Assessment and Health Promotion Lab Flashcards
1
Q
What is the ‘Chief Complaint (CC)’ in a health assessment interview?
A
The patient’s reason for seeking care, stated in their own words.
2
Q
What does the acronym OLDCARTS stand for in the History of Present Illness (HPI)?
A
Onset, Location, Duration, Characteristics, Aggravating/Relieving Factors, Radiation, Timing, Severity.
3
Q
What information is included in Past Medical History (PMH)?
A
Chronic conditions, hospitalizations, surgeries, medications, and allergies.
4
Q
What does Family History (FH) typically assess?
A
Genetic conditions such as hypertension, diabetes, and heart disease.
5
Q
What does Social History (SH) include during an interview?
A
Smoking, alcohol, drug use, exercise, diet, and sexual history.
6
Q
What is the purpose of the Review of Systems (ROS)?
A
A systematic head-to-toe inquiry about symptoms in each body system.
7
Q
What are normal skin assessment findings in a healthy adult?
A
Warm, dry, intact skin that is pink in light-skinned individuals or appropriate for ethnicity; elastic turgor.
8
Q
What are normal findings for hair during assessment?
A
Evenly distributed hair with a smooth texture.
9
Q
What are normal nail assessment findings?
A
Capillary refill less than 2 seconds; nail beds are pink and smooth.
10
Q
What does cyanosis of the skin indicate?
A
Hypoxia or low oxygen levels.
11
Q
What can pallor of the skin suggest?
A
Anemia or poor perfusion.
12
Q
What condition does jaundice of the skin suggest?
A
Liver dysfunction or elevated bilirubin levels.
13
Q
What does erythema indicate in a skin assessment?
A
Inflammation or possible infection.
14
Q
What could ecchymosis on the skin suggest?
A
Bruising or a possible bleeding disorder.
15
Q
What condition is associated with hair thinning?
A
Thyroid disease.
16
Q
What does hirsutism indicate?
A
A hormonal imbalance, often with excess androgen levels.
17
Q
What does nail clubbing typically signify?
A
Chronic hypoxia, often seen in respiratory or cardiac conditions.
18
Q
What might spoon-shaped nails (koilonychia) indicate?
A
Iron deficiency anemia.
19
Q
What are Beau’s lines and what do they indicate?
A
Horizontal depressions in the nail plate, indicating severe illness or stress.
20
Q
What are normal assessment findings for the head and face?
A
Symmetric features, no lesions or masses, and no tenderness upon palpation.
21
Q
What could facial asymmetry indicate during a head assessment?
A
Possible stroke or Bell’s palsy.
22
Q
What are abnormal findings for the head and face that may suggest trauma or pathology?
A
Asymmetry, masses, or signs of trauma such as swelling or bruising.
23
Q
What does the acronym PERRLA stand for in an eye exam?
A
Pupils Equal, Round, Reactive to Light, and Accommodation.
24
Q
What are normal findings when assessing PERRLA?
A
Pupils are equal in size, round in shape, react briskly to light, and constrict when focusing on near objects.
25
What does a non-reactive pupil indicate?
Possible brain injury or the effect of certain drugs.
26
What might unequal pupils (anisocoria) suggest?
Increased intracranial pressure (ICP) or neurological pathology.
27
What does a sluggish pupillary reaction point to?
Potential neurological impairment.
28
How are Extraocular Movements (EOMs) assessed and which cranial nerves are involved?
By having the patient follow a finger in 6 directions; cranial nerves III (oculomotor), IV (trochlear), and VI (abducens) control these movements.
29
What is a normal finding for EOMs?
Smooth, coordinated eye movements in all directions.
30
What is nystagmus, and what does it indicate?
Involuntary eye movement, which may suggest central nervous system (CNS) dysfunction.
31
What does ptosis indicate and which cranial nerve is affected?
Drooping of the upper eyelid, often due to CN III (oculomotor) palsy.
32
How is the Weber test performed and what is a normal finding?
A tuning fork is placed on the forehead; sound should be heard equally in both ears.
33
What does it mean if sound from the Weber test lateralizes to the affected ear?
Conductive hearing loss.
34
What does it mean if sound from the Weber test lateralizes to the unaffected ear?
Sensorineural hearing loss.
35
How is the Rinne test performed and what is a normal result?
Tuning fork is placed on the mastoid bone, then in front of the ear; normal finding is air conduction (AC) greater than bone conduction (BC).
36
What does it mean if bone conduction is greater than air conduction in the Rinne test?
Suggestive of conductive hearing loss.
37
What are normal assessment findings for the nose?
Midline alignment, patent nostrils, and no drainage.
38
What are possible causes of rhinorrhea?
Allergies or upper respiratory infections.
39
What might cause a deviated septum?
Congenital condition, trauma, or past injury.
40
What is epistaxis, and what can it indicate?
Nosebleed; may indicate nasal trauma, dryness, hypertension, or clotting disorders.
41
What are normal findings of the throat and mouth?
Pink, moist oral mucosa and a uvula that is midline and rises symmetrically.
42
What condition do white patches in the mouth suggest?
Oral candidiasis (thrush), commonly caused by fungal infection.
43
What does an asymmetrical rise of the uvula indicate?
Possible cranial nerve X (vagus) paralysis.
44
What do enlarged tonsils with exudate suggest?
Tonsillitis or another type of oropharyngeal infection.
45
What are vesicular breath sounds, and where are they normally heard?
Soft, low-pitched sounds heard over peripheral lung fields; they are normal.
46
What are bronchial breath sounds, and where are they normally heard?
High-pitched, loud sounds heard over the trachea; they are normal in this location.
47
What are bronchovesicular breath sounds, and where are they typically heard?
Moderate-pitched sounds heard over the major bronchi; they are normal in this area.
48
What do crackles (rales) indicate, and where are they usually heard?
Abnormal sounds heard at the lung bases; suggest fluid in alveoli, as seen in CHF or pneumonia.
49
What causes wheezes, and where might they be heard?
High-pitched sounds due to narrowed airways; heard throughout lung fields in conditions like asthma or COPD.
50
What do rhonchi indicate, and how can they be managed?
Coarse, low-pitched sounds due to airway secretions; typically heard over larger airways and may clear with coughing.
51
What is stridor, and why is it a medical emergency?
A high-pitched sound heard in the upper airway; indicates airway obstruction and requires immediate intervention.
52
What is normal chest excursion, and what does asymmetry suggest?
Normal: symmetrical chest movement. Asymmetry may indicate pneumonia or pneumothorax.
53
What does increased tactile fremitus suggest?
Lung consolidation, such as in pneumonia.
54
What does decreased tactile fremitus indicate?
Fluid or air in the pleural space, as seen in pleural effusion or pneumothorax.
55
What causes the S1 ('lub') sound, and where is it best heard?
Closure of the mitral and tricuspid valves; best heard at the apex of the heart.
56
What causes the S2 ('dub') sound, and where is it best heard?
Closure of the aortic and pulmonic valves; best heard at the base of the heart.
57
What is the significance of an S3 heart sound, and where is it heard?
Abnormal sound heard at the apex; often associated with heart failure (CHF).
58
What does an S4 sound indicate, and when does it occur?
Heard just before S1 at the apex; suggests a stiff ventricle often caused by hypertension.
59
What are murmurs, and what do they typically indicate?
Abnormal heart sounds due to turbulent blood flow; often a result of valvular disease.
60
What is the normal grade for peripheral pulses?
2+ is considered a normal pulse.
61
What does a bounding pulse suggest?
Fluid overload, as seen in conditions like CHF.
62
What does a weak or thready pulse suggest?
Possible shock, low cardiac output, or peripheral vascular disease.
63
What is jugular vein distension (JVD) a sign of?
Right-sided heart failure.
64
What four aspects are assessed when checking a patient’s orientation?
Person, place, time, and situation.
65
What are the key differences between delirium and dementia?
Delirium: Acute onset, fluctuating course, often reversible (e.g., due to infection or medications).
Dementia: Chronic, progressive, irreversible (e.g., Alzheimer’s disease).
66
What does facial asymmetry suggest during a neurological exam?
Possible stroke or Bell’s palsy.
67
What is the pronator drift test, and what does a positive finding suggest?
Having a patient hold their arms out with palms up—if one arm drifts down, it suggests a stroke or upper motor neuron weakness.
68
What does hyperreflexia typically indicate?
A central nervous system (CNS) lesion or dysfunction.
69
What does hyporeflexia indicate in a neurological assessment?
A peripheral nervous system (PNS) issue such as peripheral neuropathy.
70
What are normal findings upon abdominal inspection and palpation?
Abdomen is flat or round, soft, and non-tender.
71
What might abdominal distension indicate?
Presence of fluid (ascites), gas, or bowel obstruction.
72
What does a rigid abdomen suggest on palpation?
Peritonitis, which is a medical emergency.
73
What is the normal range for bowel sounds per minute?
5–30 bowel sounds per minute.
74
What might hyperactive bowel sounds indicate?
Diarrhea, gastroenteritis, or early bowel obstruction.
75
What are causes of hypoactive bowel sounds?
Post-operative state or paralytic ileus.
76
What does the absence of bowel sounds signify?
Possible peritonitis or bowel obstruction; requires immediate attention.
77
What does rebound tenderness suggest when present?
Pain upon release of pressure indicates peritoneal inflammation (peritonitis).
78
What is a positive Murphy’s sign, and what does it indicate?
Right upper quadrant (RUQ) pain during inspiration when palpating under the rib cage—indicates cholecystitis (gallbladder inflammation).
79
What does CVA tenderness suggest and how is it assessed?
Costovertebral angle (CVA) tenderness is assessed by tapping the lower back; flank pain suggests kidney infection or inflammation.
80
What are normal musculoskeletal findings during inspection and range of motion assessment?
Full range of motion (ROM), no swelling, and symmetrical appearance of joints and muscles.
81
What are common abnormal findings in musculoskeletal inspection and ROM?
Decreased ROM (e.g., joint stiffness or contractures), crepitus (crackling sound or feeling, often due to arthritis), swelling (indicative of injury, inflammation, or joint effusion).
82
What does a muscle strength grade of 5 mean?
Normal strength; full resistance against force.
83
What does a muscle strength grade of 4 indicate?
Slight weakness; can move against some resistance.
84
What does a grade of 3 on the muscle strength scale signify?
Movement against gravity but not against resistance.
85
What does a muscle strength grade of 2 indicate?
Movement is possible without gravity (e.g., along a horizontal plane).
86
What does a grade of 1 on the muscle strength scale mean?
Muscle contraction is palpable, but no visible movement occurs.
87
What does a muscle strength grade of 0 indicate?
No muscle contraction at all.
88
What are normal findings in a gait assessment?
A steady, coordinated, and balanced walking pattern.
89
What does ataxia indicate when observing gait?
An unsteady or uncoordinated gait that may indicate a neurological issue (e.g., cerebellar dysfunction).
90
What might a limping gait suggest during assessment?
Possible injury, pain, or musculoskeletal imbalance.
91
What happens to the epidermis and dermis with aging, and what does this increase the risk for?
Thinning of both layers increases the risk for skin tears and bruising.
92
How do changes in collagen and elastin affect the skin in older adults?
Decreased collagen and elastin lead to wrinkles, sagging, and dryness.
