Mod 1 Flashcards
Pain described as stabbing, numbness, shooting, burning, tingling
Neuropathic
When asked to describe the differences between ethnicity & race, what should the student nurse explain?
-Ethnicity & race are the same
-Ethnicity can be understood only thru ethnic worldview
-Race refers to shared identity, ethnicity is limited to biologic attributes
-Ethnicity refers to shared identity but race is limited to biologic attributes
Ethnicity refers to shared identity but race is limited to biologic attributes
To gather info about a patient’s home and work surroundings, the nurse will use which method of data collection?
-Review lab results
-Preform a thorough nursing health history
-Prolong termination phase of interview
-Conduct physical assessment before subjective info
Preform a thorough nursing health history
A ER nurse is interviewing a client c/o abdominal pain. Which of the following questions would be of priority at this time?
-What have you done to ease the pain?
-Have you had this problem before?
-Can you describe the pain?
-When did the pain begin?
When did your abdominal pain begin?
A client interview consist of 3 phases. The nurse recognizes these phases are:
-Intro, discuss, summary
-Orientation, working, termination
-Intro, control, selection
-Intro, assess, conclude
Introduction, discussion, & summary
Subjective Data includes:
-Measurements of health status
-Description of patient behavior
- Patients feelings, perceptions, and reported symptoms
-Observation of patients health status
A patient’s feelings, perceptions, & reported symptoms
The nurse is gathering a health history and the PT says he just lost his job. Job loss fits best where in HH?
-Family History
-Psychosocial History
-Environmental History
-Biographical History
Psychosocial History
The use of critical thinking skills during the assessment phase of the nursing process ensures that the nurse:
-Completes a comprehensive database
-Intervenes based on patient goals & priorities of care
-Generates a potential problem list
-Determines whether outcomes have been achieved
Completes a comprehensive database
The PT stated he “felt hot”. His vitals: 101.2 PO, b/p 166/92 & HR 101 bpm. What is subjective data?
-HR 88 bpm
-B/P 168/80 mmHg
- The statement regarding his feeling hot
-The fact that he became febrile
The statement regarding his feeling hot
The nurse decides to interview the PT using the open-ended question technique. Which is an example of this?
-Is your pain better or worse?
-Do you believe that your nausea is from antibiotic?
-What do you think has caused your depression?
-What have you done to alleviate the side effects of your meds?
What do you think has been causing your depression?
What is bradycardia?
Slow heart beat
What is tachycardia?
Fast heartbeat
The PT rates their headache 8/10. What info of OLD CARTS is this?
-O
-S
-R
-D
S=severity
A nurse using the problem oriented approach to data collection will first
-Complete observation overview
-Disregard cues/complete database in chron order
-Make accurate interpretations of data
-Focus on the patient’s presenting situation
Focus on the patient’s presenting situation
When working w/ patient of diff culture, it is important that
-Nurse protects patient from family intrusion of care
-Women as primary caregivers make independent health decisions
-Gender is not a factor when it comes to role expectations
-Working within est. family hierarchy = better outcomes
Working within est. family hierarchy =better outcomes
PT c/o trouble breathing at night. For problem-focused assessment what should nurse ask 1st?
-His personal smoking, alcohol use
-Any family members w/ heart disease?
-Changes in other body systems that seem problematic
-Onset/duration of his present breathing problem
Onset/duration of his present breathing problem
The process of data collecting begins with
-Physical exam
-Review medical records
-Patient interview
-Discussion w/ other team members
Patient Interview
A client rings the call light and says, “ I think I have a fever and my stomach hurts”. What should the RN do?
-Ask UAP to check his concerns
-Go to clients room and assess client
-See if client has an order for pain & fever
Call physician and ask them to come see the patient
Go to clients room and assess
OLD CARTS
Onset
Location
Duration
Characteristics
Aggravating factors
Relieving factors
Treatments
Severity
How many calories for protein?
4 calories per gram
How many calories for fats?
9 calories per gram
How many calories for carbohydrates?
4 calories per gram
What can affect B/P readings?
-incorrect cuff size
-arm unsupported
-repeating taking the b/p too quickly
-rate of cuff deflation
-arm position
-patient position
What is BMI scale?
