Exam 1 Concepts

Question 1

nursing process

Answer 1

A ssessment
"D elicious" iagnosis
P lanning
I mplementation
E valuation

Question 2

ethnocentrism

Answer 2

tendency to view our own way of life as most acceptable

Question 3

non-verbal behaviors

Answer 3

eye contact, personal space, touch, facial expressions, gestures

Question 4

rules of etiquette - physically

Answer 4

ensure privacy, minimize interruptions, decrease noise, maintain 4-5 ft distance, equal status seating

Question 5

rules of etiquette - nonverbal (respecting values of others)

Answer 5

appearance, posture, gestures, facial expressions, eye contact, voice, touch

Question 6

communication pitfalls

Answer 6

AVOID: false reassurance, unwanted advice, using authority, avoidance language, distancing language

Question 7

communication pitfalls cont’d

Answer 7

AVOID: professional jargon, leading questions, talking too much, interrupting, why questions

Question 8

communication tools

Answer 8

open ended questions, reflecting, summarizing, SILENCE

Question 9

language barriers

Answer 9

use trained interpreter, speak directly to pt, document use of interpreter

Question 10

H and P parts

Answer 10

chief complaint, history of present illness, review of systems

Question 11

assessment of the mind

Answer 11

A ppearance S peech L evel of consc.
B ehavior T hought I nsight/judgement
C ooperation A ffect C ognition
M ood Knowledge
P erception E ndings (life)
R eliability

Question 12

echolalia

Answer 12

repetition of words/phrases

Question 13

clanging

Answer 13

rhyming w/o reason

Question 14

delusion

Answer 14

false fixed belief

Question 15

hallucination

Answer 15

complete fabrication of the mind

auditory, visual, tactile, olfactory

Question 16

illusion

Answer 16

misinterpretation of existing objects/ideas

Question 17

loose associations

Answer 17

words loosely connected

Question 18

neologism

Answer 18

creation of new words

Question 19

CAGE questionnaire

Answer 19

substance abuse assessment; may need to ask family member to step out of room
C utting down
A nnoyed others
G uilty
E ye opener

Question 20

signs of intoxication

Answer 20

ataxia, slurred speech, dulled concentration

usually oppose withdrawal symptoms

Question 21

NAT

Answer 21

nonaccidental trauma

Question 22

red flags for violence

Answer 22

physical findings inconsistent w/pt, family, or caregiver story
bruising in atypical places
patterned injuries

Question 23

physical assessment order

Answer 23

Inspection
Palpation
Percussion
Auscultation
*unless assessing abdomen, then auscultate 1st

Question 24

palpation (parts of hand)

Answer 24

fingertips: texture, moisture, swelling, masses
dorsa of hand/fingers: temperature
ulnar surface hand/fingers: vibration (d/t turbulent blood flow)

Question 25

temperature measurement

Answer 25

blue tips for oral/axillary
red for rectal
document route used in celcius
37 degrees is nml; 38.5 degrees celcius fever

Question 26

HR measurement

Answer 26

rate, rhythm, force

50-95 bpm nml

Question 27

respiratory rate measurement

Answer 27

noble lie

10-20 breaths/min nml

Question 28

NML vital signs

Answer 28

T 37c
HR 50-95bpm
RR 10-20 breath/min
BP <120/<80 mmHg

Question 29

nociceptive pain

Answer 29

pain related to tissue damage

Question 30

neuropathic pain

Answer 30

pain related to nerve damage

ex. shingles

Question 31

phantom limb pain

Answer 31

nerves w/o input d/t amputation still firing signals

Question 32

PQRST questions

Answer 32

P rovocation, palliation
Q uality
R egion, radiation
S everity
T iming

Question 33

FLACC scale

Answer 33

pain scale typically used for children under 7yrs
F ace
L egs
A ctivity
C ry
C onsolability

Question 34

nutritional assessments

Answer 34

calorie count

24-hour recall

Question 35

body mass index

Answer 35

30-<35 obese
25-<30 overweight
19-<25 normal