93
What is the result of reduced sebaceous and sweat gland activity in elderly patients?
Causes dry, flaky skin and a reduced ability to regulate temperature.
94
What does a decrease in melanocytes cause in the aging population?
Leads to graying hair and uneven skin pigmentation.
95
What changes in nail growth are typical with aging?
Slower nail growth, with nails becoming brittle, thick, and yellow.
96
What factors contribute to skin breakdown or pressure ulcers in the elderly?
Poor mobility, excess moisture, and impaired circulation.
97
What may cause excessive bruising in older adults?
Use of anticoagulants or vitamin deficiencies (e.g., vitamin C, K).
98
What are possible causes of delayed wound healing in older adults?
Could result from diabetes, infection, or poor nutrition.
99
What does the ABCDE rule help assess, and what does it stand for?
Helps screen for skin cancer:
Asymmetry
Border irregularity
Color variation
Diameter >6mm
Evolution or change over time
100
What happens to bone density as people age, and what risk does this create?
Decreases with age, leading to increased fracture risk and osteoporosis.
101
What are the effects of cartilage degeneration in older adults?
Leads to joint stiffness and osteoarthritis.
102
What is sarcopenia, and what causes it?
Age-related loss of muscle mass and strength, leading to reduced grip strength and mobility.
103
What causes older adults to lose height over time?
Shortening of the vertebral column, typically resulting in a 1–2 inch height loss.
104
What condition does severe kyphosis ('hunchback') suggest in older adults?
Likely caused by osteoporosis-related vertebral compression fractures.
105
What do limited joint mobility and joint pain in the elderly often indicate?
May indicate osteoarthritis or rheumatoid arthritis.
106
What might shuffling gait and slow movement suggest in a geriatric patient?
Possible Parkinson’s disease and increased fall risk.
107
What effect does decreased cardiac output have in older adults?
Leads to less efficient blood circulation and potential activity intolerance.
108
How does increased arterial stiffness affect blood pressure in the elderly?
Causes elevated systolic blood pressure and increases the risk for hypertension.
109
What does a slower baroreceptor response in older adults increase the risk for?
Orthostatic hypotension, which can lead to dizziness and falls.
110
What is considered hypertension in older adults, and why is it dangerous?
Blood pressure >130/80 mmHg; increases the risk of stroke and heart attack.
111
What values define orthostatic hypotension?
A drop of >20 mmHg in systolic BP or >10 mmHg in diastolic BP upon standing.
112
What risk is associated with atrial fibrillation in the elderly?
Increased risk of embolic stroke due to irregular heartbeat.
113
What does peripheral edema in older adults suggest?
Possible heart failure, especially right-sided.
114
What does jugular vein distension (JVD) indicate in a geriatric cardiovascular exam?
Right-sided heart failure and fluid overload.
115
What happens when lung elasticity decreases with age?
Gas exchange becomes less efficient, increasing the risk for hypoxia.
116
How does a weakened diaphragm and intercostal muscles affect older adults?
Leads to decreased lung expansion and reduced exercise tolerance.
117
Why is a diminished cough reflex concerning in older patients?
Increases the risk for aspiration pneumonia and respiratory infections.
118
What does the presence of crackles in lung bases indicate?
May suggest pneumonia or heart failure.
119
What does an increased respiratory rate (>20/min) suggest?
Could indicate hypoxia, infection, or respiratory distress.
120
What causes wheezing in a geriatric respiratory exam?
Airway obstruction, as seen in COPD or asthma.
121
What does clubbing of the fingers signify in older adults?
Chronic hypoxia, often due to lung or heart disease.
122
What happens due to decreased gastric acid secretion in older adults?
Increased risk for malabsorption, especially of vitamin B12 and iron.
123
What is the impact of slower peristalsis in elderly patients?
Higher risk of constipation and reduced bowel motility.
124
What condition is associated with a weakened lower esophageal sphincter?
Gastroesophageal reflux disease (GERD), leading to heartburn and esophagitis.
125
What complications can arise from severe constipation in the elderly?
May lead to fecal impaction or bowel obstruction.
126
What might unexplained weight loss in an older adult indicate?
Possible malignancy, malabsorption, or systemic disease.
127
What do black/tarry stools or hematemesis suggest?
Signs of GI bleeding, possibly from peptic ulcers or cancer.
128
What does dysphagia mean, and what are common causes in the elderly?
Difficulty swallowing, often due to stroke or esophageal disorders.
129
How does decreased renal function affect older adults?
Leads to slower drug metabolism, and increased creatinine and BUN levels.
130
What are the effects of weakened bladder muscles in elderly individuals?
Causes urinary frequency, urgency, and nocturia (frequent nighttime urination).
131
How does decreased bladder capacity impact urinary function in older adults?
May lead to urinary retention and a higher risk for urinary tract infections (UTIs).
132
What are the types and causes of urinary incontinence in the elderly?
Stress incontinence: Leakage with coughing or laughing
Urge incontinence: Overactive bladder
Overflow incontinence: Often caused by benign prostatic hyperplasia (BPH)
133
Why are recurrent UTIs more common in older adults?
Due to urinary retention or incomplete bladder emptying.
134
What are signs of renal failure in elderly patients?
Fluid overload, elevated creatinine, and electrolyte imbalances.
135
What changes occur in women after menopause?
Decreased estrogen leading to vaginal dryness, atrophy, and changes in sexual function.
136
What are common age-related changes in men?
Decreased testosterone, which may cause reduced libido and benign prostatic hyperplasia (BPH).
137
What are shared sexual changes experienced by both older men and women?
Slower sexual response and reduced libido.
138
What does postmenopausal bleeding potentially indicate?
May be a sign of endometrial cancer and requires evaluation.
139
What are possible causes of erectile dysfunction (ED) in older men?
Diabetes, vascular disease, medications, or hormone changes.
140
What causes dyspareunia (painful intercourse) in postmenopausal women?
Often due to vaginal atrophy and hormonal changes.
141
What memory changes are considered normal in aging adults?
Mild memory loss and slower recall, but long-term memory remains intact.
142
How does aging affect reflexes and response time?
Slower reflexes and delayed reaction time to external stimuli.
143
What is delirium, and what commonly causes it in the elderly?
Acute confusion often triggered by infection, dehydration, or medications.
144
What is dementia, and how does it differ from delirium?
A chronic, progressive cognitive decline often due to Alzheimer’s or vascular dementia.
145
What are common motor symptoms of Parkinson’s disease in older adults?
Tremors, shuffling gait, and slowness of movement.
146
What does facial droop and unilateral weakness indicate in an elderly patient?
Possible stroke; requires immediate medical attention.
147
How does decreased insulin sensitivity affect older adults?
Increases the risk for Type 2 Diabetes Mellitus due to reduced glucose uptake.
148
What are the effects of decreased thyroid function in aging individuals?
Causes a slower metabolism, fatigue, and mild cold intolerance.
149
What are common symptoms of hypothyroidism in elderly patients?
Fatigue, weight gain, and dry skin.
150
What are signs of hyperthyroidism in older adults?
Unintentional weight loss and tachycardia (rapid heart rate).
151
What fasting blood glucose level is considered hyperglycemia, and what does it suggest?
A fasting glucose level >126 mg/dL suggests diabetes or impaired glucose regulation.
152
What is presbyopia and how does it affect vision?
Age-related decreased near vision requiring reading glasses.
153
What causes pseudoptosis, and how does it present?
Drooping of the eyelids due to loss of skin elasticity.
154
What is entropion, and what complication can it cause?
Inward turning of the eyelid; can irritate the cornea and cause discomfort.
155
What is ectropion, and what are its effects?
Outward turning of the eyelid; leads to dry, irritated eyes due to exposure.
156
What is the primary symptom of macular degeneration?
Loss of central vision with blurred or dark areas, affecting reading and facial recognition.
157
What is presbycusis and how does it affect hearing?
A gradual loss of high-frequency hearing, making it hard to hear speech clearly.
158
How does aging affect taste and smell, and what is the clinical concern?
Reduced ability to detect flavors and aromas, which can lead to poor nutrition and decreased appetite.
159
What can sudden vision loss indicate in an older adult?
A medical emergency such as retinal detachment or stroke.
160
What are the risks of significant hearing loss in elderly patients?
Can lead to social isolation, miscommunication, and depression.
161
What condition might cause severe dry eyes, and why is it concerning?
May indicate Sjögren’s syndrome or chronic ocular irritation, which can damage the cornea over time.
162
What is the definition of acute pain?
Pain with a sudden onset, short duration (<3–6 months), and usually resolves with healing.
163
What are common causes of acute pain?
Surgery, injury, and infections.
164
What signs and symptoms are typically associated with acute pain?
Increased heart rate, blood pressure, and respiratory rate; grimacing, guarding, and restlessness.
165
Give examples of acute pain.
Postoperative pain, sprained ankle, labor pain.
166
How is persistent (chronic) pain defined?
Pain that lasts more than 3–6 months, and may persist despite healing of the initial injury.
167
What are common causes of chronic pain?
Arthritis, cancer, neuropathy.
168
What are common symptoms of chronic pain?
Depression, fatigue, sleep disturbances, and reduced quality of life.
169
Provide examples of chronic pain conditions.
Osteoarthritis, fibromyalgia, chronic back pain.
170
What causes nociceptive pain?
Damage to body tissues.
171
What are the two types of nociceptive pain, and how do they differ?
Somatic pain: Aching, throbbing, well-localized (from skin, muscles, joints).
Visceral pain: Deep, cramping, poorly localized (from internal organs).
172
What are some examples of nociceptive pain?
Bone fractures, burns, appendicitis.
173
What causes neuropathic pain?
Injury or dysfunction of the nerves or central nervous system (CNS).
174
What are the characteristics of neuropathic pain?
Burning, tingling, shooting, or electric shock-like sensations.
175
Give examples of neuropathic pain conditions.
Diabetic neuropathy, phantom limb pain, sciatica.
176
What is referred pain?
Pain that is felt in a different location than the actual source of the pain.
177
Give examples of referred pain.
Myocardial infarction (MI) felt in the jaw or left arm.
Gallbladder pain felt in the right shoulder.
178
What is phantom pain?
Pain that is felt in a missing or amputated limb.
179
What causes phantom pain?
Nerve endings continue to send pain signals even though the limb is gone.
180
How is phantom pain treated?
Mirror therapy and nerve pain medications.
181
Who proposed the Gate-Control Theory of Pain, and when?
Melzack and Wall in 1965.
182
What is the main concept of the Gate-Control Theory?
The spinal cord contains a 'gate' mechanism that can either block or allow pain signals to travel to the brain.
183
What factors can cause the 'gate' to close and reduce pain perception?
Non-painful stimuli like massage, distraction, relaxation techniques, or ice.
184
What factors can cause the 'gate' to open, increasing pain perception?
Stress, anxiety, and focusing attention on the pain.
185
What is a key clinical application of the Gate-Control Theory?
Use of non-pharmacologic interventions such as massage, music therapy, or cold therapy to 'close the gate' and relieve pain.
186
What is the definition of pain threshold?
The minimum level of stimulus required for a person to perceive pain.
187
Is pain threshold typically consistent across individuals?
Yes, it is mostly biological and relatively uniform among people.
