero for her because it is not culturally appropriate for her to request one. C) further assess the patient's cultural beliefs and offer the patient assistance in contacting a curandero or priest if she desires. D) ask the family what they would like to do because Mexican-Americans traditionally give control of decisions to their families C) further assess the patient's cultural beliefs and offer the patient assistance in contacting a curandero or priest if she desires. Pages: 22-23 In addition to seeking help from the biomedical/scientific health care provider, patients may also seek help from folk or religious healers. Some people, such as those of Mexican-American or American Indian origins, may believe that the cure is incomplete unless the body, mind, and spirit are also healed (although the division of the person into parts is a Western concept). The nurse is reviewing concepts of cultural aspects of pain. Which statement is true regarding pain? A) All patients will behave the same way when in pain. B) Just as patients vary in their perceptions of pain, so will they vary in their expressions of pain. C) Cultural norms have very little to do with pain tolerance, because pain tolerance is always biologically determined. D) A patient's expression of pain is largely dependent on the amount of tissue injury associated with the pain. B) Just as patients vary in their perceptions of pain, so will they vary in their expressions of pain. Page: 25 In addition to expecting variations in pain perception and tolerance, the nurse should expect variations in the expression of pain. It is well known that individuals turn to their social environment for validation and comparison. The other statements are incorrect. The nurse recognizes that working with children with a different cultural perspective may be especially difficult because: A) children have spiritual needs that are influenced by their stages of development. B) children have spiritual needs that are direct reflections of what is occurring in their homes. C) religious beliefs rarely affect the parents' perceptions of the illness. D) parents are often the decision makers, and they have no knowledge of their children's spiritual needs. A) children have spiritual needs that are influenced by their stages of development. Page: 20. Illness during childhood may be an especially difficult clinical situation. Children, as well as adults, have spiritual needs that vary according to the child's developmental level and the religious climate that exists in the family. The other statements are not correct. When providing culturally competent care, nurses must incorporate cultural assessments into their health assessments. Which statement is most appropriate to use when initiating an assessment of cultural beliefs with an elderly American Indian patient? A) "Are you of the Christian faith?" B) "Do you want to see a medicine man?" C) "How often do you seek help from medical providers?" D) "What cultural or spiritual beliefs are important to you?" D) "What cultural or spiritual beliefs are important to you?" Page: 17. The nurse needs to assess the cultural beliefs and practices of the patient. American Indians may seek assistance from a medicine man or shaman, but the nurse should not assume this. An open-ended question regarding cultural and spiritual beliefs is best used initially when performing a cultural assessment. When planning a cultural assessment, the nurse should include which component? A) Family history B) Chief complaint C) Medical history D) Health-related beliefs D) Health-related beliefs Pages: 19-20. Health-related beliefs and practices are one component of a cultural assessment. The other items reflect other aspects of the patient's history. When the nurse is evaluating the reliability of a patient's responses, which of these statements would be correct? The patient: A. has a history of drug abuse and therefore is not reliable. B. provided consistent information and therefore is reliable. C. smiled throughout interview and therefore is assumed reliable. D. would not answer questions concerning stress and therefore is not reliable. B. provided consistent information and therefore is reliable. Page: 50. A reliable person always gives the same answers, even when questions are rephrased or are repeated later in the interview. The other statements are not correct. In recording the childhood illnesses of a patient who denies having had any, which note by the nurse would be most accurate? A. Patient denies usual childhood illnesses. B. Patient states he was a "very healthy" child. C. Patient states sister had measles, but he didn't. D. Patient denies measles, mumps, rubella, chickenpox, pertussis, and strep throat. D. Patient denies measles, mumps, rubella, chickenpox, pertussis, and strep throat. Page: 51. Childhood illnesses include measles, mumps, rubella, chickenpox, pertussis, and strep throat. Avoid recording "usual childhood illnesses" because an illness common in the person's childhood may be unusual today (e.g., measles). The mother of a 16-month-old toddler tells the nurse that her daughter has an earache. What would be an appropriate response? A. "Maybe she is just teething." B. "I will check her ear for an ear infection." C. "Are you sure she is really having pain?" D. "Please describe what she is doing to indicate she is having pain." D. "Please describe what she is doing to indicate she is having pain." Page: 60. With a very young child, ask the parent, "How do you know the child is in pain?" Pulling at ears alerts parent to ear pain. The statements about teething and questioning whether the child is really having pain do not explore the symptoms, which should be done before a physical examination. A 5-year-old boy is being admitted to the hospital to have his tonsils removed. Which information should the nurse collect before this procedure? A. The child's birth weight B. The age at which he crawled C. Whether he has had the measles D. Reactions to previous hospitalizations D. Reactions to previous