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NURS 300 - Health Assessment > Exam 1 > Flashcards

Exam 1 Flashcards

Chapters 1-6, 9-12, 15

1
Q

What is health assessment?

A

Gathering info about the health status of the Pt, analyzing & synthesizing those data, making judgments about nursing interventions based on the findings & evaluating patient care outcomes

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2
Q

What are the roles for the generalist nurse? (5)

A
  1. provider of care
  2. manager/coordinator/designer of care
  3. member of a profession
  4. advocate
  5. educator
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3
Q

What are the (4) core values of nursing?

A
  1. caring
  2. diversity
  3. integrity
  4. excellence
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4
Q

What are the (4) main goals of nursing?

A
  1. promote health
  2. prevent illness
  3. treat human responses to health and illness
  4. advocate for individuals, families, and communities
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5
Q

What is the nursing process?

A

Assessment
Diagnosis
Outcome Identification
Planning
Implementation
Evaluation

acronym ADPIE

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6
Q

List (3) actions to take during the analysis/diagnosis or data collection step

A
  1. recognize patterns or trends
  2. compare the data w/ expected standards or reference ranges
  3. arrive at conclusions to guide nursing care

ATI

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7
Q

List (4) factors to consider during the evaluation step when clients have not achieved their goals

A
  1. an incomplete database
  2. unrealistic outcomes
  3. nonspecific nursing interventions
  4. inadequate time for the client to achieve the outcomes

ATI

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8
Q

What is diagnostic reasoning?

A

A process in which nurses use critical thinking to cluster the assessment info and to draw inferences and propose diagnosis

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9
Q

The clinical judgment model used in the NGN style questions forms ______, ______ them, generates _____, and then takes ______.

A
  1. hypothesis
  2. prioritizes
  3. solutions
  4. action
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10
Q

What is subjective data?

A

Based on the patient’s experiences and perceptions

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11
Q

What is objective data?

A

Measurable and usually collected as part of the physical assessment

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12
Q

Assessment is all about collecting subjective and objective data. What are the (3) types of assessment?

A
  1. emergency
  2. comprehensive
  3. focused
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13
Q

Organizing frameworks for assessment include (3):

A
  1. functional
  2. head-to-toe
  3. body systems
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14
Q

Active listening, restatement, reflection, elaboration, silence, focusing, clarification, and summarizing are all techniques of ________, __________ communication

A

verbal, therapeutic

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15
Q

Physical appearance, facial expression, posture and position in relation to the patient, gestures, eye contact, tone of voice, and use of touch are all components of _______, _______ communication

A

non-verbal, therapeutic

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16
Q

What are the (8) nontherapeutic responses?

A
  1. False reassurance
  2. Sympathy
  3. Unwanted advice
  4. Biased questions
  5. Changing the subject
  6. Distractions
  7. Technical or overwhelming language
  8. Interrupting
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17
Q

What is false reassurance?

A

Provides comfort or assurance to another person about something that is not based on fact; unconsciously indicates pt’s concerns are not worth discussing and can enhance anxiety

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18
Q

T/F - Intercultural communication requires sensitivity to and knowledge of specific cultures, including language challenges, health beliefs, and gender issues

A

True

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19
Q

The (4) phases of the interview process include the:

A
  1. preinteraction phase
  2. beginning phase
  3. working phase
  4. closing phase
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20
Q

What happens during the preinteraction phase?

A

The nurse collects data from the medical record, including previous history of medical illnesses or surgeries, current medication list, and problem list

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21
Q

What happens during the beginning phase?

A

The nurse introduces themselves and states the purpose of the interview

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22
Q

What happens during the working phase?

A

-The nurse collects data by asking specific close-ended or open-ended questions
-The nurse charts the patients history and health problems

note avoid ‘why’ questions (i.e. why haven’t you stopped smoking)

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23
Q

What happens during the closing phase?

