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NUA 311: Holistic Assessment In Nursing > Exam 1 Study Guide and practice questions > Flashcards

Exam 1 Study Guide and practice questions Flashcards

1
Q

What are the methods of physical examination?

A

Inspection
Auscultation
Palpation
Percussion

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2
Q

Inspection (sounds associated with inspection and what they indicate)

A

what you see, smell, hear from patient - starts right when you enter room and continue the entire time you are with pt.

  • good lighting
  • adequate exposure
  • Occasional use of instruments, including otoscope, ophthalmoscope, penlight, or nasal and vaginal specula, to enlarge your view
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3
Q

Auscultation

A

n

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4
Q

Palpation

A

Using parts of the hand to touch and feel for:

  • texture (rough/smooth)
  • temp
  • moisture
  • consistency (soft, hard, fluid-filled)
  • mobility (fixed, moveable, still, vibrating)
  • strength of pulses
  • size
  • shape
  • degree of tenderness
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5
Q

Percussion: purposes

A

a. eliciting pain
b. determining location, size and shape
c. determining density
d. detecting abnormal masses
e. eliciting reflexes

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6
Q

What is inspection used to assess?

A

G

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7
Q

What is auscultation used to assess?

A

G

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8
Q

What is palpation used to asses?

A

G

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9
Q

What is percussion used to asses?

A

G

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10
Q

Inspection: How to perform/techniques

A

F

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11
Q

Auscultation: How to perform/techniques

A

G

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12
Q

Palpation: How to perform/techniques

A

G

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13
Q

Percussion: How to perform/techniques

A

G

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14
Q

Standard precautions when caring for patients:

A

hand hygiene
gloves
mask, eye protection, face shield
gown

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15
Q

What are the normal values/ranges for vital signs?

A

G

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16
Q

Subjective vs objective data

A

subjective = what client says (can not measure)

objective = what is observed (things you can measure)

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17
Q

What are considerations when assessing mental status in older adults?

A

H

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18
Q

How can you prevent bias?

A

G

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19
Q

What is the purpose of general survey?g

A

V

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20
Q

What information is obtained from general survey?

A

V

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21
Q

What are the steps in the nursing process?

A

Assessment, diagnosis, outcomes, planning, intervention, evaluation

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22
Q

Assessment: Attributes of this stage

A

Collecting subjective and objective data

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23
Q

Diagnosis: Attributes of this stage

A

Analyzing subjective and objective data to make a professional nursing judgement

  • nursing diagnosis
  • collaborative problem or
  • referral
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24
Q

Outcomes: Attributes of this stage

A

a. Identify expected or unexpected outcomes
b. Ensure outcomes are realistic and measurable
c. short term and long term goal measurement criteria

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25
Q

Planning: Attributes of this stage

A

determining outcome criteria and developing a plan

  • ID priorities based on patient care goals
  • develop outcomes and set time frames to meet those outcomes
  • Identify relevant interventions and utilize input from various members of the interdisciplinary health care team to plan patient care
  • document the plan of care
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26
Q

Intervention: Attributes of this stage

A

B

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27
Q

Evaluation: Attributes of this stage

A

Assessing whether outcome criteria have been met and revising the plan as necessary

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28
Q

Stages of development: Erikson

A

notes

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29
Q

Stages of development: Piaget

A

notes

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30
Q

Stages of development: kohlberg

A

notes

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31
Q

Stages of development: Freud

A

notes

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32
Q

What is the purpose of documentation?

A

a. provides chronological source of client assessment and a progressive record of assessment finding that outline the client’s course of care
b. ensures information about client is easily accessible
c. communication (prevents repetition, fragmentation, and delays in carrying out plan of care)
d. Establishes a basis for screening or validating proposed diagnoses.
e. source of information to help diagnose new problems.
f. offers as basis for determining education needs for patient
g. legal reasons

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33
Q

What is complete vs incomplete documentation?