hospitalizations Assess how the child reacted to hospitalization and any complications. If the child reacted poorly, he or she may be afraid now and will need special preparation for the examination that is to follow. The other items are not significant for the procedure. The nurse is preparing to do a functional assessment. Which statement best describes the purpose of a functional assessment? A. It assesses how the individual is coping with life at home. B. It determines how children are meeting developmental milestones. C. It can identify any problems with memory the individual may be experiencing. D. It helps to determine how a person is managing day-to-day activities. D. It helps to determine how a person is managing day-to-day activities. Page: 67. The functional assessment measures how a person manages day-to-day activities. The other answers do not reflect the purpose of a functional assessment. The nurse is performing a functional assessment on an 82-year-old patient who recently had a stroke. Which of these questions would be most important to ask? A. "Do you wear glasses?" B. "Are you able to dress yourself?" C. "Do you have any thyroid problems?" D. "How many times a day do you have a bowel movement?" B. "Are you able to dress yourself?" Page: 67. Functional assessment measures how a person manages day-to-day activities. For the older person, the meaning of health becomes those activities that they can or cannot do. The other responses do not relate to functional assessment. The nurse is assessing a 75-year-old man. As the nurse begins the mental status portion of the assessment, the nurse expects that this patient: A) will have no decrease in any of his abilities, including response time. B) will have difficulty on tests of remote memory because this typically decreases with age. C) may take a little longer to respond, but his general knowledge and abilities should not have declined. D) will have had a decrease in his response time because of language loss and a decrease in general knowledge. C) may take a little longer to respond, but his general knowledge and abilities should not have declined. Page: 72. The aging process leaves the parameters of mental status mostly intact. There is no decrease in general knowledge and little or no loss in vocabulary. Response time is slower than in youth. It takes a bit longer for the brain to process information and to react to it. Recent memory, which requires some processing is somewhat decreased with aging, but remote memory is not affected. The nurse is preparing to do a mental status examination. Which statement is true regarding the mental status examination? A) A patient's family is the best resource for information about the patient's coping skills. B) It is usually sufficient to gather mental status information during the health history interview. C) It takes an enormous amount of extra time to integrate the mental status examination into the health history interview. D) It is usually necessary to perform a complete mental status examination to get a good idea of the patient's level of functioning. B) It is usually sufficient to gather mental status information during the health history interview. Page: 73. The full mental status examination is a systematic check of emotional and cognitive functioning. The steps described here, though, rarely need to be taken in their entirety. Usually, one can assess mental status through the context of the health history interview. During a mental status examination, the nurse wants to assess a patient's affect. The nurse should ask the patient which question? A) "How do you feel today?" B) "Would you please repeat the following words?" C) "Have these medications had any effect on your pain?" D) "Has this pain affected your ability to get dressed by yourself?" A) "How do you feel today?" Page: 74. Judge mood and affect by body language and facial expression and by asking directly, "How do you feel today?" or "How do you usually feel?" The mood should be appropriate to the person's place and condition and should change appropriately with topics. During a mental status assessment, which question by the nurse would best assess a person's judgment? A) "Do you feel that you are being watched, followed, or controlled?" B) "Tell me about what you plan to do once you are discharged from the hospital." C) "What does the statement, 'People in glass houses shouldn't throw stones,' mean to you?" D) "What would you do if you found a stamped, addressed envelope lying on the sidewalk?" B) "Tell me about what you plan to do once you are discharged from the hospital." Pages: 76-77. A person exercises judgment when he or she can compare and evaluate the alternatives in a situation and reach an appropriate course of action. Rather than testing the person's response to a hypothetical situation (as illustrated in the option with the envelope), the nurse should be more interested in the person's judgment about daily or long-term goals, the likelihood of acting in response to delusions or hallucinations and the capacity for violent or suicidal behavior. The nurse is performing a mental status examination. Which statement is true regarding the assessment of mental status? A) Mental status assessment diagnoses specific psychiatric disorders. B) Mental disorders occur in response to everyday life stressors. C) Mental status functioning is inferred through assessment of an individual's behaviors. D) Mental status can be assessed directly, just like other systems of the body (e.g., cardiac and breath sounds). C) Mental status functioning is inferred through assessment of an individual's behaviors. Page: 71. Mental status functioning is inferred through assessment of an individual's behaviors. It cannot be assessed directly like characteristics of the skin or heart sounds. Diagnostic Reasoning Process of analyzing health data and drawing conclusions to identify diagnosis 1) Attend to initially available cues 2) formulate diagnostic hypothesis 3) gather data 4) evaluate hypothesis 1st Level Priority Life threatening ABCV (airway, breathing, circulation, vital signs) Emergent, life-threatening, and require critical immediate attention. Establishing an airway, supportive breathing and circulation/cardiac, Vital signs. 