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NUR211 > study guide brainscape version 2 > Flashcards

study guide brainscape version 2 Flashcards

1
Q

What is health assessment?

A

A skill to identify normal from abnormal findings, assessing the whole patient through data collection, validation, and clustering

Health assessment includes establishing a baseline health history and ongoing data collection.

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2
Q

What does the acronym ADPIE stand for in the nursing process?

A
  • Assessment
  • Diagnosis
  • Planning
  • Implementation
  • Evaluation

ADPIE is a systematic approach used in nursing to ensure comprehensive patient care.

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3
Q

What is the primary focus of primary prevention?

A

Prevention of disease and disability, improving overall health and well-being

Examples include immunizations and health education.

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4
Q

Define critical thinking in nursing.

A

An active, purposeful, organized cognitive process involving creativity, reflection, problem solving, and judgment

Critical thinking is essential during the assessment process.

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5
Q

What are the five steps of the nursing process?

A
  • Assessment
  • Diagnosis
  • Planning
  • Implementation
  • Evaluation

Each step is essential for delivering effective nursing care.

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6
Q

What is clinical judgment?

A

An interpretation or conclusion about a patient’s needs or health problems and the decision to take action

Clinical judgment is crucial for quality nursing care.

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7
Q

What are the levels of prevention in health care?

A
  • Primary prevention
  • Secondary prevention
  • Tertiary prevention

Each level addresses different aspects of health care and patient needs.

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8
Q

Fill in the blank: The acronym CLEAR in communication stands for _______.

A

[Center, Listen, Empathy, Attention, Respect]

CLEAR is used for effective patient interviews.

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9
Q

What is the purpose of conducting a health history?

A

To gather information about a patient’s past and present health and personal beliefs influencing health

This process includes assessing psychosocial factors and health promotion practices.

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10
Q

True or False: Intuitive thinking relies solely on observable facts.

A

False

Intuitive thinking can be based on gut feelings and subtle cues.

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11
Q

What is the goal of the Quality and Safety Education for Nurses (QSEN) project?

A

To prepare future nurses with the knowledge, skills, and attitudes necessary to improve healthcare quality and safety

QSEN identifies six core competencies for registered nurses.

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12
Q

What is a nursing diagnosis?

A

Analyzing potential or actual health problems using subjective and objective data

It reflects the individual’s actual or potential health risks.

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13
Q

Define tertiary prevention.

A

Restoration of health after illness or disease has occurred

Examples include rehabilitation programs for stroke patients.

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14
Q

What is the significance of therapeutic communication?

A

Sensitive, nonjudgmental, culturally competent communication that addresses patient needs

It is essential for obtaining baseline information and fostering trust.

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15
Q

What is the role of nurses in the Patient Protection and Affordable Care Act (PPACA)?

A

To advocate for patients, provide compassionate care, and maintain competency

The PPACA aims to improve healthcare accessibility and quality.

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16
Q

List the six core competencies identified by QSEN.

A
  • Patient-Centered Care
  • Teamwork & Collaboration
  • Evidence-Based Practice
  • Quality Improvement
  • Safety
  • Informatics

These competencies are essential for nursing practice.

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17
Q

What is the review of systems (ROS)?

A

A subjective report by the patient about all body systems

It includes pertinent positives and negatives regarding symptoms.

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18
Q

What does intuitive thinking involve?

A

A gut feeling or sense of knowing not supported by observable facts

Intuition develops with experience and influences patient care quality.

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19
Q

What is therapeutic communication?

A

A process during which information is shared through the exchange of verbal and nonverbal messages, creating a relationship through interaction.

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20
Q

Who emphasized the nurse-patient relationship as the foundation of nursing practice?

A

Hildegard Peplau.

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21
Q

What must be maintained and respected during the entire patient encounter?

A

Privacy and confidentiality.

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22
Q

What law was created in April 2003 to maintain confidentiality for personal health information?

A

Health Insurance Portability and Accountability Act (HIPAA).

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23
Q

Name three dimensions of therapeutic communication for a patient-centered assessment.

A
  • Empathy and compassion
  • Unconditional regard
  • Genuineness
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24
Q

What does empathy involve in therapeutic communication?

A

A deep awareness of and insight into the feelings, emotions, and behavior of another person.

