study guide brainscape exam 1 Flashcards
What is health assessment?
A skill to identify normal from abnormal findings
It involves collecting, validating, and clustering data to assess the whole patient.
What does ADPIE stand for in the nursing process?
Assessment, Diagnosis, Planning, Implementation, Evaluation
This framework guides nurses in providing care.
What is the purpose of the assessment phase in nursing?
To collect and analyze information about the whole individual
This includes physiological, psychological, psychosocial, and spiritual/cultural data.
Define critical thinking in nursing.
A broad term used to describe a set of skills aimed at continuously collecting data and cues while creating the best plan in any situation
It includes prioritizing care and problem-solving.
What are the levels of prevention in health care?
Primary, Secondary, Tertiary
Each level focuses on different aspects of disease prevention and health promotion.
What is primary prevention?
Prevention of disease and disability; focuses on improving overall health and well-being
Example: vaccinations.
What is secondary prevention?
Early screenings and detection of disease and treatment of diseases
Example: routine health check-ups.
What is tertiary prevention?
Restoration of health after illness or disease has occurred
Example: rehabilitation for stroke patients.
What does the American Nurse Association Code of Ethics for Nurses emphasize?
High standards including the maintenance of competency and skill based on evidence-based research.
What is the purpose of conducting a health history?
To gather information about a patient’s past and present health and personal beliefs influencing health and illness.
What is the Review of Systems (ROS)?
A subjective report by the patient about all body systems
It includes pertinent positives and negatives.
Define therapeutic communication.
Sensitive, nonjudgmental, culturally competent communication that is not rushed.
What does the acronym CLEAR stand for in health history interviewing?
Center, Listen, Empathy, Attention, Respect.
What is the significance of OLDCART in health assessments?
It helps structure the assessment of the history of present illness
OLDCART stands for Onset, Location, Duration, Characteristics, Aggravating factors, Relieving factors, Treatments.
What is the difference between objective and subjective data?
Objective data is observable (e.g., vital signs), while subjective data is reported by the patient (e.g., pain levels).
What are the components of a psychosocial assessment?
Behavioral, Environmental, Social, Financial/economic.
What does a nutritional assessment include?
Physical examination, anthropometric measurements, laboratory data, and food intake.
What is Body Mass Index (BMI) used for?
To screen for the amount of body fat based on height and weight.
What percentage weight loss indicates increased risk of malnutrition?
5% weight loss can be an early indicator.
What types of pain are identified in pain assessment?
Neuropathic, Somatic, Visceral, Colicky, Cutaneous.
What is the gold standard for assessing pain?
The patient’s self-report of pain.
What is the purpose of pain assessment tools?
To systematically assess the characteristics and intensity of pain.
What are the types of headaches?
Migraine, Cluster, Sinus, Tension.
What are standard precautions in nursing?
Hand hygiene and PPE as appropriate.
What scale is used to assess pain levels from 0-10 based on patient report?
0-10 scale for pain assessment
What is the PainQuILT tool used for?
Assessing chronic pain through 16 icons representing pain characteristics
What type of scale is appropriate for clients who cannot verbalize pain?
Nonverbal descriptor scale
What are the standard precautions in physical exams?
Hand hygiene, PPE as appropriate (gloves, gown, mask, eye protection, respirators)
What is the best practice regarding hand hygiene during patient care?
Perform hand hygiene in front of the client when possible
What is the recommended approach for patient positioning during health assessments?
Use an organized approach, least invasive to most invasive
What factors can affect a patient’s ability to change positions?
Strength, limitations, and degree of wellness
What is the sequence of the physical assessment?
IPPA (Inspection, Palpation, Percussion, Auscultation)
What is the sequence for assessing vital signs?
General survey, temperature, pulse, respiratory rate, blood pressure
Where is body temperature regulated in the body?
Thermoregulatory center in the hypothalamus
Define pulse rate.
Number of times the heart beats in a minute
What does respiratory rate measure?
Breathing frequency of respiratory cycles
What is blood pressure?
The force of blood exerted on the walls of the arteries
What is cardiac output?
Stroke volume (mL) x heart rate
Define stroke volume.
Amount of blood forced out of the heart with each heartbeat
What is peripheral vascular resistance?
Resistance in the circulatory system used to create blood pressure
What are normal tonsil findings?
Soft masses of lymphoid tissue, symmetric in size, grade 1+ bilaterally
What is the function of the thyroid gland?
Endocrine function, metabolism, and hormone production
What are normal nasal findings?
Nose centrally located, septum midline, bilateral nares pink and moist
What does ‘normocephalic’ mean?
The head is normal in shape and size
What condition is characterized by growth hormone excess?
Acromegaly
What are normal findings for the eyes?
Symmetrical, clear cornea, pink conjunctiva, red reflex present, PERRLA
What does PERRLA stand for?
Pupils Equal, Round, Reactive to Light and Accommodation
What is conjunctivitis?
Bacterial or viral infection causing redness and discharge from the conjunctiva
What is a hordeolum?
Inflammation of an eyelash follicle causing redness and a lump
What is blepharitis?
Inflammation and infection of the eyelid margins
What tests are used for hearing assessment?
Rinne, Weber, Whisper, Darwin tests
What is tinnitus?
Ringing sound in the ears
What is the purpose of a Snellen chart?
Assess visual acuity
What is the function of an otoscope?
Examine the ear canal and eardrum
What does a stadiometer measure?
Body height
What does Healthy People 2030 recommend for preventing traumatic brain injury?
Recreational safety, fall prevention, car safety
True or False: Open-angle glaucoma affects African Americans more often than whites.
True
What risk factor increases the likelihood of developing glaucoma?
Diabetes