2nd Level Priority Forestall further deterioration Next to urgent priority, needs intervention prior to further deterioration Next in urgency. Those requiring prompt intervention to forestall further deterioration. Abnormal lab values, untreated medical problems, risk of infection. 3rd Level Priority Important but can wait Problems that are important to patient's health but can be addressed after more urgent problems Non life threatening problems such as trouble sleeping, lack of knowledge, activity, rest, family coping Critical Thinking Means by which we learn to assess and modify behavior before acting focused, organized thinking about such things as the logical relationships among ideas, the soundness of evidence, and the differences between fact and opinion Complete Database Complete Interview + Physical Examination Appropriate for a person that is admitted to a long-term care facility Complete health history and physical examination. It describes current and past health state Forms a baseline against which all future changes can be measured. Yields first diagnoses Focused/ Problem Centered Database Database used for a limited or short-term problem; concerns mainly one problem, one cue complex, or one body system Mini Database Follow up Database Used in all settings to monitor progress on short-term or chronic health problems The status of any identified problems should be evaluated at regular and appropriate intervals. What change has occurred? Is the problem getting better or worse? Which coping strategies are used? This type of database is used in all settings to follow up both short-term and chronic health problems Emergency Database Rapid collection of the database, usually compiled concurrently with life-saving measures Ethnicity Social Group that possesses shared traits such as geographic origin, religion, language, values Identity with a group of people that share distinct physical and mental traits as a product of common heredity and cultural traditions. Evidence Based Practice Systematic approach that emphasizes the clinicians experience, the best research evidence, patient preferences and values, and physical examination and assessment Race A group of human beings distinguished by physical traits, blood types, genetic code patterns or genetically inherited characteristics. Biomedical Theory Cause and Affect Human body is like a machine Observed and Measured Germ Theory Can be divided into smaller parts Assumes that all events in life have a cause and effect, that the human body functions more or less mechanically, that all life can be divided into smaller parts; associated with germ theory Diversity The state of being different Assimilation Adopting the traits of another culture. Often happens over time when one immigrates into a new country. Process by which people of one culture merge into and become part of another culture Process of less dominant cultures losing their culture to a more dominant culture Aculturation Adopting new cultural traits while maintaining some of the former ones To adapt to a second culture without necessarily giving up one's first culture Biculturation When an individual identifies equally with two or more cultures virtual 'straddling' of two cultures and involves the ability to efficiently bridge the gap between an individual's culture of origin and the dominant cultur Naturalistic/ Holistic A model of health and illness that views human life as only one of many forces of nature; in this paradigm, all of the forces of nature should be kept in balance or harmony, because breaking the laws of nature creates imbalance, chaos, and disease. Natural Balance Yin/ Yang Hot/ Cold Facilitation Encourages patient to say more Shows interest "mmm hmm" "go on" Silence Observe non verbal cues Gives patient time to think out their response Reflection Echoes patients words by repeating what they just said Mirrors patients words When they say "I am worried about being put on bedrest for so long and how I will be able to be a good mom to my children if I am stuck in bed" A proper response could be "So you feel worried about your children while you are going to be on bedrest? Empathy Allows feeling expression Useful in instances when patient hasn't identified their feeling or is not ready to discuss The ability to imagine and understand how someone else feels "This must be very hard for you" Even placing your hand on your patients knee Clarification When patients word choice is confusing When discussing her husband, a client shares that "I would be better off alone. At least I would be able to come and go as I please and not have to be interrogated all the time." What therapeutic communication technique is the nurse using when responding, "Are you saying that things would be better if you left your husband?" Confrontation Clarifying inconsistent information "You sound angry" "Earlier you said you did not drink but now you just said you have a few beers after work each day" "You say you are not in pain but you are grimacing" Interpretation Links events, makes associations Not based on direct observations but on inferences "Could you not want to continue treatment because you are afraid of the results?" Explanation Informing, sharing factual and objective information "You may not eat or drink for 12 hours before your surgery because ....." Summary Condenses and validates what was discussed during the assessment Review facts Allows client time to make corrections Signals termination of interview is near Open Ended Question Narrative Information Long paragraph answers Elicits feelings, opinions and ideas Builds and enhances rapport "Tell me more about your pain" "Why are you here today?" Direct/ Closed Questions Used for specific information Short 1-2 word answers Elicits cold hard facts Limits rapport "Are your headaches