Calculated by weight(lbs) x 705/ height (in2)
Normal: 18.5-24.9
Overweight: 25-29.9
Obese: 30-34.9
JNC BP Levels
Normal: <120 (SBP) & <80mm Hg (DBP)
Elevated: 120-129 (SBP) & <80mm Hg (DBP)
Hypertension:
Stage 1: 130-139mm Hg or 80-89mm Hg
Stage 2: >140mmHg or >90mm Hg (greater than or equal to)
Primary Preventions
Preventative, prevents disease from developing through healthy lifestyle
Secondary Prevention
Screenings, efforts to promote the detection of disease to halt the progression of the disease process
Tertiary Prevention
You got it already, now making ease of it,
Pain Scales (NRS, FLACC, Wong-Baker)
NRS- numeric 0-10
FLACC- for children
Wong baker faces- peds or elderly
Nociceptive Pain: Tissue damage
-Cutaneous
-Somatic
-Visceral
-Cutaneous: superficial surface of skin
-Somatic: achy, throbbing, dull, localize (ortho)
-Visceral: poor localized, just hurts, when organs are stretched weird ( stomach issies)
Sizes for BP Cuff
Small Adult: 12x22cm (4.7 x 8.6 inch)
Adult: 16 x 30cm (6.3 x 11.8 inch)
What technique assess temp, edema, tenderness & pulsation?
-Auscultation
-Percussion
-Palpation
-Inspection
Palpation
What is best way to describe clinical judgement related to vital signs?
-Collect vital signs & contacts provider if abnormal
-Delegates vital signs to most experience UAP
-Collects and analyzes data to formulate plan of care
-Collects & documents vital signs
Collects & analyzes date to formulate a plan of care
Which of the following is true?
- Culture is biologically determined
-Culture is determined by region
-Culture is learned through language and socialization
-Culture is genetically determined based on racial background
Culture is learned through language & socialization
What is best used to assess position, texture, shapes, size, and fluid?
-Heel of hand
-Palmar surface of fingers & pads
-Dorsal surface of hands
-Ulnar surface of hands
Palmar Surface of fingers/pads
Which is best to assess vibrations?
-Heel of hand
-Palmar surface of fingers & pads
-Dorsal surface of hands
-Ulnar surface of hands
Ulnar surface of the hand
The client may have a fungal infection on his leg. What supplies would nurse anticipate needing?
-Monofilament
-Snellen chart
-Wood’s lamp
-Doppler
Wood’s lamp
What is a woods lamp?
Detects fungal infections of the skin or corneal abrasions
59 YO C/O bloody stool x 24 hrs. + hx of ulcerative colitis. How should the nurse document is reason for seeking care?
- 59 yo presents w/ ulcerative colitis & bloody stools
-59 yo presents c/o bloody diarrhea
-59 yo client presents w/ “bloody stools x 24 hrs”
- 59 yo client presents today w/ ulcerative colitis
-59 yo client presents w/ “bloody stools x 24 hrs”
Clients respirations are 10/min. What is the correct term?
-Tachypnea
-Bradypnea
-Apnea
-Dyspnea
Bradypnea
Tachypnea?
Abnormal rapid breathing
Apnea?
Breathing stops and starts
Bradypnea?
Slower than normal breathing
Dyspnea?
Difficult or labored breathing
Client denies eye discharge, visual changes or eye pain. Where does this information belong in the assessment?
-Review of systems
-Physical exam
-Reason for seeking health care
-Past health history
Review of systems
Client reports experiencing shortness of breath (SOB). What would the nurse document?
-Tachypnea
-Bradypnea
-Apnea
-Dyspnea
Dyspnea
Which is correct regarding blood pressure assessment?
-Deflating cuff too quick will give too high reading
-Cuff should be inflated 50 mm Hg above the estimated SBP
-A too narrow cuff results in inaccurate and high reading
- Waiting 5 min between b/p measurements will result in false high
-A too narrow cuff results in inaccurate and high reading
What level of prevention is speech therapy?
-Primary
-Secondary
-Tertiary
-Combo of secondary and tertiary
Tertiary
What level do health professionals retrain, re-educate, and rehabilitate a client that has an impairment?
-Primary
-Secondary
-Tertiary
Tertiary
Managing a disease to slow or stop disease progression is what level of prevention. Ex. Chemotherapy
-Primary
-Secondary
-Tertiary
Tertiary
Identifying diseases in the earliest stages is what level of prevention?
-Primary
-Secondary
-Tertiary
Secondary
Intervening before health effects occur is what level of prevention? Ex. Vaccinations & altering risky behaviors
-Primary
-Secondary
-Tertiary
Primary
What is ANA’s first step in the nursing process?