188
What is the definition of pain tolerance?
The maximum amount of pain a person is willing or able to tolerate before seeking relief.
189
What factors influence pain tolerance?
Cultural background, emotions, past experiences, and mental state.
190
Give an example that illustrates the difference between pain threshold and pain tolerance.
Patient A requests pain medication frequently after surgery = low tolerance.
Patient B rarely asks for pain relief = high tolerance.
Both may have similar pain thresholds, but different tolerances.
191
What is the purpose of using pain scales in nursing assessment?
To quantify pain intensity and guide treatment decisions.
192
How does the Numeric Rating Scale (NRS) measure pain?
Patients rate their pain on a 0 to 10 scale.
193
On the NRS, what does each range indicate?
0 = No pain
1–3 = Mild pain
4–6 = Moderate pain
7–10 = Severe pain
194
Who is the Numeric Rating Scale best suited for?
Adults who can verbalize and understand numeric values.
195
How does the Faces Pain Scale – Revised (FPS-R) work?
Uses facial expressions to represent pain levels, without numbers.
196
Who is the FPS-R most appropriate for?
Children aged 3 and older and non-verbal adults.
197
How is the Wong-Baker Faces Scale different from FPS-R?
Uses cartoon faces from smiling (no pain) to crying (worst pain); includes number ratings.
198
Who is the Wong-Baker Scale primarily used for?
Pediatric patients, especially those aged 3–7 years.
199
What is the Verbal Descriptor Scale (VDS)?
Uses words instead of numbers to describe pain intensity.
200
What are common terms used in the VDS?
No pain
Mild pain
Moderate pain
Severe pain
Worst pain imaginable
201
Who benefits most from using the VDS?
Older adults and patients with cognitive impairments.
202
What does the acronym OLD CARTS help assess in pain evaluation?
It provides a structured approach to evaluate the characteristics and context of pain.
203
What does O stand for in OLD CARTS?
Onset – When the pain started.
204
What does L represent?
Location – Where the pain is, and whether it radiates.
205
What does D stand for?
Duration – How long the pain lasts and whether it is constant or intermittent.
206
What does C indicate?
Characteristics – Description of the pain (e.g., sharp, dull, burning).
207
What does A assess?
Aggravating factors – What makes the pain worse.
208
What does R stand for?
Relieving factors – What alleviates the pain.
209
What does T evaluate?
Timing – When the pain occurs (e.g., morning, night, during activity).
210
What does S represent?
Severity – Pain intensity rating using a 0–10 scale.
211
What is the purpose of the PQRSTU Pain Assessment tool in nursing?
To provide a structured approach for assessing pain, with added focus on the patient’s understanding and perception of their pain experience.
212
What does the P in PQRSTU stand for, and what does it assess?
Provocation/Palliation – What makes the pain worse or better?
213
What does the Q stand for in PQRSTU, and how should it be evaluated?
Quality – Ask the patient to describe the pain (e.g., sharp, stabbing, dull, throbbing, burning).
214
What is assessed with R in PQRSTU?
Region/Radiation – Determine where the pain is located and whether it radiates to other areas.
215
What does S stand for, and how is it measured?
Severity – Ask the patient to rate the pain on a 0–10 scale (0 = no pain, 10 = worst pain imaginable).
216
What does the T in PQRSTU refer to?
Timing – Assess when the pain started, how long it lasts, and if it’s constant or intermittent.
217
What does the U stand for in PQRSTU, and why is it important?
Understanding – Ask the patient:
“What do you think is causing your pain?”
“How is the pain affecting your daily life?”
This helps assess the psychosocial impact and guides individualized care.
218
What is the SA node commonly known as?
The natural pacemaker of the heart.
219
Where is the SA node located?
In the right atrium.
220
What is the primary function of the SA node?
To generate electrical impulses that initiate the heartbeat at a rate of 60–100 bpm.
221
What type of rhythm originates in the SA node?
Normal sinus rhythm.
222
Where is the AV node located?
Between the atria and the ventricles.
223
What is the function of the AV node?
To delay the impulse, allowing the ventricles to fill with blood before contracting.
224
What is the intrinsic rate of the AV node, and what is its backup role?
40–60 bpm; serves as a secondary pacemaker if the SA node fails.
225
Where is the Bundle of His located?
Between the AV node and the bundle branches.
226
What is the function of the Bundle of His?
To transmit the electrical impulse from the AV node to the bundle branches.
227
What is the function of the left and right bundle branches?
They carry electrical impulses down to the ventricles.
228
What is the difference between the left and right bundle branches?
Left bundle branch is larger and serves the left ventricle.
## Footnote
Right bundle branch is smaller and serves the right ventricle.
229
Where are the Purkinje fibers located?
Throughout the walls of the ventricles.
230
What is the function of the Purkinje fibers?
To cause ventricular contraction, pushing blood out of the heart.
231
What is the intrinsic rate of the Purkinje fibers if no higher pacemaker is active?
20–40 beats per minute.
232
What is the function of the heart valves?
To control the direction of blood flow through the heart and produce heart sounds (S1 and S2).
233
Which valves are associated with the S1 ('lub') heart sound?
Tricuspid valve (between right atrium and right ventricle) and Mitral valve (between left atrium and left ventricle).
234
What causes the S1 sound?
Closure of the tricuspid and mitral valves at the beginning of ventricular systole.
235
Which valves are associated with the S2 ('dub') heart sound?
Pulmonic valve (between right ventricle and pulmonary artery) and Aortic valve (between left ventricle and aorta).
236
What causes the S2 sound?
Closure of the aortic and pulmonic valves at the beginning of diastole.
237
Where is the aortic valve best auscultated?
2nd intercostal space (ICS), right sternal border.
238
Where is the pulmonic valve heard?
2nd ICS, left sternal border.
239
What is the auscultation point for Erb’s Point, and what is it used for?
3rd ICS, left sternal border – useful for hearing both S1 and S2 equally.
240
Where is the tricuspid valve auscultated?
4th ICS, left sternal border.
241
Where is the mitral (apical) valve heard?
5th ICS, left midclavicular line – also known as the point of maximal impulse (PMI).
242
Where is the white electrode (RA) placed in a 5-lead EKG?
Right upper chest (right arm area).
243
Where is the black electrode (LA) placed?
Left upper chest (left arm area).
244
Where is the green electrode (RL) placed?
Right lower chest (right leg area).
245
Where is the red electrode (LL) placed?
Left lower chest (left leg area).
246
Where is the brown electrode (C or V lead) placed?
4th intercostal space (ICS), right of the sternum (precordial lead).
247
What is the mnemonic for remembering 5-lead EKG placement?
"White on right, smoke over fire, clouds over grass, chocolate in the center"
## Footnote
White (RA) on right upper chest, Black (LA) over red (LL) on left = "Smoke over fire", White (RA) over green (RL) = "Clouds over grass", Brown (C) in center = "Chocolate in the center".
248
What is an action potential in cardiac cells?
The process of electrical stimulation that leads to contraction and relaxation of heart muscle cells.
249
What happens during depolarization in heart cells?
Sodium (Na⁺) moves into the cell.
Potassium (K⁺) moves out of the cell.
Calcium (Ca²⁺) influx triggers myocardial contraction.
250
On the EKG, what parts represent depolarization?
The P wave (atrial depolarization) and QRS complex (ventricular depolarization).
251
What happens during repolarization?
Potassium (K⁺) moves back into the cell.
Sodium (Na⁺) moves out, allowing the cell to reset for the next contraction.
252
What part of the EKG represents repolarization?
The T wave.
253
What does the P wave represent on an EKG?
Atrial depolarization, or contraction of the atria.
254
What does the QRS complex represent?
Ventricular depolarization, or contraction of the ventricles.
255
What does the T wave represent?
Ventricular repolarization, or relaxation of the ventricles.
256
What is a U wave, and when might it appear?
Represents delayed ventricular repolarization and may be seen in hypokalemia (low potassium).
257
What is the normal heart rate in sinus rhythm?
60–100 beats per minute.
258
How should the rhythm appear in normal sinus rhythm?
Regular spacing between beats.
259
What does the P wave indicate in normal sinus rhythm?
It should be present before each QRS complex.
260
What is the normal duration of the QRS complex?
Less than 0.12 seconds.
261
What should the T wave look like in normal sinus rhythm?
It should appear normal, indicating proper ventricular repolarization.
262
What is the heart rate in sinus tachycardia?
Greater than 100 beats per minute.
263
What are common causes of sinus tachycardia?
Fever
Pain
Dehydration
Stress
Exercise
264
How is sinus tachycardia treated?
By treating the underlying cause (e.g., fluids for dehydration, beta blockers if symptomatic).
265
What is the heart rate in sinus bradycardia?
Less than 60 beats per minute.
266
What are common causes of sinus bradycardia?
Normal in athletes, Hypothermia, Beta-blocker use, Heart block.
267
What are symptoms of sinus bradycardia?
Dizziness, Fatigue, Syncope (fainting).
268
What is the treatment for symptomatic sinus bradycardia?
Atropine (first-line medication), Pacemaker if persistent or severe.
269
What causes Peripheral Artery Disease (PAD)?
Atherosclerosis, which leads to poor blood flow to the extremities.
270
What are key symptoms of PAD?
Cyanotic, pale, cold extremities, Pain with walking (claudication), relieved by rest, Non-healing ulcers on toes/feet, Numbness, tingling, and weak pulses.
271
What are treatment options for PAD?
Lifestyle changes (stop smoking, healthy diet, exercise), Medications: Aspirin (antiplatelet), statins (cholesterol), Surgery: Bypass grafting, stents if severe or progressive.
272
What is atrial fibrillation (A-Fib)?
A condition where atria depolarize chaotically, causing irregular atrial activity and poor blood flow.
273
What are EKG findings in A-Fib?
Irregularly irregular rhythm, No P waves, Erratic QRS timing, Fibrillatory waves (quivering baseline).
274
What are common symptoms of A-Fib?
Palpitations, Fatigue, Dizziness, Increased risk of stroke (due to clot formation in atria).
275
What are the 3 main treatment categories for A-Fib?
Rate control: Beta-blockers (e.g., Metoprolol), calcium channel blockers (e.g., Diltiazem), Anticoagulation: Warfarin, NOACs (e.g., Eliquis), Rhythm control: Cardioversion, amiodarone, catheter ablation.
276
What is a nasal cannula, and when is it typically used?
A low-flow oxygen device with two nasal prongs, commonly used for patients who require mild oxygen support.
277
What are some advantages of using a nasal cannula?
Comfortable and non-invasive
Allows eating and talking
Suitable for long-term oxygen therapy
278
What are some disadvantages of the nasal cannula?
Drying to nasal mucosa, especially above 4 L/min
Limited FiO₂ delivery
Not appropriate for severe hypoxia
279
What is the FiO₂ delivered at 1 L/min via nasal cannula?
24% FiO₂
280
What FiO₂ is delivered at 2 L/min?
28% FiO₂
281
What FiO₂ is delivered at 3 L/min?
32% FiO₂
282
What FiO₂ is delivered at 4 L/min?
36% FiO₂
283
What FiO₂ is delivered at 5 L/min?
40% FiO₂
284
What is the maximum flow rate for a nasal cannula, and what FiO₂ does it deliver?