A

By

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34
Q

Mental status terminology, descriptors for level of consciousness and attributes of each, assessment of judgement vs thought process vs orientation vs memory

A

V

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35
Q

Health history taking, what to do when you come across an abnormal finding, expanding questioning, traps of interviewing, open vs closed ended questions, steps of the interview/ordering - what do you do first?

36
Q

Documentation of skin lesions, ABCDE, normal vs. abnormal findings, descriptors of skin lesions

37
Q

Staging of pressure ulcers, know attributes/criteria for each stage

38
Q

Prioritization of assessment needs: comprehensive vs emergent vs problem focused, etc.

39
Q

Thyroid assessment, technique, normal vs abnormal findings, what to do with abnormal findings

40
Q

BMI calculation, normal vs abnormal findings of BMI

41
Q

Nutrition assessment, weight loss assessment, appropriate questioning

42
Q

Pain assessment - measurement tools (numeric scale, Wong Baker Faces, FLACC, etc)

43
Q

Acute vs chronic pain

44
Q

COLDSPA

A

Character - describe the s/s

Onset - when did it begin?

Location - where is it? does it radiate? does it occur anywhere else?

Duration - how long does it last? does it reoccur?

Severity - 1-10

Pattern - what makes it better or worse

Associated factors / how it affects client - what other symptoms occur with it / how does it affect you?

45
Q

Physiological signs of pain

46
Q

Differentiation of conductive vs sensorineural hearing loss, techniques for assessing hearing, normal signs of aging in relation to hearing, terminology of hearing problems (I.e. Tinnitus, vertigo, etc.), equipment used, testing (ie Weber, Rinne, Whispered Voice, etc.)

47
Q

Lymph node assessment - locations, how to perform, normal vs abnormal findings, documentation

48
Q

AUDIT, CAGE, PHQ, GAD-7, how to use, why used, normal vs abnormal score

49
Q

Headache assessment - characteristics of each type and how to differentiate

50
Q

Steps of health assessment

A
  1. Prepare for the assessment (review record, review clients status with other healthcare team members, education about client’s diagnosis and tests performed)
  2. Collection of subjected and objective data
  3. Validation of assessment data
  4. Documentation of the data
  5. Analysis of the data
51
Q

phases of interview

A

introductory
working
summary and closing

52
Q

types of percussion

A

direct
blunt
indirect or mediate

53
Q

sounds elicited by percussion

A 
resonance
hyper resonance
tympany
dullness
flatness
54
Q

how to perform auscultatoin

A

eliminate distracting noise
expose part being auscultated
diaphragm

55
Q

when auscultating, what parts of the stethoscope do you use for high pitched sounds and low pitched sounds

A

high pitched - diaphragm

low pitched - bell

56
Q

Steps of validation

A
  1. Verify that subjective and objective data are reliable and accurate
  2. deciding whether data require validation
  3. determining ways to validate the data
  4. ID areas where data is missing
57
Q

What are examples of data that require validation?

A

a. discrepancies or gaps between subjective and objective data
b. discrepancies in what the client says at one time vs another time
c. abnormal / inconsistent findings

58
Q

What are 6 essential components of the diagnostic phase?

A
  1. group and analyze
  2. validate
  3. cluster - data to make inferences
  4. generate - hypoth. about clients info
  5. formulate - prof. clinical judgement
  6. validate
59
Q

organis disorders

A

due to brain disease of known specific cause (delerium, dementia, alc. and drug intoxication and withdrawal)

60
Q

PROPOSED DSM-5 DEFINITION OF MENTAL DISORDER

A

behavioral or psychological syndrome or pattern that occurs in an individual that reflects an underlying psychobiologic dysfunction

61
Q

What are the four main headings of mental status assessment? (ABCT)