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25
Q

What is unconditional regard?

A

Respecting and accepting a patient as a unique individual.

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26
Q

List two important preparations nurses should make before interviewing a patient.

A
  • Read the patient’s record
  • Arrange for a private environment
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27
Q

What is active listening?

A

Paying close attention to a patient’s report and non-verbal cues; maintaining good eye contact.

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28
Q

What should nurses avoid using during interviews to facilitate understanding?

A

Medical jargon.

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29
Q

What are some nonverbal communication cues to be aware of during an interview?

A
  • Physical appearance
  • Body language
  • Facial expression
  • Eye contact
  • Gestures
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30
Q

True or False: Nonverbal communication accounts for less than 10% of the initial message we communicate.

A

False.

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31
Q

What is the purpose of summarizing at the end of an interview?

A

To clarify and accurately capture the important points of the patient’s history or problem.

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32
Q

Fill in the blank: Effective communication should be ______, concise, and honest.

A

clear

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33
Q

What is the first phase of the interview process?

A

Introductory Phase.

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34
Q

What is the focus of the Working Phase of the interview?

A

Collecting information about the patient.

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35
Q

What should nurses do if a patient appears quiet during an interview?

A

Ask if there is anything they would like to talk about.

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36
Q

Name two barriers to effective therapeutic communication.

A
  • Asking too many questions
  • Using clichés
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37
Q

What is the role of silence in therapeutic communication?

A

Allows the patient and the nurse to think over or feel what is being discussed.

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38
Q

What should a nurse do if a patient does not understand a question?

A

Obtain clarification.

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39
Q

What is the significance of using transitional statements during an interview?

A

To help redirect the interview to another topic.

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40
Q

What should nurses demonstrate when giving feedback to patients?

A

Honesty and respect.

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41
Q

What is the first step in patient communication?

A

Introduce yourself and call the patient by the appropriate surname.

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42
Q

What is the primary focus during the Working Phase of an interview?

A

Collect information about the patient.

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43
Q

What types of questions should be asked during the Working Phase?

A

Open- and closed-ended questions.

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44
Q

What should the nurse do if a patient does not understand English?

A

Explain the right to have a language interpreter.

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45
Q

True or False: It is recommended to use family members as interpreters during an assessment.

A

False.

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46
Q

What are some strategies for communicating with hearing-impaired patients?

A

Sit closer, ensure good lighting, speak slowly and clearly, face the patient.

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47
Q

What should a nurse do if a patient cannot hear?

A

Use written communication such as a whiteboard or paper and pencil.

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48
Q

What is crucial for visually impaired patients during assessments?

A

Introduce yourself and explain the purpose of the assessment.

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49
Q

What mnemonic is used to gather details about the history of present illness?

A

OLDCART.

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50
Q

What should be documented promptly regarding allergies?

A

The type of reaction the patient has had to an allergen.

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51
Q

What does a psychosocial assessment collect information about?

A

Psychological health and all aspects of the patient’s social life.

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52
Q

List the fundamental topics included in a psychosocial assessment.

A
  • Behavioral
  • Environmental
  • Social
  • Financial/economic
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53
Q

What is the purpose of a cultural assessment?

A

Identify specific cultural factors that affect a patient’s health.

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54
Q

What should nurses do to provide culturally competent care?

A

Develop increasing awareness about the similarities and differences of diverse cultures.

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55
Q

What is the General Survey in the Review of Systems (ROS)?

A

State of health and any current complaints/concerns.

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56
Q

What should be documented if a patient is unreliable or unable to answer questions?

A

The reason for their unreliability must be documented.

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57
Q

What are the components of the ROS?

A
  • Integumentary
  • HEENT
  • Respiratory
  • Cardiovascular
  • Abdominal/GI
  • GU/Reproductive
  • Neuromuscular
  • Neuro
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58
Q

What should be asked regarding the skin during the ROS?

A

Presence of rashes, lesions, redness, itching, or changes in moles.

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59
Q

Fill in the blank: The purpose of the OLDCARTS mnemonic is to document the specific details of _______.

A

[symptom(s)].

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60
Q

What should be assessed regarding the patient’s hair during the ROS?

A

Changes in hair distribution, brittleness, or hair loss.