6 L/min, delivering up to 44% FiO₂
285
When should humidification be added to nasal cannula oxygen therapy?
When the flow rate is greater than 4 L/min.
286
What areas should be monitored for skin breakdown in a patient using a nasal cannula?
Ears and nares (nostrils).
287
How should the nasal prongs be positioned for effective oxygen delivery?
Properly inserted into the nostrils, pointing downward and comfortably fitted.
288
What is a simple face mask, and what type of oxygen therapy is it used for?
A mask that covers the nose and mouth, used to deliver moderate concentrations of oxygen for short-term oxygen therapy.
289
Who benefits most from a simple face mask compared to a nasal cannula?
Mouth breathers and patients requiring higher FiO₂ than a nasal cannula provides.
290
What FiO₂ is delivered at a flow rate of 5–6 L/min via simple face mask?
40% FiO₂
291
What FiO₂ is delivered at 6–7 L/min?
50% FiO₂
292
What FiO₂ is delivered at 7–8 L/min?
60% FiO₂
293
Why must the minimum flow rate for a simple face mask be at least 5 L/min?
To prevent carbon dioxide (CO₂) rebreathing within the mask.
294
Why is a simple face mask not recommended for COPD patients?
Due to the risk of CO₂ retention, which can worsen respiratory status.
295
What are the drawbacks of a simple face mask regarding daily activities?
It makes eating and talking difficult while in use.
296
What should a nurse ensure when applying a simple face mask?
That there is a tight seal around the face to ensure effective oxygen delivery.
297
What are signs of CO₂ retention a nurse should monitor for?
Drowsiness, confusion, and lethargy.
298
What should be done when a patient using a simple face mask needs to eat?
Switch to a nasal cannula temporarily during meals.
299
What is a non-rebreather mask (NRB) used for?
To deliver the highest concentration of oxygen (up to 100%) without intubation, especially in emergency situations.
300
How does the NRB mask prevent rebreathing of exhaled air?
Through the use of one-way valves that block the re-inhalation of exhaled carbon dioxide.
301
What are common clinical uses for a non-rebreather mask?
Severe hypoxia, Trauma, Respiratory distress, Carbon monoxide poisoning.
302
What is the appropriate flow rate for a non-rebreather mask?
10–15 liters per minute.
303
What range of FiO₂ can be delivered with a non-rebreather mask?
80–100% FiO₂.
304
What is the main advantage of using a non-rebreather mask?
Provides the highest oxygen concentration available without mechanical ventilation.
305
Why is the NRB mask ideal in emergency situations?
It delivers rapid, high-flow oxygen to patients in critical respiratory distress.
306
Why is the NRB mask not suitable for long-term use?
It carries a risk of CO₂ retention and barotrauma due to the high oxygen concentration.
307
What is a common patient complaint when using an NRB mask?
The mask can feel claustrophobic and uncomfortable.
308
What must be ensured before placing a non-rebreather mask on the patient?
The reservoir bag must be fully inflated to avoid CO₂ rebreathing.
309
What is essential to maximize the FiO₂ delivery of a non-rebreather mask?
A tight seal around the face to prevent oxygen leakage.
310
What patient signs should the nurse monitor while using a non-rebreather mask?
Respiratory distress, Confusion, Signs of CO₂ retention.
311
Why is a non-rebreather mask not appropriate for COPD patients?
The high oxygen concentration can suppress the patient’s hypoxic drive and lead to respiratory failure.
312
What is the primary function of a Venturi mask?
To deliver a precise FiO₂ by mixing oxygen with room air at controlled concentrations.
313
Why is the Venturi mask particularly useful for COPD patients?
It prevents CO₂ retention by providing controlled and accurate oxygen delivery, avoiding suppression of their hypoxic drive.
314
What FiO₂ and flow rate are associated with the blue adapter?
24% FiO₂ at 2–4 L/min
315
What FiO₂ does the white adapter provide?
28% FiO₂ at 4–6 L/min
316
What are the flow rate and FiO₂ for the orange adapter?
31% FiO₂ at 6–8 L/min
317
Which adapter delivers 35% FiO₂, and at what flow rate?
Yellow adapter at 8–10 L/min
318
What are the flow rate and FiO₂ for the red adapter?
40% FiO₂ at 10–12 L/min
319
What does the green adapter deliver?
50% FiO₂ at 12–15 L/min
320
What is the main advantage of the Venturi mask compared to other oxygen devices?
It provides the most precise and adjustable oxygen delivery.
321
Why is the Venturi mask considered the best option for COPD patients?
Because it delivers low, exact FiO₂ and reduces the risk of CO₂ retention.
322
What are two disadvantages of the Venturi mask?
It is bulky and uncomfortable for some patients.
It is not suitable for emergencies requiring rapid high-flow oxygen.
323
What must a nurse ensure when setting up a Venturi mask?
That the correct adapter color is used for the prescribed FiO₂.
324
What patient conditions should a nurse monitor when using a Venturi mask?
Watch for hypoxia and signs of CO₂ retention, especially in COPD patients.
325
What is a High-Flow Nasal Cannula (HFNC) used for?
It delivers heated, humidified, high-flow oxygen for patients with respiratory failure, severe hypoxia, or COVID-19.
326
What makes HFNC different from standard nasal cannulas?
It provides higher flow rates, humidification, and a PEEP-like (positive airway pressure) effect, which helps improve oxygenation and reduce work of breathing.
327
What is the maximum flow rate for an HFNC device?
Up to 60 liters per minute (L/min).
328
What FiO₂ range can HFNC deliver?
From 21% to 100% FiO₂, depending on flow and settings.
329
What are the main advantages of using HFNC?
More comfortable than face masks
Provides a PEEP-like effect to help keep airways open
Reduces work of breathing and improves oxygenation
330
What are the disadvantages of HFNC?
Requires specialized equipment and monitoring
Not suitable for patients with thick secretions or complete airway obstruction
331
What should nurses monitor for when a patient is on HFNC?
Signs of respiratory distress or deteriorating oxygenation.
332
Why is humidification important when using HFNC?
To prevent drying of mucosa and ensure patient comfort and secretion mobility.
333
What might be required in the setup to manage condensation in the tubing?
Heated tubing to prevent condensation buildup, which can interfere with flow and oxygen delivery.
334
What is an Oxymask, and what makes it unique?
A versatile, open-mask oxygen system that delivers a wide range of FiO₂ (24–90%) with an open design for greater comfort and less CO₂ buildup.
335
What are common clinical situations where an Oxymask may be used?
When patients need a flexible FiO₂ range, improved comfort, and the ability to speak or eat while on oxygen therapy.
336
What FiO₂ does the Oxymask deliver at 1 L/min?
24% FiO₂
337
What FiO₂ can be achieved with a flow rate of 10–15 L/min?
Up to 90% FiO₂
338
What are the key advantages of the Oxymask?
Covers a wide range of FiO₂ (24–90%)
## Footnote
Open design improves patient comfort, allows talking and eating; Lower risk of CO₂ retention compared to NRB masks.
339
What are the disadvantages of using an Oxymask?
Provides less precise FiO₂ control than other devices
## Footnote
May not be ideal for patients with extreme hypoxia requiring exact or high-flow oxygen.
340
What must the nurse ensure when applying an Oxymask?
That it has proper fit and positioning to optimize oxygen delivery.
341
What should nurses educate patients about regarding the Oxymask?
That the open design enhances comfort, allows airflow, and reduces CO₂ retention.
342
What is a high-flow nebulizer (aerosol mask) used for?
It delivers humidified oxygen combined with medications (e.g., bronchodilators like albuterol and corticosteroids), often for patients with thick secretions, COPD, or post-extubation.
343
What is the main function of combining nebulization with oxygen therapy?
To hydrate the airways while also administering respiratory medications.
344
What flow rate is typically used with a high-flow nebulizer?
10–15 liters per minute.
345
What FiO₂ range can a high-flow nebulizer deliver?
28–100% FiO₂, depending on flow rate and settings.
346
What are the main advantages of high-flow nebulizer therapy?
Hydrates airways, which is especially beneficial for thick secretions.
Delivers medications such as bronchodilators and corticosteroids directly to the lungs.
347
What are two disadvantages of using a high-flow nebulizer?
Requires a nebulizer machine.
Can cause fluid overload due to excessive moisture, especially in susceptible patients.
348
What adverse reaction should nurses monitor for during nebulizer treatments?
Bronchospasm or paradoxical reactions to medications (e.g., worsening symptoms after albuterol).
349
What is important regarding medication administration in a nebulizer treatment?
Ensuring the correct medication dose is used for safety and effectiveness.
350
What is the goal of primary prevention?
To prevent disease before it occurs in the general population.
351
What population is targeted in primary prevention?
Healthy individuals (general population without known risk factors).
352
What are examples of primary prevention strategies?
Vaccinations (e.g., flu shot, HPV vaccine), Health education (e.g., smoking cessation, safe sex education), Environmental safety (e.g., seat belts, clean air regulations), Nutrition and exercise programs (to prevent obesity and diabetes).
353
What is the goal of secondary prevention?
To detect disease early and intervene to prevent symptom progression.
354
What population is targeted in secondary prevention?
At-risk individuals (e.g., those with family history or risk factors).
355
What are examples of secondary prevention strategies?
Mammograms (early breast cancer detection), Blood pressure screenings (for early hypertension detection), Cholesterol checks (for heart disease prevention), Colonoscopy (for early colorectal cancer detection), Diabetes screening (A1C for high-risk patients).
356
What is the goal of tertiary prevention?
To manage existing disease and prevent complications or progression.
357
What population is targeted in tertiary prevention?
Patients already diagnosed with a disease.
358
What are examples of tertiary prevention strategies?
Cardiac rehabilitation (for post-myocardial infarction patients), Physical therapy (for stroke survivors), Insulin therapy (for diabetes management), Smoking cessation (for COPD patients).
359
What is the goal of quaternary prevention?
To prevent over-medicalization and avoid unnecessary interventions.
360
What population is targeted in quaternary prevention?
Patients already receiving treatment who may be at risk for overtreatment.
361
What are examples of quaternary prevention strategies?
Avoiding polypharmacy in elderly patients, Reducing unnecessary imaging tests (e.g., X-rays or CTs without indication), Preventing overtreatment (e.g., not prescribing antibiotics for viral infections).
362
What is the main focus of Pender’s Health Promotion Model?
Understanding how individual behaviors and motivation influence health promotion actions.
363
What personal factors are considered in Pender’s model?
Biological, psychological, and sociocultural characteristics.
364
How does the model evaluate a patient’s motivation to act?
By examining the patient’s perceived benefits vs. barriers to the behavior.
365
What is self-efficacy, and how is it relevant to Pender’s model?
A patient’s confidence in their ability to succeed in making a health behavior change.
366
What role do interpersonal influences play in the Health Promotion Model?
Family, peers, and social support can encourage or discourage behavior change.
367
What are situational influences in Pender’s model?
Environmental factors like the workplace or access to healthcare that affect behavior.
368
Provide an example of Pender’s HPM in action.
A patient quits smoking because they believe it will extend their life for their children and they feel confident in their ability to quit.
369
What is the focus of the Transtheoretical Model of Change?
Understanding how individuals progress through behavior change stages over time.
