NSG 316 TOPIC 1

Question 1

Follow-up database

Answer 1

A follow up will occur so that the status of any identified problems can be evaluated (this will be done at regular and appropriate intervals).

Question 2

second level priority

Answer 2

include mental status changed, acute pain, infection risk, abnormal lab values, and elimination problems.

Question 3

third level priority

Answer 3

include lack of knowledge, mobility problems, and family coping

Question 4

inspection

Answer 4

concentrated watching, first of the individual as a whole then of each body system. Inspection begins the moment you first meet the person and develop a “general survey.”

Question 5

palpation

Answer 5

applies your sense of touch to assess: temperature, moisture, organ location and size and any swelling, vibration or pulsation, rigidity or spasticity, crepitation, presence of lumps or masses and presence of tenderness of pain.

Question 6

percussion

Answer 6

tapping the person’s skin with sort, sharp strokes to assess underlying structures. Depicts location, size, and density of underlying organ.

Question 7

auscultation

Answer 7

listening to the sounds produced by the body, such as heart, blood vessels, lungs, and abdomen.

Question 8

open-ended questions

Answer 8

Asks for narrative information. It states the topic to be discussed but only in general terms. Use it to begin the interview, introduce a new section of questions, and whenever the person introduces a new topic.

Question 9

general survey

Answer 9

study of the whole person, covering the general health state and any obvious physical characteristics. four components of a general survey are physical appearance, body structure, mobility, and behavior.

Question 10

close ended questions

Answer 10

Ask for specific information, eliciting a “yes” or “no” response.

Question 11

What are the ten traps of interviewing?

Answer 11

1. Providing false assurance or reassurance
2. Giving unwanted advice
3. Using authority
4. Using avoidance language
5. Engaging in distancing
6. Using professional jargon
7. Using leading or biased questions
8. Talking too much
9. Interrupting
10. Using “why” questions

Question 12

cultural assessment

Answer 12

the systematic assessment of individuals, families, and communities regarding their health beliefs and values

Question 13

Steps to Cultural Competence

Answer 13

Understand one’s own heritage-based values, beliefs, attitudes, and practices
Identify meaning of “health” to patient
Understand how health care system works
Acquire knowledge about social backgrounds of patients
Become familiar with languages, interpretive services, and community resources available to nurses and patients

Question 14

Spirituality Assessment

Answer 14

consider spiritual needs when planning care 1.
“Do you have any religious or spiritual preferences that we can support?”

Question 15

ethnicity

Answer 15

Refers to a social group that may possess shared traits, such as a common geographic origin, migratory status, religion, language, values, traditions or symbols, and food preferences.

Question 16

Religion

Answer 16

refers to an organized system of beliefs concerning the cause, nature, and purpose of the universe, as well as the attendance of regular services. Religion is a shared experience of spirituality or the values, beliefs, and practices

Question 17

health history components

Answer 17

1. Biographic data
2. Reason for seeking care
3. Present health or history of present illness
4. Past history
5. Medication reconciliation
6. Family history
7. Review of systems
8. Functional assessment or activities of daily living (ADLs)

Question 18

functional assessment

Answer 18

Measures a person’s self-care ability in the areas of general physical health; ADLs, IADLs, and AADLs

Question 19

ADLs (activities of daily living)

Answer 19

bathing, dressing, toileting, eating, walking

Question 21

IADLs (instrumental activities of daily living)

Answer 21

refer to functional abilities necessary for independent community living. Typically IADL tasks include shopping, meal preparation, housekeeping, laundry, managing finances, taking medications, and using transportation

Question 21

AADLs (Advanced Activities of Daily Living)-

Answer 21

instruments commonly include self-care, mobility, work (either paid or volunteer), recreational activities/hobbies, and socialization.

Question 22

depression

Answer 22

is a long-term depressed mood (≥2 weeks) with lack of pleasure; disturbed sleep and appetite; feelings of hopelessness, guilt, worthlessness, sadness, loneliness, and despair; suicide ideation.

Question 23

Complete (Total Health) Database

Answer 23

Includes complete health history and full physical examination
Describes current and past health state and forms baseline to measure all future changes
Yields first diagnoses

Question 24

Focused or Problem-Centered Database

Answer 24

For limited or short term problem. Collect “mini” database, smaller in scope, concerns mainly one problem, ONE cue complex, or ONE body system

Question 25

Emergency database

Answer 25

rapid collection of the database, often compiled concurrently with lifesaving measures

Question 26

health promotion

Answer 26

the process of enabling people to increase control over, and to improve, their health

Question 27

disease prevention

Answer 27

the process of reducing risks and alleviating disease to promote, preserve, and restore health and minimize suffering and distress

Question 28

first level priority

Answer 28

high priority; emergent, life threatening AIRWAY BREATHING CIRCULATION

Question 29

AADLs (Advanced Activities of Daily Living)-

Answer 29

instruments commonly include self-care, mobility, work (either paid or volunteer), recreational activities/hobbies, and socialization.

Question 30

Delirium

Answer 30

Cognitive impairment. There is a cause for it, if we can take care of the cause we can reverse it. Elderly: Pneumonia & UTI. When they are moved to a new location: have them get used to the area.

Question 31

Dementia

Answer 31

Irreversible. Gradual it can take years can happen to younger adults. Affect ADLs: can’t dress themselves, eating, bathing, walking.

Question 32

subjective data

Answer 32

What patient says about himself or herself during history taking

Question 33

objective data

Answer 33

Observed when inspecting, percussing, palpating, and auscultating patient during physical examination

Question 34

services for preventative health care:

Answer 34

o SCREENING history for dietary intake, physical activity, tobacco/alcohol/drug use, and sexual practices
o COUNSELING for injury prevention, substance use, sexual behavior, diet and exercise, and dental health
o IMMUNIZATIONS
o PROPHYLAXIS with multivitamin with folic acid for females capable of or planning pregnancy

Question 35

what areas should you consider during a general survey

Answer 35

-Physical appearance
-Body structure
-Mobility
-Behavior

Question 36

objective data: physical appearance

Answer 36

-Age: person appears his or her stated age
-Sex: sexual development appropriate for gender and age
-Level of consciousness: person alert and oriented, attends to your questions and responds appropriately
-Skin color: color tone even, pigmentation varying with genetic background, skin intact with no obvious lesion
-Facial features: symmetric with movement
-No signs of acute distress present

Question 37

objective data: body structure

Answer 37

-Stature: height in normal range
-Nutrition: weight/ body distribution in normal range
-Symmetry
-Posture
-Position: person sits comfortably in chair or on bed or examining table, arms relaxed at sides, head turned to examiner
-Body build, contour
-Arm span
-Body length
-Obvious physical deformities

Question 38

objective data: mobility

Answer 38

gait:
- should have base as wide as shoulder width
- foot placement accurate, smooth, even, well balanced
- range of motion is deliberate, accurate, smooth and coordinated
- no involuntary movement

Question 39

objective data: behavior

Answer 39

facial expression, mood and affect, speech, dress, personal hygiene