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health assessment > exam 1 > Flashcards

exam 1 Flashcards

1
Q

which of the following DOES NOT define health assessment ?

A

last step of the nursing process-evaluation

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2
Q

the purpose of the health history is to collect subjective data, which is?

A

what the person says about themselves “”

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3
Q

what is the definition of holistic health?

A

body, mind and spirit part of a whole within the environment

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4
Q

TRUE or FALSE: critical thinking is the process of purposeful thinking and reflective reasoning where practitioners exam ideas, assumptions, principles, conclusions, beliefs, and actions on the context of nursing practice.

A

true

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5
Q

under the requirements of HIPPA, client information may be shared among health care providers

A

if the team member is directly involved in the client’s care

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6
Q

a nursing database consist of all of the following EXCEPT

A

client safety

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7
Q

an emergency database is

A

an urgent, rapid collection of crucial information and is often compiled currently with lifesaving measures

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8
Q

the interview is considered a contract between you and your client. the terms of the contract include:

A
  • time and place of the interview
  • self-introduction and explanation of the role
  • purpose of the interview
  • participation expectations
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9
Q

TRUE or FALSE: open ended questions are used for specific information, short one or two word answers, just the facts, neutral interaction, and have minimal rapport building

A

FALSE. these answers describe close-ended questions

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10
Q

All of the following are interview traps or non-therapeutic communication EXCEPT:

A
  • using avoidance language
  • leading/biased questions
  • EMPATHY
  • false reassurance
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11
Q

a nurse is interpreting and validating information from an older adult client who has been experiencing a functional decline. the nurse is in which phase of the interview process?

A

working

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12
Q

when recording data during an interview, the nurse should

A

document as soon as possible

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13
Q

a client has just been admitted to the post surgical unit and the nurse is in the introductory phase of the client interview. which is the following activists should the nurse perform first?

A

explain the purpose of the interview

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14
Q

which of the following are components of the complete health history ?

A
  • biographical data
  • reason for seeking care
  • family history
  • review of systems
  • past history or history of present illness
  • functional assessment or ability to perform ADL
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15
Q

the 8 critical characteristics of a symptom include

A
  • location
  • character
  • severity and timing
  • setting
  • aggravating or relieving factors
  • associated factors
  • client perception
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16
Q

place the following focuses in the correct sequence in which the nurse should perform them when completing a health history, beginning with the sections obtained first

A
  1. biographic data
  2. reason for seeking care
  3. history of present illness
  4. past health history
  5. family health history
  6. review of body systems
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17
Q

you are performing an admission assessment on a 23 year old college student. you are reviewing developmental that appropriate for her age according to Erickson. a correct assessment is that the client should be…

A

making friends and establishing a social group

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18
Q

what must the nurse assess first when providing a culturally component health care to an Asian American client ?

A

the nurses’ heritage-based cultural values, beliefs, attitudes, and practices

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19
Q

which of the following basic functions should the nurse test FIRST in an assessment or mental status?

A

consciousness

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20
Q

which of these is a necessary tool for building cultural competence?

A

heritage assessment tool

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21
Q

the nurse understands the all of the following are components of a mental status assessment except ?

A

cultural background

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22
Q

it’s a clients second overdose in a month. the nurse says, “here we go again. i don’t know why we bother with this guy, because he will be back out there as soon as he is discharged.” the nurse…

A

must find a way to come to terms wit the way he or she feels about these type of issues and work on a way to deal with them

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23
Q

which of the following clients is at the highest risk for nutritional deficits?

A

a 65 year old female who is on a fixed income and is taking 5 medications

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24
Q

you are caring for an 80 year old client. his daughter expresses concerns about him as his wife recently passed away. you are reviewing developmental tasks appropriate for his age according to Erickson. a correct assessment is that the client should be able to…

A

adjusting to the death of spouse, family members, and friends

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25
Q

what is an integral factor in responding adequately to the health care needs of a 41 year old african american woman?

A

cultural competence

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26
Q

you are assessing the orientation of an 85 year old man. which of the following indicates that he is oriented to person, place, time, and situation? the client …

A

he knows his own name, states he is in a historical and knows which hospital, knows the date, and states he had a heart attack

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27
Q

a muslim woman has been hospitalized. to provide culturally sensitive care, when making staff assignments the nurse should. (select all that apply).

A
  • assign a female care assistant

- inform the care assistant of the client’s need to wear her veil when other visitors enter the room

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28
Q

while mentoring a colleague in the clinical setting he asks what questions would be appropriate to help in evaluating a client’s spiritual health. a correct response would be, ask the client:

A

is this illness cashing any major life changes for you or a loved one?

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29
Q

you are caring for a 38 year old Hispanic client. in order to demonstrate understanding of two step cultural competence, you should:

A

examine the client within the context of his/her cultural health and illness practices.

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30
Q

the expression of pain varies among cultures

A

true

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31
Q

a client is admitted with a drinking problem. which statement by the nurse would be most appropriate?

A

i believe that you have a drinking problem and strongly recommend that you quit drinking. i am willing to help.