on one side or both sides?" Internal Factors 1) Liking others 2) Empathy 3) Ability to listen 4) Self awareness External Factors Privacy Refuse interruptions Physical Environment Note Taking EHR Ten Traps of Interviewing 1)providing false assurance or reassurance 2) giving unwanted advice 3) using authority 4) using avoidance language 5) engaging in distancing 6) using professional jargon 7) using leading or biased questions 8) talking too much 9) interrupting 10) using "why" questions Nonverbal Skills Physical Appearance Postures Gestures Facial Expressions Voice/ Tone Touch Prevention Any action directed towards promoting health and preventing the occurrence of disease Wellness A dynamic process and view of health that moves towards optimal functioning Cultural Competence The ability to interact effectively with people of different cultures and socio-economic backgrounds. It comprises four components: (a) Awareness of one's own cultural worldview (b) Attitude towards cultural differences (c) Knowledge of different cultural practices and worldview (d) Cross-cultural skills. Developing cultural competence results in an ability to understand, communicate with, and effectively interact with people across cultures. Cultural Care Professional health care that is culturally sensitive, appropriate and competent Concept that describes the provision of nursing care across cultural boundaries and takes into account the context in which the client lives and the situations in which the client's health problems arise Title VI Act of 1964 Law that mandates that when people with limited English proficiency seek healthcare, services cannot be denied Health/ Illness The balance/ imbalance of the person both within ones being (physical, mental, spiritual) and the outside world (natural, communal, metaphysical) Ad Hoc Interpreter Using a patients family member or friend to interpret for a LEP patient Animism Belief that an inanimate object can come alive and have human characteristics Avoidance Language The use of euphemisms to avoid reality or to hide feelings Saying someone "passed on" instead of "died" Distancing The use of impersonal speech to put space between ones self and a threat Making a detached third person perspective Telegraphic Speech early speech stage in which a child speaks like a telegram - "go car" - using mostly nouns and verbs Biographical Data Name, address, age, occupation, date of birth, gender, age, birth date, marital status, occupation, race, ethnic origin, religious preference and source of history Reason for Seeking Care brief subjective statement for reason for visit Symptom: subjective Present Health or History of Present Illness Location, quality/quantity, severity, timing, setting, aggravating factors, associated factors, relieving factors, patients perception of pain For a well person this is a short statement about the general state of health PQRST provocative/palliative quality region/radiation severity timing Past Health childhood illness, accidents or injuries, serious or chronic illness, hospitalization, operations, obstetric history (G= #), immunizations, last exam date, allergies, current medications Abstract Reasoning Pondering a deeper meaning beyond the concrete Attention Concentration, ability to focus on one specific thing Consciousness Being aware of ones own existence, feelings, thoughts and being aware of the environment Awareness of ourselves and our environment Delirium An acute confusional change or loss of consciousness and perceptual disturbance that may accompany acute illness Usually resolved when the underlying cause is treated Abnormal mental state characterized by disorientation, inattention, confusion usually related to a metabolic condition Dementia A gradual progressive process that causes decreased cognitive function even though the person is fully conscious and awake An abnormal condition marked by multiple cognitive defects that include memory impairment. Mood Prolonged display of a persons feelings Orientation Awareness of the objective world in relation to self The nurse asks the patient to identify the date, the time of day and the location of the clinic. The nurse is assessing the patient's Perception Awareness of objects through any of the 5 senses Thought Content What the person thinks ( specific ideas, beliefs, use of words) Thought Process Way the person thinks (logical train of thought) Mental Status A persons emotional (feeling) and cognitive (knowing) function Components of the Mental Assessment Exam ABCT Appearance Behavior Cognition Thought Process Appearance Relaxed posture, voluntary body movements, dress, grooming, hygiene Behavior Level of consciousness, facial expression, word choice, mood and affect Cognition Orientated to person place time and self attention span, recent memory, remote memory, new learning (4 unrelated word test) Mini Cog newly developed, reliable and quick with easily available instruments 3 item recall, clock drawing Dysphonia Voice disorder, difficulty or discmfort in talking Hoarse or whispered Dysarthria articulation disorder Apahasia language comprehension disorder Blocking "Forgot what I was going to say" Sudden interruption in train of thought Confabulation Makes up events to fill up memory gaps Neologism Inventing a new word that only has meaning to the person Circumulocation "The thing you open the door with" when you cannot remember the word key Loosening Association jumps from one topic to another but unaware they are doing so can't stay on topic Flight of Ideas abrupt change in topics with a continuous flow of ideas "The pill is blue, I feel blue....