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61
Q

What is the difference between dizziness and vertigo?

A

Dizziness is feeling light-headed; vertigo is a sensation of moving around.

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62
Q

What is recommended regarding cotton-tip applicators?

A

They are not recommended to clean the inner ear.

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63
Q

What should you avoid using to clean the inner ear?

A

Cotton-tip applicators

Cotton-tip applicators can push earwax farther into the ear canal.

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64
Q

What are common symptoms to assess in the nose and sinuses?

A

Nosebleeds, nasal drainage, loss of smell, allergy symptoms, sinus infections, sinus headaches

These symptoms can indicate underlying issues that require further evaluation.

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65
Q

What is a common question to ask regarding oral health?

A

Have you been to the dentist?

This helps assess the patient’s dental health and frequency of checkups.

66
Q

What does dysphagia refer to?

A

Difficulty swallowing

67
Q

What should you assess regarding neck health?

A

Lumps, limited range of motion, stiffness, history of neck injury

68
Q

What are signs of respiratory issues to inquire about?

A

Cough, chest pain, shortness of breath, sputum production, hemoptysis, wheezing

69
Q

What is important to document regarding a patient’s cardiac health?

A

Chest pain, palpitations, dyspnea on exertion, recent electrocardiogram

Documenting regular healthcare provider information is essential.

70
Q

What percentage weight loss can indicate early risk of malnutrition?

A

5%

71
Q

How is moderate protein-calorie malnutrition indicated?

A

10-20% weight loss

72
Q

What is unplanned weight loss defined as?

A

Involuntary loss of greater than 5% of usual body weight in 1 month

73
Q

What are signs of unplanned weight loss?

A

Loose fitting clothes, decreased food intake, reduced appetite, swallowing problems

74
Q

What does malnutrition describe?

A

Deficiency, excess, or imbalance of nutrients

75
Q

What are the two broad groups of malnutrition?

A
  1. Undernutrition
  2. Overnutrition
76
Q

What is undernutrition?

A

Includes stunting, wasting, underweight, micronutrient deficiencies

77
Q

What is overnutrition?

A

Being overweight or obese

78
Q

What is the purpose of Kegel exercises?

A

To strengthen pelvic floor muscles to prevent leakage of urine

79
Q

What are signs of depression to assess during a mental health evaluation?

A

Depressed mood, decreased interest, difficulty sleeping, chronic fatigue, feelings of worthlessness

80
Q

What is the first step in assessing for suicide risk?

A

Ask about thoughts of self-harm

81
Q

What screening tool has been developed for suicide risk assessment?

A

ASQ - Ask Suicide-Screening Questions

82
Q

What does a brief suicide safety assessment (BSSA) classify?

A

Risk of suicide (low, high, imminent)

83
Q

What is a key principle of patient education during health assessments?

A

Allow plenty of time

84
Q

What is the recommended action for patients regarding health screenings?

A

Discuss recommended health screenings and health promotion

85
Q

What is malnutrition?

A

Malnutrition refers to deficiencies, excesses, or imbalances in a person’s intake of energy and/or nutrients.

86
Q

What are the two broad groups of conditions covered by malnutrition?

A
  • Undernutrition
  • Overnutrition
87
Q

Define undernutrition.

A

Undernutrition includes stunting, wasting, underweight, and micronutrient deficiencies.

88
Q

What is overnutrition?

A

Overnutrition is being overweight or obese.

89
Q

List common causes of undernutrition.

A
  • Inadequate calorie consumption
  • Inadequate intake of essential vitamins and minerals
  • Improper absorption and distribution of foods
90
Q

What factors may contribute to malnutrition?

A
  • Low income
  • Chronic illnesses
  • Dietary restrictions
  • Mental health problems
91
Q

What are the six basic diagnostic criteria for malnutrition proposed by ASPEN and AND?

A
  • Low energy intake
  • Weight loss
  • Loss of muscle mass
  • Loss of subcutaneous fat
  • Fluid accumulation
  • Diminished hand grip strength
92
Q

True or False: A diagnosis of malnutrition can be made if an individual has at least two of the five criteria.

A

True

93
Q

What is the calorie surplus needed to gain 1 pound of body fat in a week?

A

500 calories or more per day.

94
Q

What is the global epidemic related to overnutrition?

