What are the 6 steps of the nursing process? if asking for 5 remove (outcome identification) - answer-ADOPIE
Assessment
Diagnosis
Outcome
... [Show More] Identification
Planning
Implementation
Evaluation
What are the types of Health Assessment? - answer-1) Comprehensive assessment
2)Problem-based/Focused assessment
3) Emergency assessment
What are the 3 primary components of Health Assessment? - answer-History (subjective data)
Physical examination (objective data)
Documentation of data
Why do we document all of our data? - answer-Improves plan of care
It is a legal document of patient's health
Draws a baseline for future evaluations
It must be accurate, concise, and without bias
T/F If it is not documented you did not do it. - answer-True
What is context of care? - answer-it refers to circumstance or situation related to health care delivery.
1) may be related to setting or environment
2) may be related to physical, psychological, or SES circumstances involving the pt.
What is a comprehensive assessment? - answer-A detailed H&P exam performed at the onset of care in a primary care setting or on admission to a hospital or long-term facility.
What is a Problem-based/focused assessment? - answer-the problem-based or focused assessment involves a history and examination that are limited to a specific problem or complaint. This type of assessment is most commonly used in a walk-in clinic or emergency department, but it may also be applied in other outpatient setting.
What is emergency assessment? - answer-life-threatening situation
What is a screening assessment? - answer-a short examination focused on disease detection. usually conducted in health fairs.
What is Health promotion? - answer-Behavior motivated by desire to increase well-being and actualize health potential.
What is Health protection? - answer-Behavior motivated by desire to avoid illness, detect illnesses early, and maintain functioning when ill.
What are the 3 levels of health promotion? - answer-Primary= preventing disease from developing through promoting a healthy lifestyle.
Secondary= Screening efforts to promote early detection of disease.
Tertiary= minimizing disability from acute or cronic illness or injury and allowing for most productive life within lilmitations.
What are examples for the 3 levels of health promotion? - answer-Primary= Immunizations
Secondary= Mammogram
Tertiary = The disease is already present: Hypertension management.
A mother of three is being seen for a screening assessment. While planning the initial part of the visit with this patient, the nurse needs to ensure that:
a)The patient receives a refill for her thyroid medication.
b)The patient is instructed on preventive measures for hypertension.
C)Other family members are present during the interview.
D)Information about the patient's lifestyle habits is gathered. - answer-Correct Answer: D
Rationale: There are multiple types of health assessments. If a patient receives a refill, this is an episodic or follow-up assessment. If a patient is instructed in preventive measures, this is more along the lines of a comprehensive assessment. A screening assessment would require the nurse to have data about lifestyle habits.
The medical-surgical nurse is reviewing the practice related to a patient who acquired pneumonia while recovering from a hip replacement. The unit documents this event as failure to rescue and would like the nurse to develop a personal professional action plan. This plan will most likely include:
A)Reflection on action
B)Tertiary prevention of health care-associated infections
C)Reasoning patterns - answer-Correct Answer: A
Rationale: Reflection on action represents the contribution of an experience to a nurse's collective experiences. Reflection in action specifically relates to evaluating outcomes of interventions. The nurse needs to look at his practice to identify whether something can change.
A nurse is assessing a female teenager. The nurse asks the young woman to bend over and touch her toes. The nurse assesses the curvature of the spine as a means of detecting scoliosis. Assessing the curvature of the spine is an example of:
A)Health education
B)Primary prevention
C)Secondary prevention
D)Tertiary prevention - answer-Correct Answer: C
Rationale: Primary prevention is preventing the disease before it begins. Secondary prevention means that the nurse is trying to detect disease as early as possible to improve outcomes.
What are the two primary components of health assessment? - answer-Health history
Physical examination
Is a health history subjective or objective data? - answer-Subjective
Single-most important factor for successful interviewing is the ______ skill of the nurse. - answer-communication
What are some factors that affect a nurses therapeutic communication? - answer-Physical setting, nurse behaviors, type of questions asked, how questions are asked. Behavior of pt. How the pt. feels during the interview, nature of information being discussed or problem being confronted
Begin interviews with what type of questions? - answer-open-ended. encourage a free-flowing open response.
If want more precise data from your patients what type of question should you ask? - answer-Close-ended
What do directive questions do? - answer-lead patient to focus on one set of thoughts. Most often used in reviewing systems and evaluation functional status.
