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Health Assessment > Exam 1 Main Points > Flashcards

Exam 1 Main Points Flashcards

1
Q

validation of data entails
A. distinguishing normal from abnormal
B. making inferences
C. using an organized and comprehensive approach
D. checking the accuracy and reliability of the data

A

D

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2
Q

which critical thinking skill helps the nurse to see relationships among the data
A. validation
B. clustering related cues
C. identifying gaps in the data
D. distinguishing relevant from irrelevant

A

B

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3
Q

an example of subjective data is
A. decreased range of motion
B. crepitation in the left knee joint
C left knee has been swollen and hot for the past 3 days
D. Arthritis

A

C

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4
Q

which of the following is considered an example of objective data
A. Alert and oritented
B. dizziness
C. an ear ache
D. A sore throat

A

A

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5
Q

what priority would a BP 60/40

A

first

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6
Q

what priority would breathing difficulty and a pulse ox reading 88 on room air

A

first

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7
Q

what priority would hunger and thirst be

A

third

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8
Q

what priority would anxiety be

A

second

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9
Q

what priority would a temp of 103 be

A

second

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10
Q

data collection

A

collection of data about an individuals health state

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11
Q

assessment purpose

A

make judgment/diagnosis

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12
Q

subjective data

A

what a patient tells you

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13
Q

objective data

A

measurable, observations

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14
Q

what part of the nursing process would objective and subjective data fit in

A

assessment

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15
Q

what makes up the data base

A

subjective
objective
records
lab studies

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16
Q

3 dimensions on critical thinking

A

theory and experiental knowledge to preform the nursing process
commitment to learn to think critically
psychomotor and manual skill development

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17
Q

nursing process

A

assessment
diagnosis
planning
implementation
evaluation

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18
Q

assessment

A

ability to gather data that is
- accurate
- relevant
- organized
- systematic
- complete
- and differentiates normal and abnormal

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19
Q

diagnosis

A

as a nurse we cluster cues and based on those what nursing actions we are going to make

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20
Q

planning

A

what we want to happen
~goals

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21
Q

implementation

A

things we add/take away to reach a goal

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22
Q

evaulation

A

did we reach the goal

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23
Q

first level priorities

A

airway
breathing
circulation

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24
Q

2nd level priorities

A

acute pain
change in mental status
infection

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25
Q

3rd level priorities

A

lack of knowledge
Family coping
activity
rest

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26
Q

complete total health data base

A

describes current and past health state and forms a baseline to measure all future changes

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27
Q

episodic/problem centered database

A

collect mini database, smaller scope and more focused than complete

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28
Q

follow up data base

A

status of all identified problems should be evaluated at all regular and appropriate intervals

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29
Q

emergency data base

A

rapid collection of data often compiled concurrently with life saving measures

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30
Q

what is EBP

A

use of evidence based research implemented at the clinical level to ensure best patient outcomes

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31
Q

3 points to EBP

A

integration of research evidence
clinical expertise/knowledge
patient values and preferences

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32
Q

what is a general survey

A

looking/inspecting at the general state of health and obvious physical characteristics of a person

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33
Q

what is the normal amount of pain

A

depends on the patient

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34
Q

dysarthria

A

difficulty speaking caused by brain damage which results in inability to control muscles used in speech