(starts singing) "she wears bluuuue velvet" Word Salad incoherent mix of words, phrases and sentences Leonard suffers from schizophrenia and lives in an institution. One day he walked up to one of the staff members and said, "Humble ports on the window overlook flying dunk myriad nevertheless honcho overload." Leonard's speech is an example of Preservation Repitition of verbal or motor response Sheldon from Big Bang Theory "Lock the door every day, every day I lock the door" Echolocalia Parrot talk, imitation and repetition of other words and phrases Clanging Word choice is based on sound not meaning "My feet are cold. Cold, bold, told" Phobia Persistent, irrational fear of an object or situation Obsession Unwanted, persistent thoughts or impulses Compulsion Unwanted, persistent actions Delusion Firm, fixed false belief that person clings to Purpose of the health history collect subjective data about what is normal for the patient Complete assessment The complete, or total health, assessment is often collected in a primary care setting, such as a clinic or office. It is also collected when an individual is first admitted to an acute or long-term care facility. The purpose is to collect data on current and past health status against which future changes can be measured. Problem centered assessment Clients experiencing short-term, non-life-threatening issues require a problem-centered assessment. Consider the vacationer whose child gets a rash and is taken to an urgent care center. Follow-up assessment Follow-up assessments are routinely completed to monitor the health status of individuals with chronic diseases. emergency assessment Emergency assessments are completed when a client’s safety and/or life is in imminent danger, such as during a cardiac arrest, drug overdose, or at the scene of an accident. What determines the frequency of assessment needed for each individual? the person’s health and wellness needs. Data obtained from each assessment determines not only treatment for current alterations in health, but the frequency and type of follow-up assessments it is the clinical judgment of the care team that makes the final determination. Which statements about holistic health are correct? Select all that apply. Views the mind, body, and spirit as vital to overall wellness. Each person is an active part of their own health and wellness. Disease results from factors within and outside of the body. Holistic health believes health is a complex state influenced by the entire person (mind, body, and spirit) and their environment. Factors that contribute to health are both internal (e.g., genetics, lifestyle, and culture) and external (e.g., pollution, access to healthcare, and global pandemics) to the individual. From the perspective of holistic health, individuals are healthiest when they are actively involved in promoting their own wellness. The nursing health assessment focuses on supporting total health and wellness. Rapid (Screening) Assessment took a few seconds to identify the people needing medical attention, needed immediate assistance. rapid assessment, often known as the ABCs (airway, breathing, and circulation A person who is unresponsive needs immediate attention, with the priority assessment being on the ABCs Yet each health assessment begins before the examiner even has a chance to introduce themselves. It is when the examiner sees the client for the first time, notices if the client has an open airway, how they are breathing, and if their cardiac perfusion is adequate. Complete (Total) Health Assessment establishes the database for the client and is often completed in the office of the healthcare provider (office or clinic). The complete assessment includes a detailed health history, a full physical assessment, and an initial diagnosis. The database, or health record, created includes the baseline data against which the person's health will be compared, and for the healthy person includes: the person's health state; perception of health; strengths or assets such as health maintenance behaviors, individual coping patterns, support systems, and current developmental tasks; and any risk factors or lifestyle changes (J For the person who is ill the complete assessment adds a description of their health problems, their perception of illness, and their response to the alterations in health. In the acute hospital setting the complete assessment is completed at the time of admission. The admitting health provider collects data specific to the acute illness to prescribe treatments. In addition to a physical assessment, the nurse assesses the individual's perception of illness, functional ability or patterns of living, activities of daily living, health maintenance behaviors, response to health problems, coping patterns, interaction patterns, spiritual needs, and health goals. This holistic nursing assessment provides information on how to provide support during hospitalization and prepare for the client to care for themselves after discharge. Focused (Problem-Centered) Assessment A focused assessment is used to collect data related to a specific problem or short-term need. The focus is centered on one problem (rash or request for a vaccination), one cluster of cues (fever, dry cough, fatigue, and loss of taste and smell), or one body system (neurologic or cardiovascular). Follow-Up Assessment As the name implies, a follow-up assessment is completed to check the status of identified health concerns. The health concern determines the status of how frequently follow-up assessment is needed. Client with a fever on the second day after surgery. Health Problem: Client with a fever on the second day after surgery. Frequency of Follow-Up: 2-4 hours Rationale: Fever after surgery is a cue that an infection may be occurring, which requires further assessment of the operative site (redness, swelling, and drainage may indicate infection), respiratory system (medications that depress the respiratory center can allow secretions to accumulate in the lungs causing atelectasis, which can become pneumonia), and the immune system (specifically the serum white blood cells that would begin increasing in response to an infection). individual with stable heart failure. Health Problem: Individual with stable heart failure. Frequency of Follow-Up: 2-3 months Rationale: A person with a stable, chronic condition can be seen in the provider's office periodically. Child treated at an urgent care center