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NURS314 Assessment > Exam 1 > Flashcards

Exam 1 Flashcards

1
Q

data base

A

patient medical record and lab studies plus subjective and objective data

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2
Q

first priority

A

abc, vitals

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3
Q

second priority

A

risk of infection, safety and security

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4
Q

third priority

A

anything not first or second priority

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5
Q

when do you form a total health data base?

A

well child check or annual checkup

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6
Q

when do you form an episodic/focused or problem centered data base?

A

specialist-allergies

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7
Q

When do you form a Follow up data base?

A

after an episodic visit

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8
Q

Emergency data base

A

rapid compilation of data with life-saving measures if needed

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9
Q

six Phases of the Nursing Process

A 
Assessment-collect data, review clinical record, health history, physical exam, functional
Diagnosis-
Outcome Identification
Planning
Implementation
Evaluation
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10
Q

steps of cultural competency

A

• Understand one’s own heritage-based values, beliefs,
attitudes, & practices
• Identify meaning of “health” to patient
• Understand how health care system works
• Acquire knowledge about social backgrounds of
patients
• Become familiar with languages, interpretive services,
& community resources available to nurses & patients

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11
Q

list four types of databases

A

Complete (total Health) database-complete health history and full physical exam

Focused or Problem Centered Database-collect a mini database concerning only one main problem, one cue complex, or one body system

Follow up database- used to follow up on short term or chronic health problems

Emergency Database- rapid collection of data with lifesaving measures

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12
Q

a Successful Interview

A
  1. gather complete health data about health state, including description and chronology of any symptoms of illness
  2. Establish Rapport and trust
  3. Teach the person about the health state so the pt can participate in identifying problems
  4. Build rappport for continuing care-refills, follow-ups
  5. Begin teaching for health promotion and disease prevention
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13
Q

Ten Traps of Interviewing

A

False assurance disregards pt needs
Unwanted advice stalls problem solving
Biased questions leading
Talking too much
Using avoidance language avoid reality of situation
Using why questions puts person on defensive
Engaging in distancing-communicates fear-soften reality
Technical or professional Jargon confusing
Interrupting results in ineffective process
Using Authority-promotes dependency and inferiority

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14
Q

Purpose of a Complete Health History

A

establish rapport
collects subjective data
helps to view the client as a whole individual functioning within the environment
Serves as documentation for others

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15
Q

four techniques used in physical assessment

A

inspection-concentrated watching
palpation-
percussion-
ausculation

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16
Q

4 components of a mental status exam

A

appearance
behavior
cognitive function
thought processes and perception

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17
Q

Drug and alcohol assessment tools

A

audit-C
cage (cut down, annyed, guilty, eye-opener)
tweak (tolerance, worry, eye opener, amnesia, kut down)

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18
Q

effects of domestic violence

A 
Women with lifetime 
victimization experience 
were significantly more 
likely to report having
• Asthma
• Irritable bowel syndrome
• Diabetes
Both women & men with 
lifetime victimization 
experience were 
significantly more likely to 
report
• Frequent headaches
• Chronic pain
• Difficulty sleeping
• Activity limitations
• Self-assessed poor 
physical & mental health
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19
Q

CAGE test

A

cage (cut down, annoyed, guilty, eye-opener)

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20
Q

Mental Status Exam

A 
ABCT
Appearance
Behavior
Cognition
Thought Processes
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21
Q

4 Unrelated Words Test

A

this tests the person’s ability to lay down new memories. It is a highly sensivitve and valid memory test. After 5 mins, ask for the recall of the 4 words. then again at 10 then 30 mins. The normal response for persons younger than 60 is an accurate three-four word recall after a 5, 10, and 30 minute delay.

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22
Q

Most abused drug

A

alcohol

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23
Q

assess for IPV

A

at every healthcare encounter for women

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24
Q

Assessment Techniques (IPPA)

A

inspection
palpation
percussion
auscultation

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25
Q

Importance of Skin Assessment

A

skin is the body’s largest organ

guards the body from environomental stressors and adapts to other environmental influences

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26
Q

Genogram

A 
focus on questions relating to family history of 
coronary heart disease
hypertension
stroke
diabetes
obesity
blood disorders
breast/ovarian cancer
colon cancer
sickle cell
kidney disease
TB
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27
Q

Health History

Review of Symptom

A

purpose: 1) evaluate past and present state of health for each body system 2) double check in case any sig data were omitted in the Present Illness Section 3) evaluate health promotion practices

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28
Q

Health History:

Family history

A

identify diseases and conditions for which a patient may be at increased risk

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29
Q

Health History:

Past Health

A

may have residual effects on the current health state.