A

-The nurse ends the interview by summarizing and stating what the 2-3 most important patterns or problems
-The nurse informs the patient of the next steps
-The nurse asks the patient if they need anything else

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24
Q

T/F - Charts and information form family members are considered primary data and information from the patient is considered secondary data.

A

False

the individual patient is the source of primary data, charts and info from family is secondart

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25
Q

What are the (3) types of health history?

A
  1. Emergency
  2. Focused*
  3. Comprehensive**

*patient sees their primary care for a cough
**takes place during an annual physical exam, like sports physicals. It is also taken during a hospital admission.

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26
Q

The reason for seeking care, history of present illness (OLDCAARTSS), past health history, current medications and indications, family history, functional health assessment, growth and development, and ROS are all components of what?

A

comprehensive/complete health history

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27
Q

The history of present illness includes assessment: (OLDCAARTSS)

A

Onset
Location
Duration
Character/quality
Associated factors
Aggravated/alleviating
Radiating
Timing
Severity/quantity
Setting

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28
Q

Assessment of health perception, nutrition, elimination, activity, sleep, cognition, self perception, roles, sexuality, coping and values are all components of the _________ health assessment.

A

functional

note this focuses on the effects that health/illness have on a patients quality of life

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29
Q

What are ADLs?

A

actives of daily living like eating, dressing, and grooming

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30
Q

What is ROS?

A

review of systems; series of questions about all body systems that help reveal concerns as part of a comprehensive health assessment

31
Q

T/F - Hearing impairments, decreased level of consciousness, cognitive impairments, anxiety, anger, alcohol/drug use, personal boundaries, and sexual aggression are some communication challenges.

A

True

32
Q

What is a genogram?

A

a common tool used to understand a family history by the use of symbols

note similar to a family tree, “X” can symbolize death while connecting lines b/w two names mean a marriage

33
Q

What is the most important action to prevent nosocomial infections?

A

hand hygiene

34
Q

T/F - I do not need to used the standard precautions with every patient if they do not have an infection

A

False

note treat every patient the same bc you may have something on your hands from another patient that you can transfer or patient may not be showing Sx yet

35
Q

T/F - Latex glove allergies are more common in nurses and other healthcare providers than general public

A

True

36
Q

_______ _______ and personal distancing are methods to protect providers and others

A

source control

37
Q

What are the (4) techniques of physical assessment?

A
  1. inspection
  2. percussion
  3. palpation
  4. ausculation
38
Q

_______ relies on vision and smell to assess general status as well as each body system

A

inspection

39
Q

Nurses use _______ palpation to obtain an overall impression and _______ palpation to assess pain, masses, and tumors

A

light, deep

40
Q

Sounds that vary based on tone, intensity, pitch, quality, duration, and location refer to _______

A

percussion

41
Q

Medium-loud amplitude, low pitch, clear/hollow quality, with moderate duration over normal lung tissue:

A

resonant

42
Q

Louder amplitude, lower pitch, booming quality, longer duration, found normal over child’s lung but abnormal in the adult, found over lungs with increased amount of air, as in emphysema:

A

hyperresonant

43
Q

Loud amplitude, high pitch, muscial/drumlike quality, sustained longest duration found over air filled viscus (the stomach, the intestine):

A

tympany

44
Q

What tool is used to identify sounds during auscultation of the heart, lungs, and abdomen?

A

stethoscope

44
Q

Very soft amplitude, hight pitch, absolute dullness quality, very short duration, found when no air is present, over thigh muscle, bone, or over tumor

A

flat

45
Q

On the stethoscope, the _______ is used for high-frequency sounds and the _______ is used for low-frequency sounds.

A

diaphragm, bell

46
Q

What tool enables the visualization of the interior structures of the eye?

A

opthamoscope

47
Q

What tool directs light into the ear to visualize the ear canal and tympanic membrane?

A

otoscope

48
Q

How would you insert an otoscope into an adults ear?