A

appearance
behaviors
cognition
thought processes

62
Q

when is a full mental status examination necessary

A

patients whose initial screening suggests an anxiety disorder or depression

behavioral changes (memory loss, inappropriate social interaction)

brain lesions (trauma, tumor, CVA, stroke)

aphasia

symptoms of psychiatric mental illness, especially with acute onset

63
Q

mini mental state exam

A

concentrates only on cognitive functioning, not on mood or thought processes
- 11 questions, 5-10 minutes

64
Q

thought process:

A

way person thinks should be logical, goal directed, coherent, and relevant; should complete thoughts

65
Q

thought content

A

what person says should be consistent and logical

66
Q

perceptions

A

person should be consistently aware of reality; perceptions should be congruent with yours

67
Q

how would you diagnose substance abuse

A

GOLD STANDARD OF DIAGNOSIS IS WELL DEFINED IN DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, FIFTH EDITION (DSM-V)

68
Q

substance abuse: cage questionnaire

A

refers to cut down, annoyed, guilty, eye-opener

69
Q

substance abuse: audit questionnaire

A

a quantitative form that has the advantage of letting the examiner document a number for a response so it is not open to individual interpretation
– helps detect less severe alcohol problems as well as alcohol abuse disorders

70
Q

What are the 3 domains that audit questionairres come in

A
  1. alcohol consumption
  2. drinking behavior / dependence
  3. adverse consequences from alcohol
71
Q

pulse amplitude 0-3

A

0 = absent
1 = weak, diminished (easy to obliterate
2. normal (obliterate with moderate pressure
3. bounding (unable to obliterate or requires firm pressure)

72
Q

factors affecting blood pressure

A 
cardiac output
elasticity of arteries
blood volume
blood velocity (HR)
blood viscosity (thickness)
73
Q

palpation techniques: fingertips

A

best for fine tactile discrimination of skin texture, swelling, pulsation, determining presence of lump

74
Q

palpation techniques: fingers and thumbs

A

detection of position, shape, and consistency of an organ or mass

75
Q

palpation techniques: dorsa hand and fingers

A

best for determining temperature because skin here is thinner than on palms

76
Q

palpation techniques: base of fingers or ulnar surface of hands

A

best for vibration

77
Q

percussion definition

A

Tapping person’s skin with short, sharp strokes to assess underlying structure
- mapping location and size of organs

78
Q

how deep do percussion vibrations penetrate

A

Percussion vibrations penetrate about 5 cm deep

- deeper mass would give no change in percussion

79
Q

what are the 2 methods of percussion

A
  1. direct, sometimes called immediate, the striking hand directly contacts body wall
  2. indirect, or mediate, using both hands, the striking hand contacts stationary hand fixed on persons skin
80
Q

nociception

A

the term used to describe how noxious stimuli are perceived as pain

81
Q

nociception phases (4)

A

transduction
transmission
perception
modulation

82
Q

nociception: transduction

A

occurs when a noxious stimulus in form of traumatic or chemical injury, burn, incision, or tumor takes place in periphery

    • injured tissues then release a variety of chemicals, including substance P, histamine, prostaglandins, serotonin, and bradykinin
  • – neurotransmitters that propagate pain message along sensory afferent nerve fibers to spinal cord

these fibers terminate in dorsal horn of spinal cord

83
Q

nociception: transmission

A

pain impulse moves from level of spinal cord to brain

84
Q

nociception: perception

A

indictates conscious awareness of painful sensation

85
Q

nociception: modulation

A

pain is inhibited
– descending pathways from brainstem to spinal cord produce third set of neurotransmitters that slow down or impede pain impulse producting an alagesic effect

86
Q

acute pain

A 
cause generally known
short term (3-6 months)
anxiety
responds well to meds
red tissue
RICE
87
Q

chronic pain

A 
cause often unknown
long term +6 months
depression
does not respond to meds
white tissue
MEAT (movement, exercise, analgesics, treatment)

NUA 311: Holistic Assessment In Nursing (5 decks)

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