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32
Q

you are caring for a client who is in liver failure. she has been crying and wants you to fall the chaplain. you understand that a chaplain can resulted:

A
  • if a client received a new diagnosis of a terminal illness
  • if a client has issues about current faith or beliefs
  • if a client is extremely worried, angry or upset
  • if a client/significant other requests to see a chaplain
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33
Q

the rn is caring for an asian client who refuses to make eye contact during conversations. how should the rn assess the client’s response?

A

the client is treating the nurse with respect

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34
Q

a client comes into the clinic with complaints of nausea. she also states that she has lost her appetite for good. what other information can you elicit to perform a nutritional?

A
  • what are your normal eating habits?
  • any vomiting, constipation, or diarrhea?
  • notice any changes in taste, smell, chewing or swallowing?
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35
Q

which of the following is the best way to document a client appearance?

A

tense posture; clothing is clean; wearing light cotton tee shirts, shorts, shoes or coat

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36
Q

the nurse is assessing a 43 year old client who is 5’4” and weighs 274 pounds. his bp is 180/74 and he is complaining of back pain. what other risk factors should this client be concerned with considering his history ?

A
  • type II diabetes mellitus
  • coronary artery disease
  • colon cancer
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37
Q

you have been approached by a client’s spouse who is concerned about his “excessive drinking.” you know that all of the following are appropriate interventions EXCEPT:

A

inform the spouse that the client will be okay (promise)

38
Q

the nurse is assessing a client who admits to being physically abused by her spouse. the client says, “i wish i would have agreed with my husband, because then i wouldn’t have been hit.”. what is the nurse’s best response?

A

“it is not your fault that your husband lost control. changing your actions will not prevent him from abusing you again.”

39
Q

as a mandatory reporter of elder abuse, which of these must be present before a nurse notifies the authorities?

A

suspicion of elder abuse or neglect

40
Q

when documenting intimate partner violence and elder abuse, the nurse should include:

A

photographic documentation of injuries

41
Q

which of the following are health effects of violence experienced by older adults that have been abused or neglected? select all that apply

A
  • STI’s
  • fluctuations in bp and pulse
  • infectious progressing to sepsis
  • cardiac complication due to stress
42
Q

the nurse works at a clinic where routine, universal screening for intimate partner violence is done. how often should the nurse screen women coming into the office?

A

every health encounter

43
Q

a client is being assessed for range of joint movement. the nurse asks him to move his arm in toward the center of his body. this movement is called:

A

adduction

44
Q

a client tells the nurse that she is having a hard time bringing her hand to her mouth when she eats or tries to brush her teeth. the nurse knows that for her to move her hand to her mouth, she must perform which movement ?

A

flexion

45
Q

the nurse suspects that a client has carpal tunnel syndrome and wants to perform the Phalen’s test. to perform this test, the nurse should instruct the client to:

A

hold both hands back to back while flexing the wrists for 60 seconds

46
Q

when assessing muscle strength, the nurse observed that a client has complete rant of motion against gravity with full resistance. what grade should the nurse record using a “0 to 5” point scale?

A

5

47
Q

An 85-year-old client comments during his annual physical that he seems to be getting shorter as he ages. The nurse should explain that decrease tight occurs with aging because:

A

Of the shortening of the vertebral column

48
Q

The nurse is preparing to perform ROM On a client who is paralyzed from the waist down. Which type of ROM Would be most appropriate to perform on this patient’s upper extremities and Lower extremities?

A

passive ROM Le, active ROM UE

49
Q

The nurse is bathing an 80-year-old man and notices that his skin is wrinkled, thin, lax and drive. This finding would be related to which factor?

A

And increase loss of elastin and a decrease in subcutaneous fat in the elderly

50
Q

An elderly woman is brought to the emergency department after being found lying on the kitchen floor two days, and she’s extremely dehydrated. What would the nurse expect to see upon examination?

A

Dry mucous membranes and cracked lips

51
Q

A 52-year-old woman has a papule on her nose that has rounded, pearly borders and central red ulcer. She said that she first noticed it several months ago and that it has slowly growing larger. The nurse the suspects which condition?

A

Basal cell carcinoma

52
Q

The nurse is teaching her client about skin self examination. The client asked how often she should perform this assessment on her self. The nurse answers:

A

You should perform monthly skin checks

53
Q

When assessing an African-American patient, the nurse and is it the best way to assess for cyanosis is to:

A

Assess conjunctivae, oral mucosa and nail beds

54
Q

A client is admitted with a new skin lesion. Using the ABCDEF method, the nurse knows that one of the signs of melanoma would be:

A

Border irregularity

55
Q

Bio medical model

A

Cause and affect

56
Q

magicorerelogious approach

A

Supernatural

57
Q

Holistic health

A

Body, mind and spirit part of the whole within the environment

58
Q

What is health assessment?

A
  • First step of nursing
  • In nursing, usually means collecting data related to a persons health
  • Data collection using all of your senses
  • Requires careful observation, listening, feeling, smelling
  • Types of data: objective and subjective
59
Q

What does a patient database consist of?

