NUR2092 Health Assessment Exam #1 COMPLETE SOLUTIONS
Steps of the Nursing Process Correct Answer: Assessment - gather data
Diagnosis -
... [Show More] problem
Outcome Identification - goals, what we want to happen, expect to happen
Planning - treatment plan, intervention
Implementation - doing the plan
Evaluation - Was it successful, meet the goals
Define Subjective Data Correct Answer: What patient says about himself or herself during history taking
symptoms
Define Objective Data Correct Answer: Observed when inspecting, percussing, palpating, and auscultating patient during physical examination
signs
Factors of Diagnosis Correct Answer: -Cluster of data that seem to be associated in some way.
-Validate data, confirm accuracy
-Look for gaps in your information
-Interpret data and identify problems
-Document the diagnosis
Factors of Outcome Identification Correct Answer: -Identify expected outcomes related to patient individualization
-Ensure outcomes have the SMART components
-Specify short-term and long-term goal measurement criteria
What does SMART stand for? Correct Answer: Specific, Measurable, Attainable, Realistic, Timely
Factors of Planning Correct Answer: -Establish priorities based on meeting patients care goals
-Develop outcomes and set time frames for meeting outcomes
-Identify relevant interventions and utilize interdisciplinary health care team members for the patient
-Document plan of care
Factors of Evaluation Correct Answer: -Refer to outcomes
-Evaluate patient's condition and compare actual outcomes to expected outcomes
-If reached outcome: does something need to be done
-If NOT reached: identify reasons for not achieving
-Modify plan if needed
-Document in plan of care
Evidence-Based Decision Making factors Correct Answer: -Best evidence from clinical review of research literature
-The providers clinical expertise
-Patient's preference and values
-Physical examination and assessment of patient
Focused Database Correct Answer: Problem-centered
Used for a limited or short-term problem
Smaller scope and more targeted than the complete database
Complete Database Correct Answer: Includes a complete health history and full physical examination
Yielding the first diagnosis
Steps in Priority Problem Levels Correct Answer: 1. First-level priority: emergent, life threatening, immediate
2. Second- level: next in urgency, requires attention to prevent further deterioration
3. Third-Level: important to patient's health, but can be addressed after urgent problems
What are the two parts to Communicating? Correct Answer: 1. Sending
2. Receiving
In communication what are the two types in "sending"? Correct Answer: 1. Verbal: words/tone
2. Nonverbal: less conscious
In communication, what does "receiving" mean? Correct Answer: Interpretation based on past experiences, culture, and self concept
Physical and emotional state
Communication does what with a patient? Correct Answer: -Builds a relationship
-Builds rapport
Key to Communication Correct Answer: Is the receiver getting the message the way it was intended?
Active listening
Types of questions in Therapeutic Communication Correct Answer: Open-ended: narrative answers, feelings and opinions, develops rapport
Close-ended: yes/no questions, used for specific information, limits rapport
In Therapeutic Communication, what are the types of responses focused on the client's frame of reference? Correct Answer: CLARIFICATION (rephrase)
FACILITATION (nodding, Hmm,hmm)
SILENCE (when to use)
SUMMARIZE (summarize what pt stated) EMPATHY (likening to others, comfort, "I understand")
In Therapeutic Communication, what are the types barriers? Correct Answer: AVOIDANCE LANGUAGE (using other words)
CHANGING THE SUBJECT
DISTANCING (walking to the door, avoid eye contact)
BLAMING (if you didn't smoke...)
FALSE REASSURANCE (you'll be fine)
FAILURE TO LISTEN
GIVING ADVICE
Barriers in Communication include: Correct Answer: - lack of interest
- physical barriers
- patient's inability to hear you
- safety
- physiological barriers
- language/use of medical jargon, or speaking above someone's educational level
Substance Abuse Assessment Correct Answer: - Tolerance: carries from person to person
- Watch for withdrawal symptoms
- Dependence
- Addiction
Dependence vs Addiction Correct Answer: -Dependence: can be weeded off
-Addiction: destructive behaviors with what you are doing
Substance Abuse withdrawal symptoms: Correct Answer: - nausea/vomiting
- tremor
- paroxysmal sweats
- anxiety
- visual disturbances
- headache
- disorientation
Alcohol Use assessment Correct Answer: - quick assessment: frequency use of alcohol, tobacco, prescription drug for nonmusical use, illicit drugs
- AUDIT: Alcohol Use Disorders Identification Test
- CAGE: Cut down, Annoyed, Guilty, Eye-opener
CAGE questionnaire Correct Answer: Have you ever felt you should Cut down on your drinking?