A

Obesity

95
Q

List common causes of overnutrition.

A
  • Physical inactivity
  • Dietary patterns
  • Genetic factors
  • Sedentary lifestyle
  • Medications that cause weight gain
  • Food marketing and promotions
96
Q

What does a balanced diet provide?

A

Necessary vitamins and minerals.

97
Q

What is the purpose of a comprehensive nutritional assessment?

A

To evaluate a client’s nutritional status based on various data.

98
Q

What are the components of a nutritional assessment?

A
  • Physical examination
  • Anthropometric measurements
  • Laboratory data
  • Food intake information
99
Q

What is the purpose of a 24-Hour Diet Recall?

A

To identify baseline dietary patterns contributing to overnutrition or undernutrition.

100
Q

Fill in the blank: A nutritional screening is a process to identify an individual who is __________ or at risk for malnutrition.

A

[malnourished]

101
Q

What does Body Mass Index (BMI) measure?

A

The amount of body fat based on height and weight.

102
Q

What are the BMI ranges for underweight, overweight, and obesity?

A
  • Underweight: BMI < 18.5
  • Overweight: BMI ≥ 25 to 29.9
  • Obese: BMI ≥ 30
103
Q

What does a hematocrit level indicate?

A

The proportion of blood volume that consists of red blood cells.

104
Q

What is ferritin?

A

A protein that stores iron for release when the body needs it.

105
Q

What is the role of serum albumin level in nutritional assessment?

A

It measures visceral protein status and serves as an indicator of long-term protein status.

106
Q

What is the significance of a complete blood count (CBC) in nutritional assessment?

A

It is used for screening anemia and evaluating normal erythropoiesis.

107
Q

True or False: Nutritional assessments can only be performed by dietitians.

A

False

108
Q

What is the purpose of measuring abdominal circumference?

A

To assess abdominal fat distribution.

109
Q

What are the normal findings for abdominal circumference in males?

A

≤ 102 cm (40 inches).

110
Q

What are the normal findings for abdominal circumference in females?

A

≤ 88 cm (35 inches).

111
Q

What indicates an abnormal abdominal circumference in males?

A

> 102 cm (40 inches).

112
Q

What indicates an abnormal abdominal circumference in females?

A

> 88 cm (35 inches).

113
Q

True or False: Abdominal circumference is diagnostic of body fatness.

A

False.

114
Q

What does mid-upper arm circumference (MUAC) assess?

A

Body protein stores and skeletal muscle mass.

115
Q

What are the normal findings for MUAC in males?

A

≥ 23 cm.

116
Q

What are the normal findings for MUAC in females?

A

≥ 22 cm.

117
Q

What measurement indicates malnutrition in males?

A

< 23 cm.

118
Q

What measurement indicates malnutrition in females?

A

< 22 cm.

119
Q

What is Body Mass Index (BMI)?

A

A screening tool that identifies the amount of body fat based on height and weight.

120
Q

What BMI range indicates underweight?

A

Less than or equal to 18.

121
Q

What BMI range indicates overweight?

A

25-29.9.

122
Q

What BMI range indicates obesity?

A

30-39.

123
Q

What BMI indicates morbid obesity?

A

40 or higher.

124
Q

How is the waist-to-hip ratio calculated?

A

Waist (inches) / Hip (inches).

125
Q

What are the normal findings for waist-to-hip ratio in males?

A

< 0.95.

126
Q

What are the normal findings for waist-to-hip ratio in females?

A

< 0.80.

127
Q

What waist measurement indicates increased risk for cardiovascular disease in males?

A

> 40 inches.

128
Q

What waist measurement indicates increased risk for cardiovascular disease in females?

A

> 35 inches.

129
Q

What is neuropathic pain?

A

Pain caused by injury or damage to nerves.

130
Q

What type of pain is characterized as diffuse, sharp, or well-localized?

A

Somatic pain.

131
Q

What is visceral pain?

A

Vague or poorly localized pain originating from internal organs.

132
Q

What characterizes colicky pain?

A

Fluctuates in intensity and occurs in waves.

133
Q

What type of headache is characterized by unilateral, pulsatile pain?

A

Migraine.

134
Q

What is the gold standard for assessing pain?

A

The patient’s self-report of pain.