Use _____ to help concentrate on pt. responses and subtleties. - answer-listening
_______ uses verbal and nonverbal phrases to encrourage patinets to continue to talk further. - answer-Facilitation
_____ is used to gather more information. - answer-Clarification.
_______ is repeating what patient says ini different words to confirm interpretation. - answer-Restatement
_____ reflection is repeating what the patient said and encourages elaboration or more information. - answer-Reflection
______ is used when inconsistencies are noted between patient report and nurse's observations. - answer-Confrontation
_______ is used to share conclusions drawn from data. Pt. may then confirm, deny, or revise - answer-Interpretations
_______ condenses and orders data to clarify sequence of events for that pt. It emphasizes data related to health promotion, disease protection, and resolving health problems - answer-Summary
What are the components of a comprehensive health history? - answer-Biographic data
Reason for seeking care
Present health status
Past medical history
Family history
Personal and psychosocial history
Review of all body systems
Health histories can provide nurses with data needed for appropriate care. Nurses obtaining a health history should:
A) Help the patient identify personal beliefs about health.
B) Assess vital signs.
C) Inquire about activities that can affect financial stability.
D) Explain patient rights and responsibilities. - answer-Correct Answer: A
Rationale: The nurse is to help the patient define health. This will allow the nurse to better understand comments made as the health history data are collected. Vital signs are not part of the health history. Financial issues may be a part of the concerns but usually are not as important as understanding the patient's health beliefs. Patient rights and responsibilities are not part of the health history
Because a nurse seeks to create a patient-centered interview process, the nurse will:
A) Ask the patient, "Do you suffer from any arthralgias?"
B) Give the patient as little information as possible to avoid fear.
C)Ask the patient, "Can you please tell me more about your spells?"
D) Inform the patient, "You don't have to share anything with me that makes you uncomfortable." - answer-Correct Answer: C
Rationale: The word "arthralgia" may be a word that many patients do not understand. The nurse needs to be careful when withholding information related to not wanting to "scare" the patient. It is best if the nurse works with the patient on identifying what information the patient wants to receive. There could be an age-appropriate component to this (i.e., children), in which case the nurse will work with caregivers to ensure that all required information is given. In option "C," the patient has used the word "spells." The nurse should not discourage this but should investigate further. In option "D," the nurse should not say this; often there is sensitive material that must be covered or addressed to provide adequate care.
Preparation for an interview with a patient requires thoughtful consideration of the physical environment. As the physical space is arranged:
A) Desks should not be used because they bestow too much "power" on the interviewer.
B) Desks are usable as long as they are not a barrier between interviewer and interviewee.
C) Interviewer eye level should be six inches lower than interviewee eye level.
D) Interviewer eye level should be six inches higher than interviewee eye level. - answer-Correct Answer: B
Rationale: Desks are appropriate as long as they are not barriers between the nurse and the patient. The nurse and the patient should be at the same eye level because this conveys a sense of equality and team work.
What is the single-most important component to reduce infection transmission? - answer-Hand hygiene.
T/F health care professionals are not at risk of a latex allergy if they don't already have it. - answer-False; latex allergies can develop because of frequent exposure.
Physical Exams being with _____. What do we achieve from this data? - answer-Inspection. It happens right when you walk into the room. visual exam of the body, including movement and posture. Also you obtain by smell.
What is Palpation? - answer-Use of hands to feel texture, size shape, consistency, location of certain parts, and identify painful or tender areas.
With palpation what does the nurse want to make sure they have? - answer-A gentile touch, warm hands, and short nails to prevent discomfort or injury.
What do we use percussion for? - answer-Evaluate size, borders, and consistency of internal organs, also to detect tenderness, and determine extent of fluid in a body cavity.
What is direct percussion? - answer-when you strike finger or hand directly against patient's body, evaluate adult sinus by direcly taping finger on sinus. elicit tenderness over kidney by striking costovertebral angle directly with fist.
What is indirect percussion? - answer-it requires both hands, methods can vary by ststem being assessed.
What does percussion help with? - answer-tapping produces a vibration deep in body tissue, with subsequent sound waves. Peruss tow or three times in one location before moving to another. Stronger percussion is needed for obese or muscular pt.
What are the five percussion tones you can hear? What do they sound like? - answer-1) Tympany is loud, high-piched sound heard over abdomen
2) Resonance is heard over normal lung tissue.
