Exam One Flashcards
What is a Health Assessment?
The collection of data, essential as the first step in the nursing process.
What are the types of patient data in a health assessment?
Subjective Data: What the patient tells you (e.g., “I have a headache”).
Objective Data: What you can observe or measure (e.g., heart rate, bleeding).
What are the methods for gathering patient data?
Interview (subjective)
Observation
Physical exam
Charts/EHR/old records
Collaboration with other healthcare providers
What are the different types of health histories?
Complete health history
Focused/problem-centered
Follow-up
Emergency
What are the priority levels in health assessment?
First-level: Emergency (e.g., airway issues)
Second-level: Acute problems (e.g., broken bones)
Third-level: Long-term issues (e.g., physical therapy)
What are some patient considerations during a health assessment?
Developmental stage
Cultural needs
Spiritual beliefs
Education level
Language barriers
What are the phases of a patient interview?
Pre-interaction
Beginning (introductions)
Working phase (data gathering)
Closing phase (summary & next steps)
What is included in a health history sequence?
Demographic data
Past medical & surgical history
Medication reconciliation
Social history
Lifestyle
Family history
Functional assessment/ADLs
What are the steps in physical assessment techniques?
Inspection: Observation
Palpation: Sense of touch
Percussion: Tapping to assess underlying structures
Auscultation: Listening with a stethoscope
What are some abnormal findings in a mental status assessment?
Changes in LOC (lethargy, stupor, coma)
Mood and affect abnormalities (flat, euphoric, anxious)
What is the normal range for oral body temperature?
96.4°F–99.1°F (average ~98.6°F).
What are the normal values for pulse and common abnormalities?
Normal pulse: 60–100 BPM
Abnormalities: Bradycardia (<60 BPM), Tachycardia (>100 BPM)
What is the normal respiratory rate?
12–20 breaths per minute.
What is considered a normal oxygen saturation level (SpO2)?
95%–100%.
How do you document blood pressure?
Record systolic/diastolic (e.g., 120/80 mmHg), measurement arm, and position (e.g., lying down).
What are the types of pain and how are they assessed?
Acute: Short-term
Chronic: >6 months
Assessment tools: Numeric scale (1–10), Wong-Baker Faces Scale
What are the components of a general survey?
Physical appearance
Body structure
Mobility
Behavior
Describe the importance of measuring height, weight, and BMI.
Essential for assessing general health, determining medication dosages, and monitoring changes in nutritional status.
Explain the significance of vital signs in patient assessment.
Objective measures reflecting basic physiological functions, used to monitor health status and detect abnormalities.
What is included in the documentation of vital signs?
Temperature
Pulse
Respirations
Blood pressure
Pain assessment
What is the most effective temp route method
oral
How do you perform a pain assessment?
Use scales like the Numeric Rating Scale or Wong-Baker Faces Scale to evaluate pain intensity, location, quality, onset, duration, and relief measures.
Case Study: Mrs. Smith, 68 years old, presents with shortness of breath and chest pain. What is the priority nursing intervention?
Priority nursing intervention: Assess ABCs (Airway, Breathing, Circulation) and administer oxygen as needed. Consider cardiac monitoring and notify the healthcare provider.
Scenario: Mr. Johnson, 55 years old, admitted with abdominal pain and vomiting. His vital signs are: Temperature 100.4°F, Pulse 110 BPM, Respirations 22 breaths/min, Blood Pressure 130/80 mmHg. What is the potential nursing diagnosis?
Potential nursing diagnosis: Acute Pain R/T gastrointestinal disturbance AEB abdominal pain and vomiting.
Case Study: Ms. Garcia, 42 years old, complains of headache and dizziness. She has a history of hypertension. What assessment findings are concerning for potential complications?
Concerning assessment findings: Elevated blood pressure (150/95 mmHg), headache, and dizziness. Monitor for signs of hypertensive crisis and neurological changes.
Scenario: Baby Smith, 6 months old, brought to the ER with fever (temperature 102°F) and irritability. What nursing interventions are appropriate for managing the fever?
Nursing interventions: Administer antipyretics as ordered, encourage fluid intake, monitor temperature, assess for signs of dehydration, and provide comfort measures.
Writing Nursing Interventions: Mr. Johnson, admitted with dehydration. What is a relevant nursing intervention?
Administer IV fluids as ordered to restore fluid balance and monitor intake and output closely.
Writing Patient Goals: Ms. Smith, post-operative day 1 after knee replacement surgery. What is a realistic goal for pain management?
Realistic goal: Patient will report pain level ≤ 4 on a scale of 0-10 within 24 hours, using pain management strategies.
Nursing Interventions: Mrs. Brown, admitted with pneumonia. What is an appropriate nursing intervention to promote airway clearance?
Appropriate nursing intervention: Encourage deep breathing exercises, provide chest physiotherapy, and suction as needed to clear respiratory secretions.
Writing Nursing Interventions: Elderly patient with impaired mobility due to stroke. What is an appropriate nursing intervention to prevent complications?
Appropriate nursing intervention: Implement range of motion exercises, turn and reposition every 2 hours, and use pressure-relieving devices to prevent pressure ulcers.