370
What stage is a patient in if they don’t see a problem and have no intention to change?
Precontemplation – e.g., “I don’t see a problem with my smoking.”
371
What does it mean if a patient acknowledges a problem but is not ready to act?
Contemplation – e.g., “I know smoking is bad, but I’m not sure I want to quit yet.”
372
What stage involves actively planning a behavior change?
Preparation – e.g., “I will set a quit date and buy nicotine patches.”
373
When a patient has started making the change, what stage are they in?
Action – e.g., Patient has stopped smoking and is using nicotine patches.
374
What is the maintenance stage of behavior change?
When a patient is sustaining the change over time but is still at risk of relapse – e.g., “I haven’t smoked in 6 months, but I still get cravings.”
375
What is the termination stage?
The behavior change is fully integrated, and the patient has no temptation to return to the old behavior – e.g., “I will never smoke again, even when stressed.”
376
Exam Tip: If a question asks about the stage of change, what should you focus on?
The patient’s mindset and their readiness to act.
377
What is the main focus of the Health Belief Model (HBM)?
To explain how personal beliefs influence health behaviors and decisions.
378
What is Perceived Susceptibility in HBM?
The belief about how likely they are to get a disease.
379
What is Perceived Severity in HBM?
The belief about how serious the disease or condition is.
380
What is Perceived Benefit in HBM?
The belief that taking a specific action will reduce risk or improve outcomes.
381
What are Perceived Barriers in HBM?
The obstacles or costs a person sees in taking the recommended health action.
382
What are Cues to Action in the Health Belief Model?
Triggers or reminders that prompt action, such as a doctor’s advice, symptoms, or health campaigns.
383
What is Self-Efficacy in the Health Belief Model?
The individual’s confidence in their ability to successfully perform the health behavior.
384
Provide an example of HBM using diabetes.
A diabetic patient refusing insulin may have low perceived severity or high perceived barriers (e.g., fear of injections).
385
Provide an HBM example with a mammogram.
A woman gets a mammogram because she believes breast cancer is serious (high perceived severity) and her doctor recommended it (cue to action).
386
What is the focus of the Holistic Health Model?
Treating the whole person, including body, mind, and spirit—not just the disease.
387
What aspects of well-being does the Holistic Model emphasize?
Emotional, mental, spiritual, and social health.
388
What does the Holistic Health Model combine?
Traditional medicine with complementary and alternative medicine (CAM).
389
What are some examples of CAM therapies used in the Holistic Health Model?
Acupuncture, meditation, yoga for chronic pain
Massage therapy for stress relief
Music therapy for dementia
Nutritional therapy during cancer recovery.
390
What’s an important exam tip to remember about the Holistic Model?
It’s about treating the whole person, not just addressing symptoms or disease.
391
What is the focus of the cognitive domain in patient education?
Understanding facts, concepts, and information.
392
What are examples of teaching in the cognitive domain?
Teaching a patient about diabetes and insulin.
## Footnote
Explaining medication side effects.
Providing a lecture or handout on heart disease.
393
What is the focus of the psychomotor domain?
Learning physical skills through demonstration and practice.
394
What are examples of teaching in the psychomotor domain?
Teaching a patient how to inject insulin.
## Footnote
Instructing on wound care techniques.
Demonstrating proper inhaler use.
395
What is the focus of the affective domain in patient teaching?
Attitudes, values, beliefs, and emotional responses to health-related changes.
396
What are examples of teaching in the affective domain?
Helping a patient accept a new diagnosis.
## Footnote
Encouraging a smoker to quit.
Discussing end-of-life care to explore values and feelings.
397
What is the focus of Pender’s Health Promotion Model?
To explain why individuals engage in health-promoting behaviors.
398
According to HPM, how do perceived benefits vs. barriers influence behavior?
Patients assess whether the benefits of changing outweigh the barriers (e.g., "Will quitting smoking improve my life?").
399
What role does self-efficacy play in Pender’s model?
It reflects a patient’s confidence in their ability to succeed in making a behavior change.
400
How do interpersonal influences impact health behavior in this model?
Support from family and friends can encourage or discourage health-related behavior change.
401
Give an example of Pender’s HPM in practice.
A patient quits smoking to be a healthy role model for their children and because they believe they can succeed.
402
What is the focus of Orem’s Self-Care Deficit Theory?
To identify when nursing care is needed due to a patient’s inability to perform self-care.
403
What is a total self-care deficit?
When a patient is completely dependent on the nurse, such as a ventilated ICU patient.
404
What is a partial self-care deficit?
When a patient can do some things independently but still needs assistance, like a stroke patient in rehab.
405
What is supportive-educative care in Orem’s theory?
When the patient can perform self-care with teaching, such as a new diabetic learning insulin administration.
406
Provide an example of Orem’s theory in action.
A nurse teaches a stroke patient to use adaptive utensils so they can eat independently.
407
What is the focus of Cognitive Dissonance Theory?
When new information conflicts with existing beliefs, it creates discomfort, which motivates learning and change.
408
Give an example of cognitive dissonance in a patient scenario.
A patient who believes diabetes isn’t serious changes behavior after learning about diabetes complications.
409
What is the focus of the Health Belief Model?
A person’s beliefs about illness and health influence their behavior and decision to act.
410
What does perceived susceptibility refer to in HBM?
The patient’s belief about whether they are personally at risk for a condition.
411
What does perceived severity refer to in HBM?
How serious the patient believes the condition and its consequences are.
412
What is perceived benefit in HBM?
The belief that taking action will improve health or prevent disease.
413
What are perceived barriers in HBM?
The obstacles a person believes they’ll face in making a behavior change.
414
What are cues to action in HBM?
Triggers that prompt the person to act, such as doctor’s advice, media, or symptoms.
415
What is self-efficacy in the Health Belief Model?
A person’s belief in their ability to successfully carry out the desired health behavior.
416
What is the Precontemplation stage in the Transtheoretical Model?
The individual has no intention to change and does not see the behavior as a problem.
## Footnote
Example: “I don’t think my smoking is a problem.”
417
What is the Contemplation stage?
The person is thinking about changing, but is not ready to act yet.
## Footnote
Example: “I know I should quit smoking.”
418
What happens during the Preparation stage?
The individual is planning to change soon and may start taking small steps.
## Footnote
Example: “I set a quit date for next month.”
419
What characterizes the Action stage?
The individual is actively making a behavior change.
## Footnote
Example: “I quit smoking and use nicotine patches.”
420
What is the Maintenance stage?
The individual is sustaining the behavior change over time, with potential for relapse.
## Footnote
Example: “I haven’t smoked in 6 months.”
421
What defines the Termination stage?
The person has fully adopted the change with no temptation to relapse.
## Footnote
Example: “I will never smoke again.”
422
What is the focus of Self-Efficacy Theory?
A patient’s confidence in their ability to perform a task directly influences their likelihood of success.
423
Provide an example of self-efficacy in practice.
A diabetic patient is more likely to check their blood sugar regularly if they feel confident using their glucometer.
424
What is the goal of Health Promotion Theory?
To encourage positive health behaviors before illness develops.
425
What is an example of a health promotion activity in this theory?
A nurse teaching high school students about healthy eating habits to help prevent obesity.
426
What needs must be met first before patient education can be effective, according to Maslow?
Physiological needs, such as pain control or basic comfort.
427
What does safety mean in the context of learning?
Creating a secure environment where the patient feels safe to learn.
428
How do love and belonging needs affect learning?
Having support from family or community can enhance motivation and confidence.
429
What is an example of addressing esteem needs in patient teaching?
Encouraging a patient’s self-confidence and celebrating small learning achievements.
430
What is an example of self-actualization in health education?
Helping a patient set and achieve personal health goals (e.g., training for a 5K after rehab).
431
Why is motivation important in patient education?
Patients are more likely to engage and retain information when they are motivated to change.
432
Give an example of a motivated learner.
A heart attack survivor who is eager to learn about lifestyle changes to prevent recurrence.
433
Why must nurses assess a patient’s literacy level before providing written materials?
To ensure the education is understandable and accessible to the patient.
434
What strategies help improve comprehension for patients with low health literacy?
Use simple language, use the teach-back method to confirm understanding, avoid medical jargon.
435
How should a nurse address language barriers during patient education?
Use professional medical interpreters to ensure understanding.
436
What teaching strategies are helpful for patients with cognitive impairment?
Use pictures, simple instructions, and repeat key points.
437
What should be done before teaching a patient who is in emotional distress?
Address the patient’s anxiety or emotional needs first, as stress impairs learning.
438
How should nurses teach infants?
Focus on parent education, using soothing voices and touch with the infant.
439
What teaching strategy is appropriate for toddlers?
Use short, simple explanations and play-based learning.
440
How should education be delivered to preschoolers?
Use pictures and role-playing activities.
441
What method is best for school-age children?
Use demonstrations and simple, concrete explanations.
442
What approach should be taken with adolescents?
Encourage independence and use peer examples to support learning.
443
How should education be delivered to young and middle adults?
Use a practical, problem-solving approach focused on real-life application.
444
What strategies are best for older adults?
Teach at a slow pace, use repetition, and provide large print materials.
445
What is an example of a cognitive outcome?
The patient describes the signs of a stroke (knowledge-based).
446
What is an example of a psychomotor outcome?
The patient demonstrates how to inject insulin correctly (skill-based).
447
What is an example of an affective outcome?
The patient expresses confidence in using their inhaler (emotion/attitude-based).
448
What are examples of formal patient education?
Structured programs
Discharge teaching
Diabetes education classes
449
What is informal education in nursing?
Spontaneous teaching moments, such as explaining medications or diet during bedside care.
450
What are examples of self-directed learning tools for patients?
Online resources
Brochures
Educational videos
451
How is health promotion education different from illness-related education?
Health promotion education focuses on preventing disease and encouraging healthy behaviors, whereas illness-related education focuses on managing or recovering from illness.
452
What is the main goal of health promotion education?
To prevent illness, promote wellness, and improve overall health outcomes.
453
What is an example of verbal one-on-one discussion in patient education?
A nurse explaining medication side effects directly to a patient.
454
What is group instruction in the context of nursing education?
A setting where multiple patients learn together, such as a diabetes support group.
455
What is preparatory instruction, and when is it used?
Teaching patients what to expect before a procedure, to reduce anxiety and increase understanding.
456
What is an example of a demonstration as a teaching method?
A nurse showing proper hand-washing technique.
457
How are analogies used in patient education?
To simplify complex concepts by comparing them to familiar things, e.g., 'Your heart is like a pump' to explain congestive heart failure.
458
What is an example of using role-playing in patient education?
Practicing emergency responses with children to help them learn how to act in real-life situations.
459
What is the purpose of simulation in nursing education?
To allow patients or students to practice procedures, like CPR on a manikin, in a safe, controlled environment.
460
What should be done before and after all medication procedures to prevent infection?
Perform hand hygiene.
461
When should clean gloves be used during medication administration?
When administering any medication, especially those involving contact with mucous membranes or skin.
462
What is the Right Patient, and how is it verified?
Confirm the correct patient using two identifiers, such as name and date of birth (DOB).
463
What is the Right Medication, and how do you confirm it?
Ensure the medication label matches the MAR (Medication Administration Record).