3)Hyperresonance is heard in overinflated lungs, as in emphysema.
4) Dullness is heard over liver
5) Flatness is heard over bones and muscle.
What is auscultation? - answer-listening to sounds within body; nurse commonly uses stethoscope to facilitate auscultation.
T/F the way a stethoscope works is by magnifying the sounds when you press it against the skin. - answer-False; it blocks out extraneous sounds when evaluating the patient and allows you to focus on a specific aream.
On a stethoscope what is the diaphragm usually used for? - answer-used to hear high-pitched sounds such as breath sounds, bowel sounds, and normal heart sounds. Structure screens out low-pitched sounds.
On a stethoscope what is the bell normally used for? - answer-Used to hear soft, low-pitched sounds like extra heart wounds. press lightly to body.
What is a sphygmomanometer? - answer-A blood pressure cuff,
What is pulse oximety measured in? Where do we put the sensors? - answer-% of estimate of oxygen saturation in arterial blood and pulse rate. Sensor taped to ear, finger, or toe
What is a penlight used for? - answer-Used to illuminate inside of mouth or nose, highlight a lesion, or evaluate pupillary constriction.
Light transmitted from otoscope may be substituted as a focused light source.
When does general inspection begin? - answer-The moment nurse meets the patient.
Body temperature is regulated by the ______. Expected temperature ranges from 96.4 to 99.1. - answer-Hypothalamus
T/F Temperature during menstrual cycle increases .5-1.0 F. At ovulation and remains elevated until menses cease because of progesterone secretion. - answer-True
If taking a oral temperature delay ____ if patient ingested hot or cold, liquids or smoked - answer-10 minutes.
Why do we put oral electronic thermometer under the tongue in the sublingual pocket? - answer-This location receives blood supply from carotid artery; thus indirectly reflects core temperature.
T/F Tympanic temperature is the most reliable mode to retrieve a temperature. - answer-False. It has questionable accuracy.
_____ artery is most frequently used to measure heart rate because accessible and easily palpated. - answer-Radial
What arteries are common alternative sites to assess pulse rate? - answer-Brachial, and carotid
Where do you auscultate the heart? - answer-Located over the fifth intercostal space at the mid clavicular line.
What does respiratory rate involve? - answer-counting number of ventilator cycles and inhalation and exhalation, each minute.
What are some factors that increase respiratory rate? - answer-fever, anxiety, exercise, depth, and high altitude
What are some ways to describe the respiratory rate? - answer-regular or irregular. Depth by observing excursion or movement of chest wall. Depth described as deep, normal, or shallow.
What is cardiac output? - answer-the volume of blood ejected from heart each minute.
What is Peripheral resistance? - answer-force that opposes flow of blood through vessels; when arteries are narrow, peripheral resistance to blood flow is high, and reflected in elevated blood pressure.
How is Blood pressure measured? - answer-in millimeters of mercury (mm Hg)
What is the systolic blood pressure? - answer-maximum exerted on arteries when ventricles eject blood from heart
What is diastolic blood pressure? - answer-represents minimum amount of pressure exerted on vessels when ventricles of heart relax.
What physiologic factors affect blood pressure. - answer-Age: From childhood to adulthood there is gradual rise.
Gender: After puberty, women usually have a lower blood pressure than men; however, after menopause, women's blood pressure may be higher than men's.
Race: Incidence of hypertension is twice as high in black Americans as in whites.
Diurnal variations: Pressure is lower in early morning and peaks in late afternoon or early evening.
Emotions: Anxiety, anger, or stress may increase blood pressure.
Pain: Acute pain may increase blood pressure.
Personal habits: Caffeine or smoking within 30 minutes before measurement may increase reading.
Weight: Obese patients tend to have higher blood pressures than nonobese patients.
The nurse is working in a primary care clinic. She walks into the room, and the general inspection begins. What is not part of the general inspection?
A) Patient's facial expressions are consistent with verbalized emotions.
B) Patient is wearing clothes that are normally worn by whites.
C) Patient is staring down at the floor through most of the interview.
D)Patient's gait is strong and symmetrical. - answer-Rationale: Cultural assessment is important. However, nurses must be careful to make assumptions, generalizations, or both. In America, the common dress of people of many cultures is the same.