Have people Annoyed you by criticizing your drinking?
Have you ever felt bad or Guilty about your drinking?
Have you ever had a drink first thing in the morning to steady your nerves (Eye-opener)?
Domestic Violence Assessment includes: Correct Answer: - need to ask every client needs to be assessed for the risk/evidence of abuse
- use own words in nonjudgemental way
- Abuse Assessment Screen
- Walker's Cycle of Violence: tolerance, explosion, honeymoon
Assessment of Intimate Partner Violence (IPV) Correct Answer: - HITS: hurt, insult, threaten, scream
- 1-5 points: never to frequently
- 10 or more: indicate IPV
When should you report for Domestic Violence cases Correct Answer: children/elder
adult- not required
Warning signs of Human Trafficking include: Correct Answer: - injuries/signs of physical abuse
- malnourished
- disoriented
- lack of identification
- few personal belongings
- avoids eye contact
- minor appearing in relationship with older person
- works long hours, lives in work environment
- fearful, anxious, submissive
- fearful of law enforcement
- cannot freely contact friends/family
Human Trafficking Screening factors: Correct Answer: - best to speak to client alone: try not to raise suspicions
- treat each case as unique
- assume victim is at risk of harm
- do NOT start with sensitive questions
- determine need for interpreter
When Should You Do If You Suspect a Patient is a Human Trafficking Victim? Correct Answer: - Call 911 first then call the Human Trafficking Center
- victim will need assistance with shelter, medical care, and legal
- ICE has a Victim Assistance Program
The General Survey Process: Correct Answer: 1. begin with first contact
2. general impressions of client (age, sex, LOC, skin color, facial features)
3. physical appearance (facial expression, speech, dress, hygiene
4. body structure (stature, nutrition, symmetry, posture, position, body build)
5. body movement (gait, ROM, assistive devices, involuntary movements)
6. emotional/mental status and behavior (mood/affect, speech, appropriate behavior for setting)
Two primary components of Health History are: Correct Answer: 1. Health History - Subjective date
2. Physical Assessment - Objective data
Components of Comprehensive Body System Health History: Correct Answer: - biographic data
- reason for seeking care
- present health status
- past medical history
- family history
- personal and psychological history
- review of body systems
Biographic data includes: Correct Answer: name, address, birth date, gender, marital status, ethnic group, occupation, primary language, and source of info/reliability
Reason for seeking care is commonly known as Correct Answer: the "chief complaint"
this is in the patients words and ask what symptoms they are having
Cause of Illness: Biomedical Correct Answer: diseases caused by bacteria, viruses
involves scientific theories
Cause of Illness: Magicoreligious Correct Answer: Illness caused by supernatural forces
May use folk remedies
Voodoo, Witchcraft, Faith-healing
Cause of Illness: Naturalistic Correct Answer: Illness caused by loss of natural balance
Yin/Yang
flow of energy
Mini-Cog Assessment Correct Answer: Four unrelated word test
Repeat at 5 min, 10 min and 30 min
Testing for Dementia and Alzheimer's
Short-term memory dysfunction
What does PQRSTU stand for? Correct Answer: Palliative(provocative), quality, radiate, severity, time, understanding
Components of Past Health History Correct Answer: Child illnesses
Accidents/injuries
Operations/hospital stays
Serious /chronic illnesses
Obstetric history
Immunizations
Allergies
Current medications
Last examination date
Components of Social History Correct Answer: Where do they live?
Are they safe?
Do they have clean water, heat, air-conditioning?