464
What does the Right Dose refer to?
Administering the correct amount, considering age, weight, and clinical condition.
465
What is the importance of the Right Route?
Ensures medication is given via the correct method (e.g., oral, IV, IM), as ordered.
466
What is the acceptable time window for the Right Time?
Administer medication within 30–60 minutes of the scheduled time.
467
What should be included in the Right Documentation?
Record the date, time, dose, route, and site of administration.
468
What does the Right to Refuse mean for patients?
Patients have the right to refuse medication after being informed of the risks and benefits.
469
What are common purposes for intradermal injections?
Tuberculosis (TB) screening and allergy testing.
470
What are the appropriate sites for intradermal injections?
Inner forearm and upper back.
471
What is the recommended needle size and gauge for an ID injection?
25–27 gauge, 3/8–5/8 inch needle.
472
At what angle should you insert an ID injection?
5–15°, with the bevel up.
473
What is the maximum volume for an intradermal injection?
0.1 mL.
474
What are the key steps in giving an intradermal injection?
Hand hygiene, apply gloves
Clean skin in circular motion
Insert needle just under epidermis
Inject slowly to form a wheal (bleb)
Do not massage or tightly cover
475
What medications are commonly given subcutaneously?
Insulin, heparin, and some vaccines.
476
What are appropriate SubQ injection sites?
Upper arms
Abdomen (avoid 2 inches around the umbilicus)
Thighs
477
What is the needle size and gauge for a SubQ injection?
23–27 gauge, 3/8–5/8 inch needle.
478
What angle is used for SubQ injections?
45° for thin patients
90° for normal or obese patients
479
What is the typical volume for a SubQ injection?
0.5–1 mL
480
What are the steps for administering a SubQ injection?
Hand hygiene, apply gloves
Clean site and allow to dry
Pinch skin, insert needle quickly
Inject slowly, remove at the same angle
Apply gentle pressure, do not massage
Fully document medication and site
481
What are common purposes for intramuscular injections?
Vaccines, antibiotics, and hormones.
482
What are the recommended IM sites and maximum volumes?
Deltoid: Max 0.5–1 mL
Ventrogluteal: Max 1–2 mL
Vastus Lateralis: Max 2–3 mL
483
What is the needle size and gauge for IM injections?
20–23 gauge, 1–2 inch needle.
484
What is the correct injection angle for IM injections?
90°
485
What are the steps for performing an IM injection?
Hand hygiene, apply gloves
Clean site
Pull skin taut, insert with a quick motion
Aspirate (pull back slightly) – if no blood, proceed
Inject slowly
Withdraw and massage lightly
Document: site, drug, volume, initials
486
When is it acceptable to mix medications in the same syringe?
Only if the medications are compatible—this should be verified using a drug reference guide or by consulting a pharmacist.
487
What should you do before mixing two medications in the same syringe?
Check for compatibility between the medications.
488
What is the first step when preparing to mix two medications in one syringe?
Draw the total air volume equal to the total volume of both medications.
489
What do you do after drawing air?
Inject air into vial A (first medication) and draw the full dose of that medication.
490
What must be done after drawing the first medication?
Tap the syringe to remove any air bubbles.
491
After removing air from the first dose, what comes next?
Inject air into vial B and draw the second dose of medication.
492
How do you combine the medications gently after drawing both?
Roll the syringe gently to mix the medications (if needed, and if appropriate).
493
What final checks are done before administration?
Check the total volume and expel any air bubbles from the syringe.
494
What types of medications should never be mixed in one syringe?
Incompatible or interacting medications should never be mixed.
495
Which types of medications should not be crushed for NG tube administration?
Enteric-coated, sustained-release, and sublingual medications.
496
What is the proper way to crush and prepare medications for NG administration?
Crush each medication separately.
Dissolve each in 15–30 mL of warm water.
Do not mix medications in the same cup.
497
What should be done before administering medications via NG tube?
Stop tube feeding 30 minutes prior to med administration.
Flush the NG tube with 15–30 mL of water.
498
How should medications be administered through an NG tube?
Administer one medication at a time.
Flush with 15–30 mL of water between each medication.
499
What should be done after giving all medications via NG tube?
Perform a final flush with water and do not mix medications with formula.
500
What technique is used for NG tube insertion?
Clean technique.
501
What type of lubricant should be used during insertion?
Water-soluble lubricant.
502
What action helps ease NG tube insertion?
Have the patient swallow water during insertion.
503
What should you do if you encounter resistance during insertion?
Stop immediately and do not force the tube.
504
How is the NG tube typically secured in adults?
Taped to the nose or cheek.
505
What method is used to secure the NG tube in infants?
Loop method.
506
What are acceptable methods to verify NG tube placement before use?
pH check of gastric contents.
Auscultation over the stomach.
X-ray if required for confirmation.
507
How often should NG tubes be repositioned?
Every 4 hours.
508
What areas should be assessed for skin breakdown with NG tube use?
Nares and lips.
509
How often should oral care be provided to patients with NG tubes?
Regularly, to prevent dryness and infection.
510
When should the tape or securement device be replaced?
When it becomes soiled or loose.
511
What is the first step before giving any oral medication?
Verify the medication order and ensure all 7 rights of medication administration are followed.
512
What should you inspect on the oral medication before giving it?
Correct drug name
Appearance (no discoloration, crumbling)
Expiration date
513
What can be used to assist patients with swallowing pills?
A medication cup, applesauce, or pudding—if allowed by policy and compatibility.
514
What must you confirm before administering oral medications?
The patient’s identity, using two identifiers (e.g., name and date of birth).
515
When should oral medications be given?
At the right time and via the correct route as ordered.
516
What should you verify after giving oral medications?
That the medications were fully swallowed by the patient.
517
What must be done immediately after administration?
Document the administration on the MAR (Medication Administration Record).
518
What does the GTPAL acronym stand for in obstetric history?
G – Gravida (total number of pregnancies)
T – Term births (after 37 weeks)
P – Preterm births (before 37 weeks)
A – Abortions (spontaneous or elective)
L – Living children
519
What is the Last Menstrual Period (LMP) used for during prenatal assessment?
To calculate the Estimated Due Date (EDD).
520
What are examples of important complications from previous pregnancies to assess?
Preeclampsia, preterm labor, and cesarean delivery.
521
What genetic screening or diagnostic tests might be done during pregnancy?
Non-Invasive Prenatal Testing (NIPT)
Chorionic Villus Sampling (CVS)
Amniocentesis
Maternal Serum Alpha-Fetoprotein (MSAFP)
Carrier screening for genetic conditions
522
How is fundal height measured, and when should it correlate with gestational age?
Measure from symphysis pubis to the fundus
From 20 to 36 weeks, fundal height should equal gestational age ±2 cm
523
When can fetal heart rate (FHR) be detected with Doppler, and what is the normal range?
Around 10–12 weeks gestation
Normal FHR: 110–160 bpm, assess for rate and regularity
524
What is the purpose of Leopold’s Maneuvers?
To determine:
Lie (longitudinal or transverse)
Presentation (e.g., cephalic or breech)
Position (e.g., LOA, ROA)
Descent (engagement in pelvis)
525
What areas are checked for edema, and why is this important?
Feet and ankles—pitting edema can be a sign of fluid retention or preeclampsia.
526
Why is a urine dipstick test performed during prenatal visits?
To check for proteinuria, which may indicate preeclampsia.
527
How is pregnancy weight gain evaluated?
Based on the patient’s pre-pregnancy BMI to ensure appropriate gestational weight gain.
528
What nutritional elements are important to assess during pregnancy?
Adequate intake of folic acid, iron, balanced diet, and hydration.
529
Why is psychological adaptation monitored during prenatal care?
To identify anxiety, depression, or bonding concerns that may affect maternal and fetal well-being.
530
What are the two types of fetal heart rate (FHR) monitoring?
Continuous and intermittent monitoring.
531
What are reassuring FHR characteristics?
FHR between 110–160 bpm
Moderate variability
No late decelerations
532
What are non-reassuring FHR patterns?
Bradycardia or tachycardia
Absent variability
Variable or late decelerations
533
How is frequency of contractions measured?
From the beginning of one contraction to the beginning of the next.
534
What is duration in contraction monitoring?
From the start to the end of a single contraction.
535
How is intensity of contractions assessed?
By palpation, rated as mild, moderate, or strong.
536
What is resting tone, and why is it important?
The baseline uterine tone between contractions—the uterus should relax to allow fetal oxygenation.
537
What does a Sterile Vaginal Exam (SVE) assess?
Dilation (0–10 cm)
Effacement (0–100%)
Station (-5 to +5 relative to ischial spines)
Presentation (e.g., vertex, breech)
538
What are the two types of membrane rupture?
Spontaneous Rupture of Membranes (SROM)
Artificial Rupture of Membranes (AROM)
539
What assessments are performed after membranes rupture?
Color, odor, and time of rupture are documented to assess for infection risk and fetal status.
540
What is a bloody show, and what does it indicate?
A mucous discharge mixed with blood—common with cervical dilation or labor onset.
541
What maternal vital signs should be closely monitored during labor?
Blood pressure, especially for signs of preeclampsia:
Elevated BP
Proteinuria
Headache
Vision changes
542
What are key aspects of maternal supportive care during labor?
Providing emotional support
Assisting with frequent repositioning
Promoting hydration
Facilitating pain relief options
543
How should the uterus feel and where should it be located after birth?
It should be firm, midline, and at or below the umbilicus.
544
What does a boggy uterus indicate, and how is it treated?
It may indicate uterine atony (risk for hemorrhage). The nurse should massage the fundus until it becomes firm.
545
What are the stages of lochia, and when do they occur?
Rubra (1–3 days): Red
Serosa (3–10 days): Pink/brown
Alba (10–14+ days): White/yellow
546
What should be assessed when monitoring lochia?
Amount, color, and odor (a foul odor may indicate infection).
547
What common breast changes may occur postpartum?
Engorgement and tenderness.
548
What should be assessed during breastfeeding?
Latching technique
Milk transfer
Nipple condition (check for cracks, pain, or bleeding)
549
What are important bladder assessments postpartum?
Monitor for urinary retention or incontinence.
550
What should be assessed regarding bowel function?
Ask about gas, flatus, and bowel movements to ensure normal return of function.
551
What vital signs should be monitored during postpartum recovery?
Temperature, blood pressure, heart rate, and respiratory rate.
552
How should pain be assessed and managed postpartum?
Assess the pain level regularly and evaluate the effectiveness of interventions (e.g., medication, positioning, ice packs).
553
What are signs of postpartum blues?
Mood swings, weeping, and irritability—typically self-limited and mild.
554
What are key signs of postpartum depression?
Persistent sadness or detachment
Loss of interest in the baby
Thoughts of self-harm or harming the infant
555
What should nurses do to support psychological adjustment?
Screen for mood disorders
Encourage bonding
Provide emotional support and resources
556
What must be assessed to determine if the mother is ready for discharge?
Ability to care for the infant
Recognition of complication signs (e.g., fever, heavy bleeding)
Ability to perform self-care (e.g., incision care, hygiene)
Understanding of contraception options, if discussed
557
What are the five components of the APGAR score?