The nurse collects patient data through assessment of vital signs. Many nurses will delegate the performance of temperature data collection to unlicensed assistive personnel. As the nurse talks to the assistant, the nurse knows to teach that:
A) Tympanic thermometers touch the tympanic membrane.
B) Axillary temperatures are taken with the red probe on the electronic thermometer.
C) Axillary temperatures are usually most accurate because of the local blood supply.
D) Rectal thermometers are placed 2.8 cm to 3.5 cm into the rectum. - answer-Correct Answer: D
Rationale: Tympanic thermometers need to seal the ear canal but do not touch the tympanic membrane. Red tipped probes indicate rectal temperatures only. Axillary temperatures are considered the least accurate.
A woman in labor suffers from preeclampsia. Nurses in the labor and delivery unit need to assess her blood pressure. The nurse explains to the patient that:
A) Using a cuff that is too narrow will give a reading that is inaccurate and high.
B) Deflating the cuff too quickly will make the reading inaccurate and high.
C) Deflating the cuff 5 mm Hg per second will make the reading inaccurate and high.
D) Waiting 3 minutes before repeating the blood pressure measurement will result in a false-high blood pressure measurement. - answer-Correct Answer: A
Rationale: Cuff width should be 40% of the circumference of the limb to be used to assess blood pressure. Quick deflation (faster than 2 mm Hg to 3 mm Hg per second) makes the blood pressure measurement inaccurate and low. Waiting 3 minutes between repeat blood pressure measurements will help ensure an accurate second reading.
The nurse (is/isn't) responsible for asking about beliefs-- this is essential for individualized care. - answer-is
What is culture? - answer-All the socially transmitted behavioral patterns, arts, beliefs, knowledge, values, morals, customs, lifeways, and characteristics that influence a worldview
What is Ethnicity? - answer-Social groups within a culture and social system that shares common cultural and social heritage that includes: language, history, lifestyle, religion, or all of these.
What is race? - answer-genetic in origin and includes physical characteristics: skin color, bone structure, eye color, and hair color.
T/F individuals from the same racial group are also from the same culture - answer-False.
Individuals from the same racial group are not necessarily from the same culture.
What is religion? - answer-an organized system of beliefs, rituals, and practices in which an individual participates.
What is spirituality? - answer-Its a broader concept than religion and may include: Prayer, Meditation, Walking in the woods, Listening to music, Intentional appreciation of beauty, Being present in the world with others
How many national standards for the importance of culturally and linguistically appropriate care (CLAS) are there? How many do nurses use? - answer-There are 14 national standards to ensure euitable and effective treatment.
Which part of the CLAS are we suppose to know? - answer-Standard 1 directly affects nurses. Healthcare organizations should ensure that patients receive: Effective, understandable, and respectful care. Care provided in a manner compatible with cultural health beliefs and practices and preferred language. Furthermore, The Joint Commission requires that a spiritual history be taken from every patient admitted to hospital.
To ensure you don't stereotype what must a nurse do? - answer-Recognize the uniqueness of each individual. Cultural heritage equals "roots."
This helps explain activities and beliefs. Differences exist within cultures and groups.
Beliefs and attitudes in the United States have been shaped by stereotypical images and misinformation. Each patient deserves personalized assessment.
When dealing with cultural diversity remember... - answer-Be sensitive.
Ask questions.
Gather specific information.
Do not stereotype.
Do not assume care for one individual of a culture is appropriate for another individual of same or similar culture.
Regardless of culture or race, each patient is unique—take time to know each patient
Staff development educators are responsible for assisting staff nurses in being adequately prepared to perform their duties as they care for patients from many different cultures and backgrounds. As the educator works with a new nurse from the Philippines, the educator will include:
A) Training on American food choices.
B) Assistance with competency in skin lesions on dark skin.
C) Practice in assessing patients' personal beliefs and practices.
D) Information on immigration and privacy laws. - answer-Correct Answer: C
Rationale: Training on a specific population is of value. However, it is more important for a nurse to understand how to assess each individual patient related to cultural background and beliefs. The reason for this is twofold. First, Western society is becoming so heterogeneous that it is difficult for nurses to know about all cultures. Secondly, individual patients may experience their culture differently than other members of that social group.
What is the primary responsibility of all health care providers? - answer-Pain relief
Pain assessment is also known as the ____ vital sign - answer-fifth
T/F The nurse can judge a persons perception of the pain and can make their own score. - answer-False only the patient can perceive their own pain. [Show Less]