A
  1. use the largest speculum that will fit comfortably in the patient’s ear
  2. straighten the patients ear by pulling the auricle up, back, and slightly away from the head
  3. stick otoscope in pointing it slightly down and forward
  4. have patient title head towards opposite shoulder if needed
49
Q

How would you insert an otoscope into a child’s ear?

A
  1. use the largest speculum that will fit comfortably in the patient’s ear
  2. pull the auricle down and back to straighten ear canal
  3. pull the auricle by the earlobe if necessary
50
Q

What tool is used to determine vibration sense and hearing loss?

A

tuning fork

51
Q

What tool is used to test neurological responses of the deep tendons to assess for abnormalities of the central or peripheral nervous system?

A

reflex hammer

*used on knee, ankle, brachial, elbow, and wrist tendons
**most common type is Taylor hammer

52
Q

T/F - The patient record serves many purposes other than a legal document.

A

True

note serves as communication, care planning, quality assurance, financial reimbursement, education, and research

53
Q

Why does the computerized patient record help ensure patient safety and enhance communication?

A

because it is legible, time dated, increases compliance, permits multiple simultaneous users, and permits surveillance of patient data to identify patients at risk

54
Q

_______ _______ and _______ _______ are important in appropriately communicating and documenting assessment data to keep patients safe.

A

critical thinking, clinical judgement

55
Q

List at (3) critical thinking skills for each of the five steps of the nursing process: ASSESSMENT

A

1.
2.
3.

56
Q

List at (3) critical thinking skills for each of the five steps of the nursing process: DATA COLLECTION

A

1.
2.
3.

ATI

57
Q

List at (3) critical thinking skills for each of the five steps of the nursing process: PLANNING

A

1.
2.
3.

ATI

58
Q

List at (3) critical thinking skills for each of the five steps of the nursing process: IMPLEMENTATION

A

1.
2.
3.

ATI

59
Q

List at (3) critical thinking skills for each of the five steps of the nursing process: EVALUATION

A

1.
2.
3.

ATI

60
Q

Documentation should have these (7) characteristics:

A
  1. accurate
  2. objective
  3. organized
  4. concise
  5. complete
  6. legible
  7. follow HIPAA guidelines
61
Q

What is HIPAA?

A

-stands for the Health Insurance Portability and Accountablity Act of 1996
-regulates all areas of information management, including reimbursement, coding, and security of records

62
Q

T/F - A nurse stated “four of my patients on my last shift had MRSA” to her best friend who is an middle school teacher at a public bar. Has she violated HIPAA?

A

True

*though no names were given you should never discuss patients or their situations in public spaces, especially with those not involved in the patient’s care

63
Q

What are some formats of nurse progress notes?

A

narrative, SOAP notes, PIE notes, DAR notes

64
Q

What does the format SOAP stand for?

A

Subjective assessment findings
Objective assessment findings
Analysis of the assessment data to identify a problem or indicate whether the problem is improving the problem
Plan for treating or improving the problem

65
Q

What does the format PIE stand for?

A

Problem
Interventions
Eevaluation

66
Q

What does the format DAR stand for?

A

Data
Action
Response

67
Q

T/F - Handoffs occur when one care provider transfers the responsbility for patient care to another provider.

A

true

68
Q

What is SBAR?

A

S
B
A
R

note it’s a mental model for organizing communication

69
Q

Verbal communication of patient status occurs at (4):

A
  1. at handoff
  2. over the phone
  3. over text message
  4. during rounds
70
Q

When does the general survey begin and end?

A

within the first moments of patient encounter, progresses through the history and physical examination, and continues with each subsequent interaction

71
Q

What are the (6) vital signs? What are their normal ranges?

A
  1. temp (97.7-98.6F / 36.5-37C)
  2. HR (60-100)
  3. RR (12-20)
  4. BP (<120/70)
  5. O2 (94%+)
  6. pain

note vital signs may vary on a number of things. ask what their normal is if out of ranges.

72
Q
A

NURS 300 - Health Assessment (4 decks)

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