-Diagnosis
-Implementation
-Planning
-Assessment
Assessment
ANA’s nursing process?
Assessment, diagnosis, outcome identification,planning, implementation, Evaluation
The mother of a 16 mo old states her daughter has an earache. What is the best response?
-Maybe she is teething
-Are you sure she is having pain?
-I will check for an ear infection
-Describe what makes you think she is having pain
-Describe what makes you think she is having pain
A pt w/ a left BKA reports pain in his LLE. He asks, “How I can feel pain- my foot is gone!” What is a good response?
-“After your amputation, pain perception increases”
-“Nerves send impulses to the brain- you feel pain although your leg is gone”
-“Amputating your leg caused damage to the normal tissues”
-“This is unexpected and you should see the pain center soon”
-“Nerves send impulses to the brain- you feel pain although your leg is gone”
What is the correct term for the moment boiling water is perceived as painful?
-Pain tolerance
-Pain threshold
-Pain intensity
- Pain Stimulus
Pain Threshold
The patient dislocated his shoulder while playing soccer causing what type of pain?
-Cutaneous
-Visceral
-Somatic
-Neuropathic
Somatic
Bowel disorders, labor pain, GI infection & organ cancer are what type of pain?
-Cutaneous
-Visceral
-Somatic
-Neuropathic
Visceral
When assessing mental status, the nurse uses which techniques?
-Asking them about relatives who have mental disorders
-Having them describe their ability to work w/ others
-Asking them to recall how they cope w/ stress
-Having them demonstrate their ability to reason & calculate
-Having them demonstrate their ability to reason & calculate
A PT who has anorexia nervosa reports a healthy diet & no protein calorie malutrition. Which lab value best confirms?
-Prealbumin
-Blood glucose
-Serum albumin
-Serum Cholesterol
-Prealbumin
What is prealbumin?
Reflection of protein & calorie intake for the previous 2-3 days
PT presents to ED w/ SOB & CP. He receives an EKG & labs. What level of prevention?
-Prim
-Sec
-Tert
-Health prevention
Secondary
PT presents to rehab after a CVA w/ right side weakness & unable to speak. What level of prevention?
Tertiary
ChooseMyPlate program includes guidelines for
-Children under 2
-Increasing portion size
-Balancing calories
-Eliminating fats
Balancing calories
Patient has a calculated BMI of 34. This is classified as:
-Overweight
-Unclassifiable
-Normal Weight
-Obese
Obese
What is serum albumin?
Measures circulating protein, occur over 3-4 weeks
The nurse is caring for a new PT. Which intervention is the best example of being culturally appropriate?
-Maintain personal space of 2 ft
-Consider ethnicity the most important factor in care plan
-Ask permission before touching patient
-Insist family members to provide most personal care
Ask permission before touching a patient during the physical assessment.
A PT w/ chronic leg pain controls it w/ imagery & hypnosis. What is the best response when asked how these work?
-Both strategies prevent transmission of painful stimuli to the brain
-The strategies work by affecting the perception of pain
-These techniques block the pain pathways of the nerves
-These slow the release of chemicals in the spinal cord that cause pain
The strategies work by affecting the perception of pain
The RN cares for a patient who was admitted a few hrs ago. Which action can the RN delegate to a UAP?
-Finish documenting the admission assessment
-Obtain the health history from the patient’s caregiver
-Develop the patient’s problem list
-Take the patient’s temp, pulse, and BP
-Take the patient’s temp, pulse, and BP
When assessing for a possible blood clot in the lower leg of a patient, which action should the nurse take first?
-Feel for the temp of leg
-Check the patient’s pedal pulses using fingertips
-Visually inspect the leg
-Compress the nail beds to determine capillary refill time
Visually inspect the leg
When admitting a patient who has just arrived on the unit w/ a severe headache, what should the nurse do first?
-Inform the patient that the headache will be treated after the hx
-Complete only basic demographic data before addressing patient’s pain
-Take initial vital signs and address the headache before completing the hx
- Medicate the PT for the headache before doing health history and examination
-Take initial vital signs and address the headache before completing the hx
A nurse is caring for a PT w/ heart failure. Which task is appropriate for the nurse to delegate to experienced UAP?
-Assist w/ bathing & toileting
-Monitor for shortness of breath or fatigue after ambulation
-Determine whether the patient is ready to increase the activity level
-Instruct the PT about the need tp alternate activity & rest
-Assist w/ bathing & toileting
PT’s vital are: b/p 178/92, HR 54, RR 26, Temp 98.9 PO, Which best describes this PT?