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35
Q

dysphonia

A

diffuculty speaking due to physical disorder of the mouth, tongue or vocal cords

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36
Q

aphasia

A

loss of ability to understand or express speech caused by brain damage

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37
Q

4 components of general survey

A

physical appearance
body structure
mobility
behavior

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38
Q

physical appearance

A

age
sex
level or consciousness
skin color
facial features

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39
Q

body stature

A

stature
nutrition
symmetry
posture
position
body build/contor

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40
Q

mobility

A

gait
range of motion

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41
Q

behavior

A

facial expression
mood and affect
speech
dress
personal hygiene

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42
Q

normal temp range

A

35.8-37.3

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43
Q

normal stroke volume

A

70mL

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44
Q

pulse is a pressure wave created by

A

stroke volume

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45
Q

force of pulse scale

A

0-3

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46
Q

pulse force 1

A

weak/thready

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47
Q

pulse foce 2

A

normal

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48
Q

pulse force 3

A

bounding

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49
Q

what to document when taking pulse

A

site
rate
force
rhythm

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50
Q

what do you do if you can’t palpate the pulse

A

use a doppler

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51
Q

1 breath consists of

A

1 inspiration and 1 expiration

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52
Q

Respiratory rate

A

10-20

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53
Q

normal pulse ox rate

A

97-100

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54
Q

systolic

A

maximum pressure felt on the artery during left ventricle contraction

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55
Q

diastolic

A

pressure against the vessel between contractions

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56
Q

what lasts longer diastole or systole

A

diastole

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57
Q

pulse pressure

A

difference between systolic and diastolic blood pressure

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58
Q

orthostatic hypotension drop in systolic of

A

20

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59
Q

orthostatic hypotension increase in

A

pulse >20

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60
Q

why would there be an increase in orthostatic hypotension in elderly

A

due to vascular changes with aging

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61
Q

common errors with blood pressure assessment

A

arm placement
patients hold arm up
legs are crossed
examiner eyes not level with manometer or meniscus
incorrect cuff size
failure to palpate for level of inflation
deflate too fast or too slow
stopping during descent and then reinflating
failure to wait 1-2 mins between readings
subconscious bias
diminished hearing ability of exmainer
defective equipment
number preferences

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62
Q

korotkoff 1

A

systolic

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63
Q

korotkoff 5

A

diastolic

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64
Q

which patient would be most likely to present with a pulse rate that is lower than normal
A. 70 year old telephone salesman presenting dehydration
B. 20 year old runner who had surgery for a fractured leg
C. 67 year old who presented with an exacerbation of his COPD

A

B

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65
Q

common errors in blood pressure measurement include
A. taking blood pressure in an arm that is at the level of the heart
B. waiting <1-2 mins before repeating the blood pressure reading in the same arm
C. waiting 30 mins if the client has just smoked a cigarette
D. using a blood pressure cuff whose bladder is 80% of the arm circumference

A

B. we want to wait at least 1-2 (>1-2)

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66
Q

order for assessment

A

inspection, palpation, percussion, auscultation

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67
Q

inspection

A

careful thorough observation

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68
Q

do we listen over clothes

A

no

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69
Q

palpation uses the sense of

A

touch

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70
Q

can we determine the disease state by palpating

A

no

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71
Q

light palpation

A

use to detect surface characteristics

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72
Q

deep palpation

A

use intermittent pressure to examine abdominal contents

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73
Q

fingertips are used for

A

fine discrimination such as texture, swelling, pulsation, presence of lumps

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74
Q

grasping action are used for

A

detect shape, size, position, consistency of an organ

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75
Q

base of fingers are used for

A

detect vibration

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76
Q

dorsum of hands are used for

A

temp changes

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77
Q

bimanual palpation

A

compare both sides

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78
Q

if the patient states they have pain should we palpate that first or last

A

last

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79
Q

always begin with light or deep palpation

A

light

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80
Q

percussion

A

tapping the skin with short, sharp stokes that produce a vibration to assess underlying structures

81
Q

structures with air will produce

A

louder, longer, deeper sound because it can vibrate freely

82
Q

denser more solid structures produce

A

softer, higher, shorter, sound because they can’t vibrate as easily

83
Q

resonant

A

over lung fields, sound clear, hollow

84
Q

tympany

A

over abdomen sounds drum like

85
Q

dull

A

over organs sounds like a muffled thud

86
Q

flat

A

over bone, muscle, tumor, sound comes to a dead stop

87
Q

diaphragm

A

high pitched sounds

88
Q

bell

A

detect low pitched sounds

89
Q

preform exam from the _______ side of the patient

90
Q

the bell of the stethoscope
A. is used for soft, low pitched sounds
B. is used for high pitched sounds
C. is held firmly against the skin
D. magnifies sounds

91
Q

what is the correct order for assessment

A

inspection
palpation
percussion
auscultation

92
Q

_______________ can affect mental status

A

electrolytes

93
Q

components of a mental status exam

A

appearance
behavior
cognition
thought processes and perception

94
Q

appearance

A

body movements
dress
grooming
hygiene

95
Q

behavior

A

level of consciousness
facial expression
speech
mood and affect

96
Q

cognitive functioning

A

oritentation
attention span
recent memory
remote memory
new learning

97
Q

thought processes

A

thought content
perceptions
suicidal thoughts

98
Q

multiple cognitive deficits
(dementia/delirium)

99
Q

may develop in addition to diseases during period of hospitalization
(dementia/delirium)

100
Q

acute disturbance of consciousness and cognition
(dementia/delirium)

101
Q

chronic disturbance of consciousness and cognition
(dementia/delirium)

102
Q

medical conditions preclude this condition
(dementia/delirium)

103
Q

long and short term memory loss with short term more pronounced
(dementia/delirium)

104
Q

affects speech and language
(dementia/delirium)

105
Q

you have a patient that comes in with multiple cognitive deficits and a chronic disturbance of consciousness and cognition with speech and language issues

106
Q

is dementia reversible

A

no irrereversible

107
Q

is delirium reversible

108
Q

levels of consciousness

A

alert
lethargic
obtubnded
stupor/semi coma
coma

109
Q

alert

A

Awake or readily aroused; oriented, fully aware of external and internal stimuli and responds appropriately; conducts meaningful interpersonal interactions.