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30
Q

Childhood illnesses

A

measles, mumps, rubella, chickenpox, pertussis, and strep throat

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31
Q

Serious childhood illness that may have sequelae for the person in later years

A

rheumatic fever, scarlet fever, poliomyelitis

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32
Q

Health History: Present health or History of present illness

A

location, character/quality, quantity/severity, timing (onset, duration, frequency), setting (what brings symptoms on? shoveling snow?), Aggravating/Relieving Factors, Associated Factors (often review medications now), Patient’s Perception (how does this affect your daily activities)

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33
Q

Health History: Present Health or History of Present Illness
PQRSTUVW

A

PROVOCATION- what brings illness on?
QUALITY/QUANTITY-how does it look, feel sound? How intense is it?
REGION/RADIATION-where is it? does it spread?
SEVERITY SCALE-how bad is it on 1-10? is it getting worse?
TIMING- onset, duration, frequency
UNDERSTAND PATIENT’S PERCEPTION- what do you think it means? helps you assess patients’ levels of anxiety
VARIABLES-associated factors
WHERE-setting occurred

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34
Q

ABCDE of skin assessment

A 
asymmetry
border irregularity
color variation
diameter greater than 6 mm
elevation or enlargement
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35
Q

assess skin

A 
temperature
moisture
texture
thickness
edema
mobility and turgor
lesions
36
Q

cherry angiomas

A

small, smooth, and slightly raised bright red dots that commonly appear on the trunk in all adults older than 30 years.

37
Q

vitiligo

A

complete absence of melanin pigment in patchy areas of white or light skin on the face, neck, hands, feet, body folds, and around orifices. can occur in all races, although dark skinned people are more severly affected and potentially suffer a greater threat to their body image

38
Q

ashen grey color in dark skin or marked pallor in light skin

A

anemia, shock, arterial insufficiency

39
Q

pallor of impending shock accompanied by

A

rapid pulse rate
oliguria
apprehension
restlessness

40
Q

pallor of anemia accompanied by

A 
spoon nails
fatigue
exertional dyspnea
rapid pulse
dizziness
impaired mental function
41
Q

erythema

A

intense redness of the skin from excess blood (hyperemia) in the dialted superficial capillaries. expect to also find fever, local inflammation, and blushing

42
Q

erythemai

A

polycythemia, venous stasis, carbon monoxide poisoning, and extravascular presence of red blood cells (petechiae, ecchymois, hematoma)

43
Q

cyanosis

A

bluish, mottled color that signifies decreased perfusion means the tissue do not have enough oxygenated blood.

44
Q

cyanosis accompanied by

A

(indicates hypoxia) occurs with shock, heart failure, chronic bronchitis, congenital heart disease

45
Q

Jaundice

A

yellowish skin color indicates rising amounts of bilirubin in blood.

46
Q

jaundice accompanied by

A

light or clay-colored stool and dark, golden urine

47
Q

hyperthyroidism

A

skin is smoother and softer, like velvet

48
Q

hypothyroidism

A

skin feels rough, dry and flaky

49
Q

bilateral edema

A

consider heart or kidney failure

50
Q

unilateral edema

A

consider local or peripheral cause

51
Q

What do lesions with blue-green fluorescence indicate?

A

fungal infections

52
Q

clubbing of nails

A

occurs with congenital cyanotic heart disease and neoplastic and pulmonary disease. chronic lung inflammation, bronchial tumors, heart defects with left to right shunts. cause fragmented platelets to become trapped in the fingertip vasculature, releasing platelet-derived growth factor and promoting growth of vessels which shows as clubbing

53
Q

mongolian spot in infants

A

hyperpigmentation at the sacrum but sometimes on the abdomen, thighs, shoulders, or arms due to deep dermal melanocytes. generally fades during the first year

54
Q

cafe au lait spot in infants

A

a large round or oval patch of light brown pigmentation, but six or more of these spots, each with a diameter more than 1.5 cm are diagnostic of neurofibromatosis, an inherited neurocutaneous disease.