for a rash. Health Problem: Child treated at an urgent care center for a rash. Frequency of Follow-Up: As needed, if rash does not go away Rationale: Anyone treated for a rash should follow up with their healthcare provider if the rash lingers or worsens after treatment is provided, as needed. Client with acute chest pain being treated in the emergency department. Health Problem: Client with acute chest pain being treated in the emergency department. Frequency of Follow-Up: Continuous Rationale: A person having acute chest pain will receive continuous monitoring, interventions, and follow-up assessment during treatment. Introduction to Physical Assessment Techniques Assessment data is collected by the examiner using their senses of sight, touch, hearing, and, at times, smell. The skills used to collect data are inspection (sight and, at times, smell), palpation (touch), percussion (touch and hearing), and auscultation (hearing). The purpose of each assessment skill is to provide the examiner with cues regarding the health of an individual seeking care. Abdominal Assessment Techniques Inspection: What do you see and/or smell? Auscultation: What do you hear? Percussion: What do you hear? Palpation: What do you feel? Cardiac Assessment While performing a cardiac assessment on a client with an incompetent heart valve, the nurse anticipates hearing a low-pitched murmur using the bell portion of the stethoscope. The diaphragm of the stethoscope detects higher-pitched sounds. sensitivity Have an awareness of your own culture and how it may impact the therapeutic relationship with someone of a different culture. Does this client believe they are getting the same quality examination that someone of a different ethnic group will get? competency Strive to learn about different cultural practices and beliefs, especially when it comes to physical interaction. Are there areas where touch is forbidden? Are there garments that should not be removed? humility Understand that there may be perceived power imbalances within the social structure that perpetuate oppression. Consider power and privilege and how they relate to the physical assessment. Are there ways you can demonstrate respect for their culture during the examination? safety Be aware of power differentials that may affect health equity. How can you communicate your purpose as their best interest? How can you help them to feel safe during this clinical process? purpose of Health History is for the healthcare provider to collect subjective data and the client's perception of health A health history A health history includes demographic data, the reason for seeking care (medical or psychological, illness or wellness), past medical history, family medical history, and review of systems. is a comprehensive record of a client's past and present health status A comprehensive health history biographic data, the reason for seeking care, present health or history of present illness, past history, medication reconciliation, family history, review of systems, and functional assessment. The most accurate history is furnished by the client or an interpreter. Less accurate sources include friends or family. is usually collected during the client's first visit. A focused health history is completed when a client presents with a specific problem. additional assessments that emphasize areas besides the physical aspects of the client's health including each client's self-defined culture, nutrition, religion, spiritual preference, and mental status. Biographic data is information about a person's identity. Name, address, and phone number; age and birth date; birthplace; gender; relationship status; race; ethnic origin; occupation; primary language spoken Reason for seeking care first questions to ask a pt is : Statement from client describing reason for the visit This is to find out the client's main concern (also known as a chief complaint). documented in quotes indicating that these are the client's own words. It is not a diagnostic statement by the examiner. If there are multiple concerns, focus on the most severe first. Examples of reasons for seeking care: "I am having chest pain." "I am here for a yearly physical." "My child has had a fever since yesterday." The examiner is documenting the reason for seeking care. Which statement is documented correctly? the client stating, "I have pain in my right ankle." Present health or history of present illness: Statement of general health. For each symptom, include the eight characteristics The purpose is to collect as much data about the reason for seeking care as possible and to document it in a narrative format. PQRSTU (help with question to ask) P = Provocative or Palliative What makes the symptom worse? What makes the symptom better? Q = Quality or Quantity What does the symptom feel like? Please describe it for me. If more than one "feeling," which one is the worst? R = Region or Radiation Where is the symptom located? Is the symptom located anywhere else? S = Severity On a scale of 0-10, with "0" being none and "10" being the most severe, how would you rate the severity of the symptom? T = Timing When did the symptoms begin? How long does it last? How often does it occur? U = Understanding Client Perspective How has the symptom affected you? What do you think it means? Past history Prior major illnesses, hospitalizations, and surgeries can provide cues to current health issues. The history can also indicate what health issues the client may be at risk for in the future. Past health history topics include childhood illnesses, accidents or injuries, chronic illnesses, hospitalizations and surgeries, immunizations, last examination dates, allergies, and obstetric history for women. Which information is included in past history? Select all that apply. Childhood illnesses Hospitalizations Immunizations Medication reconciliation Accurate list of current medications and dosages is a national client safety initiative Medication reconciliation is the process of comparing the medications