110
Q

lethargic

A

Not fully alert; drifts off to sleep when not stimulated; can be aroused to name when called in normal voice but looks drowsy; responds appropriately to questions or commands but thinking seems slow and fuzzy; inattentive; loses train of thought; spontaneous movements are decreased.

111
Q

obtunded

A

Sleeps most of time; difficult to arouse—needs loud shout or vigorous shake; acts confused when is aroused; converses in monosyllables; speech may be mumbled and incoherent; requires constant stimulation for even marginal cooperation.

112
Q

stupor/semi coma

A

Spontaneously unconscious; responds only to persistent and vigorous shake or pain; has appropriate motor response (i.e., withdraws hand to avoid pain); otherwise can only groan, mumble, or move restlessly; reflex activity persists.

113
Q

coma

A

Completely unconscious; no response to pain or any external or internal stimuli (e.g., when suctioned, does not try to push the catheter away); light coma has some reflex activity but no purposeful movement; deep coma has no motor response.

114
Q

sedation scale

115
Q

sedation scale S

A

asleep, easy to arouse

116
Q

sedation scale 1

A

awake and alert

117
Q

sedation scale 2

A

slightly drowsy, easily aroused

118
Q

sedation scale 3

A

frequently drowsy, arousable, drifts off to sleep during conversation

119
Q

sedation scale 4

A

somnolent, minimal or no response to physical stimulation

120
Q

glasgow coma scale measures

A

motor, verbal, eye response

121
Q

Glasgow coma scale what number determines coma

122
Q

broca AKA

A

expressive aphasia

123
Q

wernicke AKA

A

receptive aphasia

124
Q

what aphasia type is most common and severe

125
Q

global aphasia is caused by

A

large lesion that affects anterior and posterior language areas

126
Q

how would someone with global apahsia present

A

speech is absent or only a few words
no compresension
can’t respect, write or read

127
Q

brocas/expressive is caused by

A

lesion in the motor cortex of the anterior portion of the brain

128
Q

can people with broca/expressive hear and read

A

yes
auditory and reading comprehension are intact

129
Q

how would someone with brocas/expressive present

A

able to understand
can’t express self using language
can’t respect or read aloud

130
Q

wernicke/receptive is caused by

A

lesion in the posterior area of language center

131
Q

how would a patient present with wernicke/receptive

A

can hear sounds but can’t relate to them
speach is fluent
patient had great urge to speak
words are made up and frequented
incomprehensible speech
impaired repetition, reading and writing

132
Q

how do you communicate with broca/expressive

A

speak clearly
books on tape
picture board
written words
yes/no questions
email

133
Q

how can you communicate with wernicke/receptive

A

picture board
don’t keep talking and repeating
don’t write, can’t read
use gestures to help with understanding

134
Q

a major characteristic of dementia is
A. impairment of short and long term memory
B. hallucinations
C. sudden onset of symptoms
D. substance induced

135
Q

pain is subjective or objective

A

subjective

136
Q

what are some examples of holistic pain relief

A

music, relaxation, massage, biofeedback, acupuncture
tubes to decompress/relieve pressure
anxiolytics
improving breathing and oxygenation
positioning
heat and/or cold application

137
Q

4 concepts or nociception

A

transduction
transmission
perception
modulation

138
Q

transduction

A

stimulus takes place in periphery

139
Q

transmission

A

pain moves from spinal cord to brain

140
Q

perception

A

conscious awareness of pain sensation

141
Q

modulation

A

inhibition or pain sensation

142
Q

when we treat pain we take 4 basic approaches toward each of these 4 components within the neuroatomic pathway

A
  1. we can modify the source of pain
  2. we can attempt to alter the central perception or pain
  3. we can modulate the transmission or pain in the CNS
  4. we can block the transmission of pain to the CNS
143
Q

how do we modify the source of pain (transduction)

A

general anesthetic
anti inflamatory

144
Q

how do we modify the movement of painful stimuli (transmission)

A

narcotics
opioids

145
Q

how do we modify the awareness of pain (perception)

A

distractions
exercise
music
acupuncture

146
Q

how do we inhibit the pain (modulation)

A

Pharmaceutical

147
Q

neuropathic pain is normal or abnormal

148
Q

does neuropathic pain follow the predictable phases of nociceptive pain

149
Q

what pain is the most difficult pain to assess and treat

A

neuropathic

150
Q

neuropathic pain is perceive

A

long after injury heals

151
Q

visceral pain

A

organ pain

152
Q

deep somatic pain

A

tendon, blood vessles

153
Q

cutaneous pain

A

skin pain, superficial

154
Q

referred pain

A

felt at a particular site but originates in another location

155
Q

acute pain

A

short term
self limiting
follows a predictable trajectory
dissipates after injury heals
has a protective quality
activates autonomic nervous system
vital sign indication
malignant pain