Appearance (Color), Pulse (Heart Rate), Grimace (Reflex Irritability), Activity (Muscle Tone), Respiration (Breathing Effort)
558
What does an APGAR score of 7–10 indicate?
The newborn is stable.
559
What does an APGAR score of 4–6 suggest?
The newborn is in moderate distress and may need support.
560
What does an APGAR score of 0–3 mean?
The newborn is in critical condition and needs emergency resuscitation.
561
What is a score of 2 in each APGAR category?
Appearance: Completely pink, Pulse: ≥100 bpm, Grimace: Cry or active withdrawal, Activity: Active motion, Respiration: Strong cry
562
What is the normal head circumference for a newborn?
33–35 cm
563
What is the normal length range of a newborn?
45–55 cm
564
What is the expected weight range for a newborn?
2,500–4,000 grams
565
What is the normal axillary temperature for a newborn?
36.5–37.5°C (97.7–99.5°F)
566
What skin findings are assessed in a newborn?
Color, bruising, jaundice, rashes, lanugo, vernix
567
What should be assessed in the head of a newborn?
Fontanels: Anterior should be open and soft, posterior may be closed
568
What facial features should be checked for symmetry and function?
Eyes, ears, nose, and mouth
569
What chest findings should be assessed?
Symmetry, Breath sounds, Clavicle integrity
570
What is checked on the abdomen?
Umbilical cord: 2 arteries, 1 vein, Bowel sounds
571
What should be assessed in the genitalia?
Swelling, Ambiguity, Descended testes (in males)
572
What must be checked regarding the anus?
Patency (open and able to pass stool)
573
What should be assessed in the extremities?
Movement, Digit number and formation, Muscle tone
574
What should be checked on the spine?
Straightness, Closure of neural tube (no defects or openings)
575
What are the key newborn reflexes?
Rooting, Sucking, Moro (startle), Grasp, Babinski
576
What does the presence of newborn reflexes indicate?
Normal neurologic function
577
What feeding assessments are performed?
Latch, Swallowing ability, Feeding tolerance
578
When should the newborn have their first void and stool?
Within the first 24 hours after birth.
579
What complications should be monitored in early feeding?
Jaundice, Excessive weight loss, Signs of dehydration
580
What methods help with thermoregulation in newborns?
Drying quickly after birth, Skin-to-skin contact, Maintaining a warm environment
581
What are recommended nutritional supports postpartum?
Encourage breastfeeding or formula feeding, based on family preference and infant need.
582
What supports bonding between infant and parents?
Early skin-to-skin contact, Encouraging parental involvement in newborn care
583
What is the primary function of serotonin (5-HT)?
Mood regulation, sleep, appetite, and cognition.
584
What mental health disorders are linked to low serotonin levels?
Depression and anxiety.
585
What type of medications increase serotonin availability?
Selective Serotonin Reuptake Inhibitors (SSRIs) like fluoxetine.
586
What is dopamine responsible for in the brain?
Reward, motivation, and emotion regulation.
587
What conditions are linked to dopamine imbalances?
↑ Dopamine: Psychosis, schizophrenia
↓ Dopamine: Anhedonia, Parkinsonism
588
How do antipsychotics affect dopamine levels?
They block dopamine receptors to reduce symptoms of psychosis.
589
What is the role of norepinephrine (NE) in mental health?
Regulates arousal, attention, and the stress response.
590
What disorders are associated with low norepinephrine?
Depression, ADHD, and PTSD.
591
What medication classes increase NE availability?
SNRIs (Serotonin-Norepinephrine Reuptake Inhibitors)
TCAs (Tricyclic Antidepressants)
592
What is the function of GABA?
It is the brain’s primary inhibitory neurotransmitter, promoting calm and stability.
593
What symptoms arise from low GABA levels?
Anxiety and panic disorders.
594
What medication class enhances GABA activity?
Benzodiazepines.
595
What does glutamate do in the nervous system?
Plays a key role in learning, memory, and is the primary excitatory neurotransmitter.
596
What conditions are linked to glutamate imbalances?
Neurodegeneration, mood disorders.
597
What emerging treatment involves glutamate modulation?
Ketamine-based therapies for treatment-resistant depression.
598
What is a social network map, and why is it used?
A visual tool to map a client’s relationships and assess isolation, support, or enmeshment.
599
What should be evaluated when assessing communication quality?
Tone used
Descriptors for others (e.g., affectionate, judgmental)
Barriers to communication
600
How is conflict resolution style assessed?
By exploring how the client handles disagreements: assertively, passively, or aggressively.
601
What is a way to assess empathy and emotional insight?
Use reflective questioning to evaluate the client’s ability to understand others’ feelings (perspective-taking).
602
What are the four attachment styles, and what are they based on?
Secure
Anxious
Avoidant
Disorganized
These are based on early childhood relationship experiences.
603
What are examples of interpersonal deficits in mental health?
Poor social perception
Mistrust
Intimacy difficulties
Difficulty connecting with others
604
Why is it important to assess cultural and diversity influences in relationships?
To understand how cultural identity and norms shape relational expectations and behavior.
605
What does functional impact mean in interpersonal assessment?
How relational issues affect work, school, self-care, and daily life.
606
What is the purpose of obtaining collateral input during mental health assessments?
To gather additional observations from family or caregivers (with consent) for a broader perspective.
607
What is the purpose of the Perceived Stress Scale (PSS-10)?
To measure a person's subjective perception of stress over the past month.
608
What specific aspects of stress does the PSS-10 focus on?
Feelings of unpredictability, uncontrollability, and overload in life.
609
How many items/questions are included in the PSS-10?
10 questions.
610
What type of scale is used for responses on the PSS-10?
A Likert scale from 0 (never) to 4 (very often).
611
What is the total score range of the PSS-10?
0 to 40.
612
What score on the PSS-10 indicates high perceived stress?
A score of 20 or higher.
613
Give an example of a question that assesses stressful feelings on the PSS-10.
“How often have you felt nervous and stressed?”
614
Give an example of a positively worded item on the PSS-10.
“How often have you felt confident in handling personal problems?”
615
How does the PSS-10 complement physiological stress assessments?
It offers a subjective psychological view of stress that can complement vital signs or lab indicators of stress.
616
How is the PSS-10 useful in clinical treatment planning?
It helps support holistic care by identifying stress as a contributor to mental or physical health conditions.
617
What should be evaluated regarding the frequency and intensity of anger?
The range from mild irritation to rage, and the identification of triggers.
618
What are the different expression patterns of anger?
Externalized aggression (e.g., yelling, physical violence)
Internalized anger (e.g., self-harm, withdrawal)
Passive-aggressive behaviors
Chronic resentment
619
What are potential consequences of unmanaged anger?
Strained or damaged relationships
Job loss or disciplinary issues
Legal problems
Safety concerns (to self or others)
620
What are examples of adaptive anger control strategies?
Healthy communication techniques
Relaxation methods (deep breathing, mindfulness)
621
What are examples of maladaptive anger control strategies?
Substance use
Social withdrawal
Avoidance of conflict resolution
622
What early life factors might contribute to chronic anger?
Trauma history
Insecure attachment styles
Negative thought patterns learned in early relationships
623
What are common physiological signs of anger?
Muscle tension
Flushed skin
Clenched jaw or fists
Rapid breathing or heart rate
624
What should be assessed in a safety/risk evaluation for anger?
Violent ideation
Risk of self-harm
Potential for harm to others
625
What should be included in a substance use history?
Age of first use, frequency and amount of use, route of administration (oral, inhalation, injection, etc.), current use status.
626
What physical and psychological signs may indicate substance use?
Physical: Injection sites, poor hygiene, slurred speech. Psychological: Cravings, mood swings, anxiety, or irritability.
627
How is functional impact of substance use evaluated?
By assessing how use affects work performance, academic functioning, relationships, and legal status.
628
What should be explored under motivation and readiness to change?
Past quit attempts, barriers to quitting (e.g., lack of support, withdrawal symptoms), stage of change (e.g., precontemplation, contemplation).
629
Why is it important to ask about family history in a substance use assessment?
To identify multigenerational patterns and genetic predisposition to substance use disorders.
630
What medical conditions should be screened for in individuals with substance use?
Liver disease (e.g., from alcohol use), infections (e.g., HIV, Hepatitis B/C from IV drug use), history of overdose.
631
What are common psychiatric comorbidities with substance use disorders?
Mood disorders (e.g., depression, bipolar disorder), PTSD, psychosis, ADHD.
632
What factors are assessed during a risk assessment in substance use cases?
Withdrawal danger (e.g., alcohol, benzodiazepines), risk of overdose, harm to self or others.
633
What mood-related symptoms are commonly associated with depression?
Persistent sadness
Feelings of hopelessness
Feelings of worthlessness
634
What is anhedonia, and how does it relate to depression?
Anhedonia is the loss of interest or pleasure in previously enjoyable activities—a core feature of depression.
635
What are examples of vegetative signs in depression?
Appetite changes (increase or decrease)
Sleep disturbances (insomnia or hypersomnia)
Fatigue
Psychomotor agitation or retardation
636
What are common cognitive symptoms of depression?
Difficulty concentrating
Indecisiveness
Repetitive negative thoughts
637
What are somatic complaints often seen in depression?
Headaches
Gastrointestinal distress
These often occur without an identifiable physical cause.
638
What questions are important when assessing for suicidality?
Do you have thoughts of harming yourself (ideation)?
Do you have a plan?
Do you have the intent to follow through?
Have you had any past suicide attempts?
639
What are some known risk factors for depression?
History of trauma
Family history of depression or suicide
Recent losses (e.g., death, job loss)
Chronic stressors
640
What areas of functioning should be evaluated in depression?
Ability to maintain employment or school performance
Personal hygiene and self-care
Managing daily responsibilities at home or in relationships
641
What are the core psychological symptoms of anxiety?
Excessive worry, Restlessness, Fatigue, Muscle tension, Irritability
642
What are common physical symptoms of anxiety?
Sweating, Palpitations, Shaking, Sleep disturbances
643
What should be assessed when identifying anxiety triggers?
Specific environments, situations, or thoughts that heighten anxiety or provoke panic.
644
What are common types of anxiety disorders?
Generalized Anxiety Disorder (GAD), Social Anxiety Disorder, Panic Disorder, Phobias, Obsessive-Compulsive Disorder (OCD), Post-Traumatic Stress Disorder (PTSD)
645
What should be assessed in the history and course of anxiety symptoms?
Onset and duration, Symptom fluctuation over time, Precipitating events or stressors
646
What are common maladaptive coping mechanisms in anxiety?
Avoidance behaviors, Compulsions (especially in OCD), Substance use
647
How can anxiety affect daily functioning?
It may disrupt work, school performance, and interpersonal relationships.
648
What disorders commonly co-occur with anxiety?
Depression, Substance use disorders, Chronic medical illnesses (e.g., IBS, cardiovascular conditions)
649
What safety concerns should be evaluated in someone with anxiety?
Suicidal thoughts triggered by panic or hopelessness, Inability to function in daily life, Potential for self-harm due to overwhelming fear or avoidance
650
What tools are used to assess level of consciousness?
AVPU scale (Alert, Verbal, Pain, Unresponsive)
Glasgow Coma Scale (GCS)
651
What are the components of orientation in a mental status exam?