-Tachycardic, tachypneic, hypertensive, febrile
-Bradycardic, tachypneic, hypertensive, afebrile
-Bradycardic, apneic, hypertensive, febrile
-Tachycardic, bradypneic, hypotensive, afebrile
-Bradycardic, tachypneic, hypertensive, afebrile
Febrile vs Afebrile
Febrile- fever, abnormal temp
Afebrile- no fever, normal temp
PT is sitting upright, eyes open & says their name correctly, think they’re at the park & its 2010. The PT is:
-A&OX1
-A&OX2
-A&OX3
-A&DX3
-A&OX1
Orientation
X1 person
X2 place
X3time
Ask patient year, location, name
Time is first thing to be lost, then orientation to place, and orientation to person is last to be lost
Which vitamin must be ingested daily?
-Vit A
-Vit D
-Vit C
-Vit K
Vitamin C
Neuropathic Pain
-Results from injury or nerves
-burning, shooting, tingling, numbness
Acute pain
- rapid, varies in intensity & duration
Chronic Pain
Limited, persistent, last 6 months or longer
Pain Threshold
-does not vary among people
- point where stimulus is perceived as pain
Pain Tolerance
-decreases after repeated exposure
-increases after alcohol, meds, distractions
Duration or intensity of pain a person will endure
What is blood glucose?
Reflects carbohydrate metabolism
What is a standard drink?
12oz beer, 8-9 fl oz malt liqour, 5fl oz of wine, 1.5 fl oz shot
Expected findings associated w/ nutrition
-Normal BMI 18.4-24.9
-Well nourished, alert
-skin w/o lesions, cracks, bruising, smooth, elastic
- Hair is shiny, nails pink & intact w/o deformity, smooth & firm
-Eye mucous membrane pink, moist, free of lesions
Unexpected findings associated w/ nutrition
- High BMI= indicator of poor nutrition
-Irritability, disorientation (niacin deficiency)
-Multiple bruises = vit c & k deficiency
-Fatty acid deficiency = dry flaky skin/eczema - Edema= dehydration
-bumpy skin - vit a deficiency
-hair is dull & falls out easily
-spoon shape nails - iron deficiency
-eyes pale= anemia
-mouth lesions/dental = poor nutrition intake
-Muscle weakness= low protein
ANA Standards of Nursing Practice
Standard 1: Assessment
Standard 2: Diagnosis
Standard 3: Outcome Identification
Standard 4: Planning
Standard 5: Implementation
Standard 6: Evaluation
Clinical Judgment Cognitive Skill
-Recognize cues (what matters most)
-Analyze cues (what could it mean)
-Prioritize hypothesis (where do i start)
-Generate solutions (what can i do)
-Take action (what will I do)
-Evaluate outcomes (did it help)
Components of assessment
-Health history
-Physical examination
-Laboratory findings
-Diagnostic findings
-Documentation of data
Comprehensive Assessment
- detailed health history & physical exam upon admission
-regular full health exam
Problem-based/focused assessment
- Exam limited to specific problems or complaints (ex. sprained ankle)
-Generally walk in clinic or ER
Episodic/Follow Up Assessment
Following up with provider about previous identified problem
Shift Assessment
-When PT are hospitalized, these are conducted each shift
-Identify changes
Screening Assessment
Short exam focused on disease detection ( ex. bp screening, glucose, cholesterol)
3 Parts of Patient Interview
-Intro
-Discussion
-Summary
Components of Comprehensive Health History
-Biographic data
-Reason for seeking care
-History of present illness (OLD CARTS)
-Present health status (Current conditions, meds, allergies)
-Past medical history (childhood illness, surgeries, accidents etc)
-Family history
-Personal and psychosocial history (occupation, mental health, habits etc.)
-Review of all body systems
4 Basic Techniques of Physical Assessment
-Inspection(looking)
-Palpation(feeling)
-Percussion (tapping)
-Auscultation (hearing)
Inspection- What do I see?
- All body systems
-First - Equipment: Penlight, otoscope (ear), ophthalmoscope, speculum (vagina)
Palpation- What do I feel?
-Size, shape, location, identify painful areas
-Use palmar surface & finger tips (light 1cm, then deep 4cm)
-Dorsal surface for temp (back hand)
-Painful areas last
Percussion- What do I hear?