prescribed with the medications the client is taking Medications include prescriptions, over-the-counter drugs, and herbal supplements. It is important to record the name, dosage, frequency, route, and purpose. The examiner will review the list and address duplications, omissions, interactions, and the need to continue the medication. Scope of Medication Reconciliation Which information should be included in a medication reconciliation? Select all that apply. St. John's Wort 300 mg for depression Multivitamin 1 tablet Acetaminophen 500 mg as needed for pain Atenolol 50 mg for high blood pressure Family history Mapping of familial illnesses and diseases Family history documents the biological relationships and medical history of a client. It can be used as a visual method to recognize health patterns and shared risks. Family history can track common chronic diseases, such as cardiovascular disease, diabetes, and some cancers. chart called a pedigree or genogram. Review of systems Client's description of the health of each of their body systems The purposes of this section are (1) to evaluate the past and present health state of each body system, (2) to double-check in case any significant data were omitted (leave out) in the Present of Present Illness section, and (3) to evaluate health promotion practices. Last Physical Examination The client states, "My last physical exam was last year." This would be documented under? functional assessment or review of system review of systems. The review of systems includes the date of the client's last physical exam and other health promotion practices. The functional assessment measures the client's ability to complete tasks and activities associated with daily living. Developmental and Cultural Assessments For pediatric clients, a developmental assessment should be integrated into the health history. This would include questions about growth and developmental milestones, such as walking. For adolescents, questions about safety practices and sexuality may be added. To provide culturally competent care, a cultural assessment should be added as well. Questions about a client's norms, values, and beliefs that influence healthcare practices can help the examiner provide more individualized care. Functional assessment Client's level of function and ability to perform daily tasks Functional status is important for clients who have chronic illnesses, disabilities, or age-related challenges. Types of Assessments Social Roles Interpersonal relationships Partner violence Economic Education Financial status Transportation Mental health Coping mechanisms Spiritual practices Physical health Activity and exercise Sleep Nutrition Elimination Personal habits (alcohol or drug use) Self-care capacity Ability to complete activities of daily living (examples: feeding, bathing, dressing) Environmental hazards Analyzing Health History Data After the collection of the health history, the examiner analyzes the data to determine the next steps. The examiner will look for symptoms related to the main complaint, patterns within the data, and areas for follow-up. The health history will determine or confirm the basis for the objective portion of the health assessment. Developmental Assessment Which question would be asked as part of a developmental assessment? "When did your child get their first tooth?" Quality of Pain The examiner would like to assess the quality of the client's pain. Which question should the examiner ask? Quality refers to the description of the pain in the client's own words and the examiner could ask, "What does the pain feel like?" Asking about what makes the pain feel better is a palliative question. Severity is measured by rating the pain. Understanding the impact of pain on lifestyle is also important but does not measure quality. Surgical History The client states they had their appendix removed 10 years ago. The examiner would document this under which portion of the health history? past history Surgical history would be asked and documented under the past history portion of the health history. Information about the health of close relatives is obtained during the family history. The review of systems is an inventory of each body system through a set of questions that gather data related to the present illness and health promotion practices. A functional assessment measures the person's ability to complete tasks and activities associated with daily living. Assessment of Functional Ability During a clinic appointment, the examiner notes that a client with cancer looks fatigued and is wearing dirty clothes. The client has lost 20 pounds since their last visit. Which statements by the examiner therapeutically assess the client’s functional ability? Select all that apply. "Tell me more about your support system." "Can you tell me how you are doing at home managing your daily activities?" "How is your lack of energy impacting what you want to do?" "I think you need a home care nurse to come in at least once a week" and "I am going to contact the social worker since it seems you need assistance at home" are based on the examiner's opinion and not client data. Plan of Assessment The examiner has collected the following subjective data from a 55-year-old client: Reason for seeking care: Low back pain History of present illness: Started two days ago after lifting furniture. Stabbing pain in the lower back rated 7/10. Lying flat makes pain decrease. Ice makes it better temporarily. Past history: Left knee replacement 5 years ago Medication reconciliation: Acetaminophen 500 mg every 6 hours for pain as needed Family history: History of high blood pressure on father's side; diabetes on mother's side Review of systems: Non-remarkable Functional assessment: Cannot work due to pain What would the examiner assess first? Complete a focused assessment of the back. The information collected indicates the current problem is low back pain. This would be the examiner's main focus of the physical examination. The left knee replacement is in the