A
  • Subjective data
  • Objective data
  • Patient records
  • Laboratory and other diagnostic test results
60
Q

Types of databases

A
  • Complete our total health
  • Focus or problems centered: mini database
  • Follow up
  • Emergency
  • Depends on: clinical situation, patient presentation and location
  • Examples: clinic, ER, trauma center, crisis, wellness exam, home health, critical situation/crisis, etc.
61
Q

The nursing process

A 
Assessment 
diagnosis
outcome identification
planning
implementation
Evaluation
62
Q

Critical thinking

A

Sounds judgements.
No protocol you can memorize
Develop tools to make sound decisions-ex case studies
Requires to put assessment tools together

63
Q

Interview process

A

Most important part of data collection
Initiate contact with patient to collect subjective data
Gather complete and accurate data about health state
Interview contract-what the patient needs and excepts from their health care

64
Q

Parts of the interview

A

Introduction-briefly explain process, purpose of interview, how long it will take, who will be there, any physical exam that maybe required
(interview)Working phase/body-gather data, use verbal skills, ask questions
Open ended questions
Closed/direct

65
Q

Internal factors that affect communication

A

Empathy
Liking others
Listening ability
Self awareness

66
Q

External factors that affect communication

A

Related to interview environment/setting
Psychological privacy
Interruptions
HCP-dressed appropriate

67
Q

Interviewing traps

A

1.Giving unwanted advice
2.False assurance/reassurance
“If you were in my shoes what would you do?”-trap!!
3.Using authority “your doctor knows best”
4.using avoidance language
5.distancing -using the instead of your
6.using professional Jargon-HCP medical terms/adjust vocabulary
7.using leading/biased questions “you don’t smoke do you ?”
8.talking too much
9.interrupting
10.asking “why” questions

68
Q

Complete health history

A
  • date/time
  • biographical data
  • source(who is giving the information)
  • reason for seeking care
  • past health and history of present illness
  • past history
  • family history
  • review of symptoms
  • functional assessment
  • ADLs
69
Q

Biographical data

A
  • name
  • address
  • phone number
  • age/DOB
  • birthplace
  • gender
  • marital status
  • race
  • ethnic origin
  • occupation
70
Q

Present health or history of present illness

A 
Location
Character or quality 
Severity or quantity 
Timing 
Setting 
Aggravating or relieving factors
Client perception PQRSTU acronym
71
Q

PQRSTU

A 
P- provocative 
Q- quality and quantity
R- region
S-severity scale
T-timing
U-do you understand the patients pain
72
Q

Auscultation

A

Listening to sounds produced by the body

73
Q

Diaphragm-flat

A

Use for high pitched sounds
Breath sounds
Bowel sounds
Normal heart sounds

74
Q

Bell-raised

A

Use for low pitched sounds

Abnormal heart sounds

75
Q

Normal adult bp

A

120/80

76
Q

Neuroanatomic pathway pain

A

Originates-CNS, PNS

77
Q

Spiritual assessment

A

Spiritual wellness

  • faith/beliefs
  • life and self responsibility
  • life satisfaction
  • fellowship and community
  • rituals and practice
  • vocation
  • expectations
78
Q

JAREL spiritual well being scale

A

scale that has set questions to help get a better understanding of who may need spiritual support

79
Q

routine spiritual nursing assessment for patients

A

nurses gather data
triggering a chaplain consult
nurses use judgment
advance directive or durable power of attorney for health care decisions

80
Q

questions nurses might ask regarding spiritual health

A

tell me what life means to you
Are you in need of religious/spiritual or emotional support?
is this illness, causing any major life changes for you or a loved one?
have you had any major stress or change in lifestyle recently?
Is there anything we need to know that your religion, culture or background?

81
Q

Considerations for a chaplain referral

A 
New diagnosis of a terminal illness
issues about current faith or beliefs
extremely worried, angry or upset
patient/significant other request
Organ donation
82
Q

CAGE

A

cut down
annoyed
guilty
eye opener

brief

83
Q

heritage assessment tool

A
  1. do you mostly participate in social activities with members of your family?
  2. do you mostly have friends from a similar cultural background as you?
  3. do you mostly eat the food of your family‘s tradition?
  4. Do you mostly participate in the religious traditions of your family?
84
Q

R.E.S.P.E.C.T

A 
realize 
examine 
select
pace
encourage 
check 
touch 
JUST ASK
85
Q

cultural characteristics

A

culture is learned
culture is shared
culture is adapted
culture is dynamic

86
Q

mental status

A

emotional (feeling)
cognitive (knowing)
stressful or traumatic life event

87
Q

mental disorders

A

person has a greater than expected to reaction. occurs in a pattern and associated with some type of distress

88
Q

organic disorders

A

physiological basis
uti-can cause a person to become confused
dehydration-low sodium-confused
fever-delirious

89
Q

psychiatric mental illness

A

no clearly established etiology

depression

90
Q

aphasia

A

tests word comprehension-point to an object and have the patient name them
reading-read available print
writing-make up and write a sentence
higher intellectual functions

91
Q

mini mental state examination (MMSE)

A 
time orientation 
place orientation 
register/recall 3 words
serial 7s calculation
name object 
repetition 
comprehension
reading 
writing a sentence 
intersecting polygons

health assessment (4 decks)

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