Evaluate: size, borders, consistency, tenderness, fluid
Five tones:
Tympany- loud, high-pitch, abdomen
Resonance- low- pitch, normal lung tissue
Hyperresonance- overinflated lungs such as emphysema
Dullness- over liver and solid organs
Flatness- bones and muscle
Auscultation- What do I hear?
-Listening to sounds within the body
-Uses stethoscope
Listen for sound characteristics: Intensity, Pitch, Duration, Quality
Helpful tip: close your eyes when listening to block out other sensory information
Optimize quality:
Quiet room
Place stethoscope DIRECTLY on skin NOT over top of clothes
Friction of body hair can sound like abnormal sounds- crackles in the lungs
Snellen Chart (what you see for eye exam)
-vision from far away
Tuning Fork
Tests auditory screening and assessment of vibratory sensation
Doppler ( looks like ipod touch)
-Amplifies sounds that are hard to hard w/ stethoscope
-Swishing pulsating sounds
Skinfold Caliper
Test for body fat
Jaegar & Rosenbaum Charts (Vision)
-Test for near vision
Goniometer
-Two rulers and a pizza cutter
-Measures degree of knee flex/extend
Percussion Hammer (Triangle)
-Deep tendon reflex test
-Triangular stick
Monofilament (small)
-Small, flexible wire like device
- test for sensation of lower extremities
Transilluminator
-Lightbox
-Shows characteristics of tissue, fluid, and air within a specific body cavity
General Survey
Initial data before examining body
-Vital signs
-Observations
Conversions
1kg=2.2lbs
1L=1kg=2.2lbs
Orthostatic Hypotension
-Low blood pressure, dropping too fast
Hypoxemia
Low oxygen in blood concentration
Dysrhythmia
Irregular heart beat
Apical Pulse
Pulse Point in chest at bottom of heart
Hypotension
-Uusually <90mm Hg
General Inspection
-Initial meeting: age, physical appearance, hygiene, body structure
Movement- range of motion, gait,
Emotional and mental status behavior- tone, mood, alertness, speech
Genetics
Study of heredity, function/comp of single genes
Genomics
Study of gens and their functions: incorporates all the genes and their relationships.
Context of Care
Refers to circumstances or situations related to healthcare delivery. May be related to environment, setting, physical, psychological or socioeconomic. Different types of assessments are preformed.
Patient tells the nurse that he has had a headache and nausea for three days which type of assessment should the nurse perform?
Focused assessment
Patient is admitted to the medical surgical unit with a diagnosis of hypertension the nurse is using nursing process to develop the plan of care which steps should the nurse incorporate? 
Assessment, diagnosis, outcome identification,planning, implementation,evaluation
A patient complains of a cough for four days unrelieved with position changes the nurse interprets this as a symptom and documents to finding under ______ on the patient’s chart
History bc it is subjective data from the patient
What objective data does a nurse collect during a physical assessment? 
Heart Murmur, Vital signs
The nurse is incorporating the principles from the Institute of medicine recommendations into the health assessment of a patient in the long-term care setting what principles should the nurse consider?
-Use evidence to support interventions
-place the patient at the center of care
-use technologies and informatics in delivering care
-include other disciplines in the plan of care
The student nurse is preparing to assess a patient in the hospital clinical setting which components best describe the concept of health assessments?
Collection of objective data, analysis of data, planning and evaluation of data
What is symptom analysis?
Systematic collection of subjective data related to the patient’s chief complaint
The nurse is assessing a patient’s activity level, which question or comment best facilitates discussion with the patient regarding his or her level of activity
What do you do to get exercise?
The nurse is conducting an interview with a patient who is mentally challenged the nurse knows that __________ assessment is to preferred method for the interview
Focused assessment: short simple
The nurse needs to assess an adolescent patient’s risk for a sexually transmitted diseases what technique shows the most sensitivity?
“ how many young people have questions regarding STDs what questions do you have?”
The introduction phase of the interview, the nurse asked why the patient came into the clinic this is known as______
History of present illness, may be problem or routine care issues
The nurse is focusing the interview for a patient who complains of headaches and nausea which interview format is based on body function as opposed to body systems? 
Functional health patterns: based on body systems
The nurse knows that the single most important factor in conducting an interview with the communication process which factors will most likely affect the positive interview process and therapeutic communication?
Obtaining patients history, asking closed ended questions, maintaining privacy
Sounds: tympany, resonance, dullness, flatness
Tympany- heard over abdomen
Resonance- heard on healthy lung tissue
Dullness- over liver
Flatness- over bones & muscles
Usually easier from resonance to dull