55
Q

harlequin color change in infants

A

occurs when the baby is in a side-lying position. The lower half of the body turns red and the upper half blanches with a distinct demarcation line down the midline

56
Q

Erythema toxicum in infants

A

common rash that appears in the first 3-4 days of life. sometimes called the flea bite, consists of timy punctate red macules and papules on the cheeks, trunk, chest, back, and buttocks.

57
Q

Acrocyanosis in infants

A

a bluish color around the lips, hands, and fingernails and feet and toenails. may last a few hours and disappears with warming

58
Q

Cutis marmorata in infants

A

transient mottling in the trunk and extremities in response to cooler room temperatures.

59
Q

persistant, generalized cyanosis in infants

A

indicates distress such as cyanotic congenital heart disease

60
Q

persistent or pronounced cutis marmorata in infants

A

occurs with down syndrome or prematurity

61
Q

green-brown discoloration of the skin, nails, and cord in infants

A

occurs with passing of meconium in utero, indicating fetal distress

62
Q

Jaundice in infants

A

jaundice on the first day of life may indicate a hemolytic disease
jaundice after two weeks of age may indicate biliary tract obstruction

63
Q

excessive sweating in children

A

may accompany hypoglycemia, heart disease, or hyperthyroidism

64
Q

Senile lentigines in seniors

A

liver spots
clusters of melanocytes that appear after extensive sun exposure
not malignant

65
Q

Keratoses in seniors

A

raised, thickened lesions that look crusty, scaly, and warty. Seborrheic keratosis looks dark, greasy, and stuck on
do not become cancerous

66
Q

actinic (senile or solar) keratosis

A

red/tan scaley plaques that increase over the years to become raised and roughened
premalignant and may develop into squamous cell carcinoma

67
Q

xerosis

A

dry skin in seniors

68
Q

acrochordons

A

skin tags

69
Q

sebaceous hyperplasia

A

consists of raised yellow papules with a central depression. they have a pebbly look.

70
Q

lymph node: preauricular

A

in front of the ear

71
Q

lymph node: posterior auricular

A

mastoid

72
Q

lymph node: occipital

A

at the base of the skull

73
Q

lymph node: submental

A

midline, behind the tip of the mandible

74
Q

lymph node: submandibular

A

halkway between the angle and the tip of the mandible

75
Q

lymph node: Jugulodigastric

A

under the angle of the mandible

76
Q

lymph node: Superficial cervical

A

overlying the sternomastoid muscle; chain of two

77
Q

lymph node: deep cervical

A

deep under the sternomastoid muscle; chain of three. have patient tip head toward the side being palpated

78
Q

lymph node: posterior cervical

A

in the posterior triangle along the edge of the trapezius muscle

79
Q

lymph node: supraclavicular

A

just above and behind the clavicle, at the sternomastoid muscle; have the patient hunch the shoulders and elbows forward

80
Q

when lymph nodes are abnormal, where do you look?

A

upstream of drainage for the source of the problem

81
Q

how to palpate lymph nodes

A

use gentle, circular motion of fingertips

82
Q

normal lymph nodes feel

A

movable, discrete, soft, and nontender

83
Q

respect of cultural competent assessment

A

Realize you must know heritage of yourself & patient

Examine patient within cultural context

Select simple questions & speak slowly

Pace questioning throughout exam

Encourage patient to discuss meaning of health &
illness with you

Check patient’s understanding & acceptance of
recommendations

Touch patient within boundaries of his or her heritage

84
Q

phases of the interview process

A

Pre-interaction phase
• Beginning phase
• Working phase
• Closing phase

85
Q

4 types of health history

A

COmPleTe health history
• inTeRvAl health history
• PROBlem-fOCused or chief complaint-focused health history
• sPeCiAl health history

86
Q

chief complaint

A 
A	short	statement	in	client’s	own	words	
•	symptom(s),	feeling(s),	or	need(s)
•	subjective	information
•	Record	exactly	as	stated	&	use	quotation	marks
•	This	is	not	a	diagnosis
•	“What	brought	you	here	today?”
87
Q

what characteristics are included in the summary of each client symptom?

A

pqrstuvw

NURS314 Assessment (2 decks)

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