135
Q

What does the OLDCARTS acronym stand for in pain assessment?

A

Onset, Location, Duration, Characteristics, Aggravating, Relieving, treatment, severity

136
Q

What is the numeric rating scale used for?

A

Patients rate pain from 0-10.

137
Q

What are standard precautions in healthcare?

A

Minimum infection prevention practices that apply to all patient care.

138
Q

What are the five moments for hand hygiene according to WHO?

A
  • Before touching a patient
  • Before clean/aseptic procedures
  • After body fluid exposure/risk
  • After touching a patient
  • After touching patient surroundings.
139
Q

What sequence is followed in physical assessment?

A

Inspection, Palpation, Percussion, Auscultation (IPPA).

140
Q

What regulates body temperature?

A

The thermoregulatory center in the hypothalamus.

141
Q

What is the term for the number of times the heart beats in a minute?

A

Pulse Rate

Pulse rate is a vital sign that reflects the heart’s activity.

142
Q

Define Respiratory Rate.

A

Breathing frequency of respiratory cycles

One increase and one decrease counts as 1 towards the respiratory rate.

143
Q

What does Blood Pressure measure?

A

The force of blood being exerted on the walls of the arteries

Blood pressure is critical for assessing cardiovascular health.

144
Q

How is Cardiac Output calculated?

A

Stroke volume (mL) x heart rate

Cardiac output is an important measure of heart function.

145
Q

What is Stroke Volume?

A

The amount of blood that is forced out of the heart with each heartbeat

Stroke volume is a key component of cardiac output.

146
Q

Define Peripheral Vascular Resistance.

A

Resistance in the circulatory system that is used to create blood pressure

Peripheral vascular resistance is important for maintaining blood flow.

147
Q

What is the normal appearance of tonsils?

A

Soft masses of lymphoid tissue, symmetric in size and grade 1+ bilaterally

Tonsils play a role in the immune system.

148
Q

Describe the normal findings of the thyroid gland.

A

A butterfly-shaped gland in the anterior portion of the neck, palpable from a posterior position

The thyroid is crucial for metabolism and hormone production.

149
Q

What are normal nasal findings?

A

Nose located centrally, septum midline, bilateral nares pink and moist

These findings indicate a healthy nasal structure.

150
Q

What does a normal cephalic finding indicate?

A

The head is normocephalic, with no signs of trauma

Normocephalic means the head is of normal shape and size.

151
Q

What characterizes Acromegaly?

A

Enlargement of the bones of the hands, feet, and face due to growth hormone excess

Acromegaly is caused by pituitary gland dysfunction.

152
Q

What features are assessed in a dilated eye examination?

A

Internal structures including the fundus, macula, and optic disc

This examination is vital for detecting eye diseases.

153
Q

What is Conjunctivitis?

A

A bacterial or viral infection causing erythema of the sclera and yellow-green drainage

It is a common eye condition requiring medical attention.

154
Q

What defines a Hordeolum?

A

Inflammation of an eyelash follicle causing redness, inflammation, and a lump

Commonly known as a stye.

155
Q

What does Blepharitis entail?

A

Inflammation and infection of the eyelid margins, leading to redness and crusting

Associated with overproduction of oil by eye glands.

156
Q

What are normal ear findings during hearing tests?

A

Tests include Rinne, Weber, Whisper, and Darwin test

These tests help assess hearing function.

157
Q

What is Tinnitus?

A

Ringing sound in the ears

Tinnitus can indicate underlying auditory issues.

158
Q

What is presbycusis?

A

Gradual loss of hearing in both ears

It is often associated with aging.

159
Q

What tool measures visual acuity?

A

Snellen chart

This chart is commonly used in eye examinations.

160
Q

What is the purpose of an Otoscope?

A

To examine the ear canal and eardrum

It is essential for diagnosing ear conditions.

161
Q

What does Healthy People 2030 recommend for TBI prevention?

A

Health promotion efforts including recreational safety, fall prevention, and car safety

Focus on safety measures to reduce the risk of traumatic brain injury.

162
Q

What is the prevalence of open-angle glaucoma in African Americans?

A

Affects three to six times more often than whites, six times more likely to cause blindness

Diabetics are also at higher risk for glaucoma.

NUR211 (12 decks)

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