past and financial options are a secondary priority and more the work of a social worker. Range of motion of the arms does not address potential issues with the lower back. Biographic Examples The examiner is completing a health history on a client who presents with abdominal pain. Which is an example of biographic information that may be obtained during a health history? Past surgeries History of immunizations Personal values and beliefs Current occupation Current occupation Current occupation is part of biographic data. Past surgeries and immunizations are in past history. Personal values and beliefs can be under functional assessment or cultural assessment. Gathering Subjective Data An examiner is performing a health history on a client who is being admitted to the hospital. Which questions should be used to gather subjective data? Select all that apply. "Do you have a history of heart disease?" "How does the shortness of breath impact your life?" "How often do you forget to take a dose of your medication?" "Where are you working right now?" "Can I listen to your lungs?" "Do you have a history of heart disease?" "Where are you working right now?" "How often do you forget to take a dose of your medication?" "How does the shortness of breath impact your life?" Language Barrier in Health History A client is struggling to complete the health history questionnaire because English is not their primary language. Which action should the examiner implement? Read the questionnaire to the client. Request an interpreter to assist the client. Have the client call a family member. Do not have the client complete the questionnaire. Request an interpreter to assist the client. Communicating through an interpreter aids in effective, accurate communication and provides a better experience for the client. Review of Systems General Overall Health State: "I have gained 5 pounds in the last month." Health Promotion: "My last ECG was in 2015." Cardiovascular: "I have no chest pain." Neurologic System: "I sometimes have headaches." Gastrointestinal: "I have had no change in appetite." Respiratory: "I do not have shortness of breath." Communicable Disease Risk Factors Which is important health history information that can increase a client’s risk of influenza? Select all that apply. Pre-existing medical condition causing immunosuppression Occupation involving close physical contact with the public Advanced age Annual flu immunization Easy access to healthcare Pre-existing medical condition causing immunosuppression Occupation involving close physical contact with the public Advanced age Health History Assessment: Abnormal Findings A client has a symptomatic, contagious, upper respiratory disease. Which health history question is most important to ask? Are you currently pregnant? What is your ethnicity? Who lives in your house with you? What medications are you taking? Who lives in your house with you? Since the client is contagious, it is important to know who lives in the house with the client. Health History Assessments A health history is a comprehensive record of a client's past and present health status. A comprehensive health history is usually collected during the client's first visit. A focused health history is completed when a client presents with a specific problem. The most accurate history is furnished by the client or an interpreter. Less accurate sources include friends or family. When to Notify It is important for a nurse to tell a client to seek medical care if the client exhibits: signs of dehydration shortness of breath chest pain confusion or dizziness worsening of chronic conditions Reporting Data Data that should be reported includes: signs of dehydration shortness of breath confusion or dizziness chest pain Samantha’s Case Study: Diagnosis Medical Diagnosis: COVID Nursing Diagnosis: Fatigue Impaired Comfort Infection Risk Diagnosis In the scenario, which part of the health history was the most important in the primary care provider making the diagnosis? Family history History of present illness Functional assessment Past health history History of present illness Collecting information about the present illness by having the client explain symptoms is essential to an accurate diagnosis. Past health history and family history can help identify more chronic conditions and functional assessment collects information about activities of daily living. contact tracing even more questions are asked to help identify who the infected individual may have had contact with. This is called contact tracing and is done with contagious diseases. Planning A client with COVID asks why the nurse has to know where the client has traveled in the last 30 days. Which responses provided by the nurse are correct? Select all that apply. “I need to know if where you traveled is experiencing an outbreak.” “Symptoms begin 2 to 14 days after you come into contact with the virus.” “These questions allow us to track where you could have gotten it from or who you exposed the virus to.” “The questions help slow the spread of the virus.” Asking specific questions about the present illness allows for tracking of where the client could have gotten it from or to who the client exposed the virus. Location of travel is important to track current disease outbreaks. Because symptoms begin 2 to 14 days after viral contact, travel over the last 30 days is important to know The questions help slow the spread of the virus. Implementation Before placing a client on medication, it is important to verify other current medications or supplements the client may be taking. What is this process called? Drug testing Drug recall Medication reconciliation Medication examination Medication reconciliation Medication reconciliation is producing an accurate list of all medications a client is taking and comparing that list against the healthcare provider's orders. Evaluation Which outcome would be appropriate for a client with COVID who has been sent home to self-isolate? The client can describe the symptoms of COVID. The