Person
Place
Time
Situation
652
How is attention and concentration assessed?
Serial 7s (counting backward by 7s)
Digit span test (repeat numbers forward and backward)
653
What types of memory are evaluated in the MSE?
Immediate recall
Short-term memory (e.g., 5-minute recall)
Long-term memory (e.g., historical events, personal history)
654
What aspects of speech are assessed in the MSE?
Clarity
Coherence
Articulation
655
What are some types of thought process abnormalities?
Tangential thinking (goes off-topic)
Circumstantial thinking (includes excessive detail)
Flight of ideas (rapidly shifting thoughts)
656
What are examples of abnormal thought content?
Delusions
Hallucinations
Obsessions
Suicidal or homicidal ideation
657
What is assessed under mood and affect?
Mood = internal emotional state (self-reported)
Affect = external expression (congruence, intensity, stability)
658
What types of hallucinations are evaluated under perception?
Auditory
Visual
Tactile
659
What is meant by insight in a mental status exam?
The patient’s awareness of their condition or symptoms.
660
How is judgment evaluated?
By assessing the patient’s ability to make safe and logical decisions (e.g., hypothetical scenarios).
661
What are the clinical purposes of the Mental Status Exam?
To differentiate psychiatric vs. medical vs. neurological causes of altered mental status
To detect delirium, psychosis, or cognitive impairment
662
What are the main purposes of conducting an IPV assessment?
To ensure patient safety, identify abuse-related trauma, address various forms of harm (physical, sexual, emotional, financial), evaluate risk level and support needs, and fulfill mandatory reporting when applicable.
663
What are validated tools used for IPV screening?
HITS (Hurt, Insult, Threaten, Scream), Abuse Assessment Screen (AAS), Danger Assessment Tool.
664
How should IPV screening be conducted?
Ask questions in private (without partners or children present) and use a nonjudgmental tone.
665
What are some sample IPV screening questions?
"Do you feel safe in your current relationship?"
"Has anyone ever hurt you physically or made you feel afraid?"
"Has a partner ever forced you into sexual activity against your will?"
"Is anyone controlling your finances, work, or who you see?"
666
What are some examples of physical abuse?
Hitting, slapping, choking, restraining.
667
What defines emotional/psychological abuse?
Threats, insults, gaslighting, intimidation.
668
What constitutes financial abuse?
Controlling access to money, stealing assets.
669
What is stalking in the context of IPV?
Repeated unwanted contact or surveillance behaviors.
670
What are forms of abuse affecting vulnerable groups?
Child abuse: neglect, physical harm, harsh discipline; Elder abuse: neglect, physical harm, financial exploitation; Human trafficking: forced labor or sexual exploitation.
671
What details should be gathered in an abuse history?
Nature of abuse (what happened, methods used), frequency and duration, severity (injuries, threats, escalation), use of weapons or strangulation, victim's resistance efforts.
672
What are best practices for documentation in IPV cases?
Use nonjudgmental, objective language, record direct quotes when possible, avoid assigning blame.
673
What are high-risk indicators for lethality in IPV cases?
Access to weapons, strangulation attempts, threats to kill, stalking or obsessive behaviors, recent attempt to leave, pregnancy.
674
What are components of a safety plan?
Safe contacts and emergency shelters, escape routes, social work or advocate involvement.
675
How does IPV impact mental health?
Can cause PTSD, anxiety, depression, and suicidal ideation.
676
What physical effects may result from IPV?
Injuries, chronic pain, somatic complaints (headaches, GI symptoms).
677
How can IPV affect daily functioning and parenting?
Impaired ability to work or maintain relationships, parental stress or danger to children, disrupted sleep and nutrition.
678
What are demographic risk factors for IPV?
Female gender, young age, LGBTQ+ status.
679
What life stages increase vulnerability to IPV?
Pregnancy, childhood, elderly age.
680
What social and psychiatric factors raise IPV risk?
Isolation, lack of support, depression, PTSD, substance use.
681
How does economic or immigration status influence IPV risk?
Poverty, housing instability, fear of deportation, language barriers.
682
What role does disability play in IPV risk?
Individuals with physical, cognitive, or sensory impairments are at higher risk.
683
What are examples of trusted individuals that can support IPV victims?
Family members, friends, case managers.
684
What community resources support IPV survivors?
Domestic violence shelters, hotlines, support groups.
685
What legal resources may be available to victims?
Protective orders, custody services, legal aid.
686
What should a comprehensive safety plan include?
Emergency contact numbers, safe places to go, transport arrangements.
687
What types of abuse are typically mandated for reporting?
Child abuse or neglect, elder or dependent adult abuse, abuse of vulnerable individuals.
688
Who must be notified when mandatory reporting laws apply?
Child Protective Services (CPS), Adult Protective Services (APS), law enforcement, if required.
689
What are best practices for documenting abuse disclosures?
Use objective language, include exact quotes from the patient, document date, time, and who was contacted, describe behaviors, injuries, and verbal statements.
690
What should nurses do during every patient encounter related to IPV?
Screen all patients routinely and privately, use a nonjudgmental, trauma-informed approach.
691
What should be included in an interdisciplinary IPV response?
Collaboration with social work, psychiatry, and advocacy services.
692
Why is follow-up care essential in IPV cases?
To monitor safety, ensure continuity of care, and assess treatment progress.
693
What percentage of total caloric intake should come from carbohydrates?
45–65% of total calories.
694
What is the recommended daily protein intake based on body weight?
0.8–1.2 g/kg of body weight.
695
What percentage of daily calories should come from fats?
20–35% of total caloric intake.
696
Why is it important to prioritize complex carbohydrates over simple sugars?
Complex carbs provide longer-lasting energy, more nutrients, and are higher in fiber.
697
What should be evaluated when assessing protein intake?
Source (animal vs. plant)
## Footnote
Adequacy, especially in illness, wound healing, and aging.
698
What types of fats should be emphasized for a healthy diet?
Unsaturated fats, such as omega-3s and olive oil.
699
Which fats should be limited or avoided in a nutritional plan?
Saturated fats and trans fats, due to their association with cardiovascular risk.
700
What signs may indicate iron deficiency?
Anemia
Fatigue
Pallor
Heavy menstrual bleeding.
701
In which populations is vitamin B12 deficiency most commonly monitored?
Vegans
Individuals post-gastric surgery
Elderly
People with GI disorders (e.g., Crohn’s).
702
What symptoms or risks are associated with calcium and vitamin D deficiencies?
Bone weakness or osteoporosis
Muscle cramps
Poor bone development or maintenance.
703
What vitamin deficiencies are indicated by bruising easily?
Deficiency in vitamin C or vitamin K.
704
What might peripheral neuropathy signal in terms of micronutrient deficiency?
A B-vitamin deficiency (especially B1, B6, or B12).
705
What does night blindness suggest about a patient's vitamin status?
Possible deficiency in vitamin A.
706
What is the recommended daily fluid intake for adults based on body weight?
30–35 mL/kg/day.
707
What are common signs of dehydration?
Decreased skin turgor
Dry mucous membranes
Tachycardia
Hypotension
Confusion.
708
Under what conditions are fluid needs increased?
Fever
Vomiting or diarrhea
Heavy exercise
Hot or humid climates.
709
What is considered significant unintended weight loss?
More than 5% of body weight lost in 1 month
More than 10% lost in 6 months
710
What are common symptoms of insufficient nutrition?
Poor wound healing
Fatigue
Weakness
711
What factors commonly contribute to undernutrition?
Dysphagia
Oral health issues
Loss of appetite
Financial hardship or food insecurity
712
What BMI value may indicate protein-calorie malnutrition?
BMI less than 18.5 kg/m²
713
What are examples of anthropometric indicators of PCM?
Low BMI
Reduced mid-arm muscle circumference
Loss of subcutaneous fat
714
What dietary factors are assessed in PCM?
Inadequate protein/calorie intake
GI symptoms that limit intake (e.g., nausea, diarrhea)
715
What are common biochemical lab findings in PCM?
Low albumin, prealbumin, transferrin
Anemia
Micronutrient deficiencies
716
What physical signs may be observed in PCM?
Muscle wasting
Dry skin, brittle hair or nails
Edema
Impaired immunity
Frequent infections
717
What aspects of oral health are evaluated in a nutrition screen?
Dental status (missing teeth, cavities)
Dentures (fit and condition)
Mucosal lesions or sores
718
What signs indicate swallowing dysfunction?
Coughing, choking, or throat clearing while eating
Pocketing food in the cheeks
719
What tools help assess swallowing safety?
EAT-10 Questionnaire
Bedside swallow screen
720
What should be considered if there is a delayed swallow trigger?
Speech therapy referral
Use of modified texture diets (e.g., pureed or thickened liquids)
721
What tool uses food group categories to assess meal composition?
MyPlate Guidelines – evaluates fruits, vegetables, grains, protein, and dairy based on age, gender, and activity level.
722
What is a strength and limitation of the 24-hour diet recall?
Pro: Quick snapshot of recent intake
Con: May not reflect usual eating habits
723
What should be documented during a 24-hour recall?
Portion sizes
Meal timing
Preparation methods
724
How does a food diary (3–7 days) help in dietary assessment?
Provides comprehensive data and is best for long-term planning and counseling.
725
What are the BMI categories for overweight and obesity?
Overweight: 25–29.9
Obesity: 30 or higher
726
At what waist circumference is metabolic risk increased?
≥ 40 inches in men
≥ 35 inches in women
727
What comorbidities should be screened for in obesity?
Type 2 diabetes
Hypertension
Hyperlipidemia
728
What psychosocial or hormonal factors can contribute to excess weight?
Emotional eating
Thyroid dysfunction
Weight-gain-promoting medications
729
What BMI typically indicates anorexia nervosa?
BMI <17.5
730
What physical signs are common in anorexia?
Dry skin, hair thinning, brittle nails
Lanugo (fine body hair)
Bradycardia, hypotension
731
What lab findings are common in anorexia?
Hypokalemia
Low glucose
Suppressed estrogen/testosterone
732
How does weight typically present in bulimia nervosa?
Normal or fluctuating weight
733
What physical signs are associated with bulimia?
Dental erosion
Swollen parotid glands
GI symptoms (e.g., bloating, constipation)
734
What lab abnormalities are seen in bulimia?
Metabolic alkalosis (↑ bicarbonate)
Hypokalemia (↓ potassium)
735
What dietary factors contribute to hyperlipidemia?
Intake of saturated fats, trans fats, and dietary cholesterol.
736
How does alcohol use affect lipid levels?
Excess alcohol raises triglycerides.
737
What values are included in a lipid panel?
Total cholesterol
LDL
HDL
Triglycerides
738
What are some secondary causes of hyperlipidemia?
Diabetes
Hypothyroidism
Certain medications (e.g., steroids)
739
What tools are used for dietary assessment?
24-hour recall
MyPlate
Food diary
740
What are examples of anthropometric measures?
BMI
Waist circumference
Mid-arm circumference (MAC)
741
What clinical signs may indicate malnutrition?
Hair, skin, nails abnormalities
Mucosal changes, edema
742
What are common biochemical indicators in nutrition assessment?
Albumin, prealbumin
Electrolytes
743
What are functional signs of poor nutrition?
Low activity tolerance
Impaired ADLs
Poor immune function