Do they work, do they feel safe?
Do they exercise?
Review of Symptoms components Correct Answer: Be specific
gives an opportunity to re-ask questions now that they are comfortable
evaluate health promotion practices
Factors that affect Nutritional Status Correct Answer: physiologic
psychologic
developmental
cultural
economic factors
Assessing Nutritional Status methods Correct Answer: 24 hour recall
food diary - most comprehensive
food frequency
typical food intake
direct observation- % of food eaten
Best Screening Tool for Dietary Intake Correct Answer: 24 hour recall method
Nutritional assessment includes Correct Answer: Anthropometric measurements
swallowing assessment
lab tests
Define mental status Correct Answer: Client's level of cognitive and emotional functioning
a state of well being
Delirium Correct Answer: Acute confusional change or loss of consciousness and perceptual disturbance that may accompany acute illness; usually resolves when underlying cause is treated
Dementia Correct Answer: Gradual progressive process, causing decreased cognitive function even though the person is fully conscious and awake; not reversible
Components of Mental Health Survey (ABCT) Correct Answer: Appearance
Behavior
Cognition
Thought Process
Primary, secondary, tertiary prevention Correct Answer: 1. Primary prevention-- aims to prevent disease BEFORE it occurs. (ex. seat belts, smoking education)
2. Secondary prevention-- aims to REDUCE impact of a disease or injury. (ex. screening for things early).
3. Tertiary prevention-- Aims to soften the impact of an ongoing illness or injury that has lasting effects. Help manage long term problems. (ex. cardiac rehabilitation programs).
How does the data base vary according to clinical setting? Correct Answer: It could be complete, focused or problem-centered, follow-up, or emergency (quick assessment to provide immediate care)
4 assessment techniques Correct Answer: Inspection
Pulsation
Percussion
Auscultation
Nociceptive pain Correct Answer: Triggered by events outside the nervous system from actual trauma or tissue damage
Acute
Responsive to opiates/anti-inflamatories
Neuropathic Pain Correct Answer: Abnormal processiing
from injury to nerve fiber or CNS
chronic
Poorly responsive to pain medications
Pain assessment tools Correct Answer: Numeric rating scales
Wong baker FACES
FLACC (under 3 years old)
CRIES (pre term infants)
PAINAD (dementia)
Phantom Pain Correct Answer: Pain that feels like it is coming from a body part that has been amputated.
Breakthrough Pain Correct Answer: Severe pain that erupts while a patient is already medicated with long-acting painkiller
Referred Pain Correct Answer: Felt at a particular site but originates from another location. Both sites are innervated by the same spinal nerve, and it is difficult for the brain to differentiate the point of origin. For example, left arm pain for heart attack.
Chronic Pain Behaviors Correct Answer: Bracing, Rubbing, Diminished activity, Change in appetite, Adaptation, Often little indication, Self distribution
Acute Pain Behaviors Correct Answer: Grimacing or other facial expressions
Bracing or holding injured area
Rocking
Changes in activity
Limping
Culture Correct Answer: Customs, beliefs and attitudes that distinguishes one group of people from another.
Transmited through language, material objects, ritual, institutions and art, from one generation to the next
Ethnicity Correct Answer: Relating to races or large groups of people who have the same customs, religion, origin and culture
Acculturation Correct Answer: adapting to and acquiring another culture
Assimilation Correct Answer: minority group takes on culture of the dominant culture
two way process
Biculturalism Correct Answer: divided loyalty
identifies with two cultures
Ethnocentrism Correct Answer: Belief in the superiority of one's belief or way on life
Race Correct Answer: identification of individuals or groups by shared genetics heritage and biological or physical characteristics
Material vs. Nonmaterial Correct Answer: material: things you can touch
non material: verbal, non verbal language, beliefs, customs, social structures
Cultural Competence methods Correct Answer: know self, understand own heritage
know the cultures in your area
avoid stereotyping
be aware of your biases/prejudices
learn new communication skills
Palpation Correct Answer: process of using one's hands to examine the body [Show Less]