156
Q

chronic pain

A

continues beyond the expected time
malignant and nonmalignant pain
does not stop when injury heals
has no protective qualities
the level of pain may not correspond with physical findings
could have increased tolerance

157
Q

acute pain signs and symptoms

A

protective
diaphoresis
anxiety
restless/stillness
moaning

158
Q

chronic pain signs and symptoms

A

normal vital signs
skin warm and dry
depressed
anxiety
anger/irritability
substance abuse
no protective behavior
bracing, rubbing
sighing
appetite change
reduced activity

159
Q

is pain a normal process of aging

160
Q

pain assessment questions

A

where is your pain
when did it start
what does your pain feel like
how much pain do you have now
what makes it better or worse
how does it limit your activities
how do you behave when in pain
what does you pain mean to you
why do you think you are having pain

161
Q

PQRST

A

provoke
quality
radiates
severity
time

162
Q

2 types of pain rating scales

A

numeric
descriptor

163
Q

what do elderly think about pain and treatment

A

no pain medication because of addiction

164
Q

which type of pain would cause cholecystitis
A. somatic
B. visceral
C. cutaneous
D. chronic

A

B. visceral

165
Q

what anticipated finding regarding patients with chronic pain should guide a nurses care planning
A. patients with chronic pain have trouble sleeping
B. patient with chronic pain show elevated blood pressure
C. patients with chronic pain need less medications
D. patients with chronic pain may show few or no outward signs of pain

166
Q

T/F
you have to have physical signs for pain to exist

167
Q

T/F
self report is the most accurate indicator of pain

168
Q

T/F
prolonged use of narcotics pain medications leads to addiction

169
Q

T/F
older adults ahem decreased pain sensations

170
Q

a confused elderly patient with dementia with a broke hip
what pain scale

A

descriptive

171
Q

a 20 year old who just had four wisdom teeth extracted
what pain scale

172
Q

a 50 year old person with chronic rheumatoid arthritis
what pain scale

173
Q

aging skin

A

drier, flatter skin
decrease sebum and sweat production
decrease elasticity
decreased number of functioning melanocytes
decrease elastin, collagen, subq fat
change in temp regulation
changes in nail

174
Q

are older adults more or less at risk for pressure injuries

A

more at risk due to changes in circulation and decreased ability to form new collagen

175
Q

unstageable pressure wound

A

covered, not able to see depth, needs to be debrided

176
Q

who might be able to have an inability to sense temp, friction

A

diabetic patients

177
Q

warfarin does what to blood vessels

A

makes them more fragile

178
Q

braden scale categories

A

sensory preception
moisture
activity
mobility
nutrition
friction/shear

179
Q

mobility

A

if they CAN move

180
Q

activity

A

if they ARE moving

181
Q

stage 1 pressure injuries

A

intact skin with nonblanchable redness

182
Q

stage 2 pressure injuries

A

partial thickness, loss of dermis, presents as abrasion or blister

183
Q

stage 3 pressure injuries

A

full thickness, subq tissue may be visible, presents as deep craters

184
Q

stage 4 pressure injuries

A

full thickness skin loss, tissue necrosis or damage to muscle or bone or surrounding structures

185
Q

most of the time stage 4 require

A

skin grafting

186
Q

measure depth of injury with

187
Q

wound and skin lesion documentation

A

color
characteristics of edges and wound bed
size and shape
depth/tunnels/raised
odor
clock method
drainage characteristics
treatment method, patient tolerance, date, time, signature

188
Q

subjective data of skin

A

pervious history of skin disease
change in mole
change in pigmentation
excessive dryness or moisture
pruritus (itching)
excessive brusing

189
Q

objective data of skin

A

color
elevation
pattern or shape
size
location and distribution on body
exudate

190
Q

brisk capillary refill

191
Q

sluggish capillary refill

A

over 3 second

192
Q

ABCDE skin mole

A

asymmetry
border
color
diameter
elevation

193
Q

annular/circular

194
Q

grouped

A

small groupings
(tryphobia)

195
Q

gyrate

196
Q

linear

197
Q

a patient who is admitted for liver failure would be likely to show which of the following skin changes
A. Cyanosis
B. Flushing
C. Rubor
D. Jaundice

198
Q

when assessing inflammation in a dark skinned person, the nurse may need to
A. assess the skin for cyanosis and swelling
B. assess the oral mucosa for generalized erythema
C. Palpate the skin for edema and increased warmth
D. palpate the skin for tenderness and local areas of ecchymosis

Health Assessment (20 decks)

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