study guide brainscape version 2 Flashcards
What is health assessment?
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.
What does the acronym ADPIE stand for in the nursing process?
- Assessment
- Diagnosis
- Planning
- Implementation
- Evaluation
ADPIE is a systematic approach used in nursing to ensure comprehensive patient care.
What is the primary focus of primary prevention?
Prevention of disease and disability, improving overall health and well-being
Examples include immunizations and health education.
Define critical thinking in nursing.
An active, purposeful, organized cognitive process involving creativity, reflection, problem solving, and judgment
Critical thinking is essential during the assessment process.
What are the five steps of the nursing process?
- Assessment
- Diagnosis
- Planning
- Implementation
- Evaluation
Each step is essential for delivering effective nursing care.
What is clinical judgment?
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.
What are the levels of prevention in health care?
- Primary prevention
- Secondary prevention
- Tertiary prevention
Each level addresses different aspects of health care and patient needs.
Fill in the blank: The acronym CLEAR in communication stands for _______.
[Center, Listen, Empathy, Attention, Respect]
CLEAR is used for effective patient interviews.
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
This process includes assessing psychosocial factors and health promotion practices.
True or False: Intuitive thinking relies solely on observable facts.
False
Intuitive thinking can be based on gut feelings and subtle cues.
What is the goal of the Quality and Safety Education for Nurses (QSEN) project?
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.
What is a nursing diagnosis?
Analyzing potential or actual health problems using subjective and objective data
It reflects the individual’s actual or potential health risks.
Define tertiary prevention.
Restoration of health after illness or disease has occurred
Examples include rehabilitation programs for stroke patients.
What is the significance of therapeutic communication?
Sensitive, nonjudgmental, culturally competent communication that addresses patient needs
It is essential for obtaining baseline information and fostering trust.
What is the role of nurses in the Patient Protection and Affordable Care Act (PPACA)?
To advocate for patients, provide compassionate care, and maintain competency
The PPACA aims to improve healthcare accessibility and quality.
List the six core competencies identified by QSEN.
- Patient-Centered Care
- Teamwork & Collaboration
- Evidence-Based Practice
- Quality Improvement
- Safety
- Informatics
These competencies are essential for nursing practice.
What is the review of systems (ROS)?
A subjective report by the patient about all body systems
It includes pertinent positives and negatives regarding symptoms.
What does intuitive thinking involve?
A gut feeling or sense of knowing not supported by observable facts
Intuition develops with experience and influences patient care quality.
What is therapeutic communication?
A process during which information is shared through the exchange of verbal and nonverbal messages, creating a relationship through interaction.
Who emphasized the nurse-patient relationship as the foundation of nursing practice?
Hildegard Peplau.
What must be maintained and respected during the entire patient encounter?
Privacy and confidentiality.
What law was created in April 2003 to maintain confidentiality for personal health information?
Health Insurance Portability and Accountability Act (HIPAA).
Name three dimensions of therapeutic communication for a patient-centered assessment.
- Empathy and compassion
- Unconditional regard
- Genuineness
What does empathy involve in therapeutic communication?
A deep awareness of and insight into the feelings, emotions, and behavior of another person.
What is unconditional regard?
Respecting and accepting a patient as a unique individual.
List two important preparations nurses should make before interviewing a patient.
- Read the patient’s record
- Arrange for a private environment
What is active listening?
Paying close attention to a patient’s report and non-verbal cues; maintaining good eye contact.
What should nurses avoid using during interviews to facilitate understanding?
Medical jargon.
What are some nonverbal communication cues to be aware of during an interview?
- Physical appearance
- Body language
- Facial expression
- Eye contact
- Gestures
True or False: Nonverbal communication accounts for less than 10% of the initial message we communicate.
False.
What is the purpose of summarizing at the end of an interview?
To clarify and accurately capture the important points of the patient’s history or problem.
Fill in the blank: Effective communication should be ______, concise, and honest.
clear
What is the first phase of the interview process?
Introductory Phase.
What is the focus of the Working Phase of the interview?
Collecting information about the patient.
What should nurses do if a patient appears quiet during an interview?
Ask if there is anything they would like to talk about.
Name two barriers to effective therapeutic communication.
- Asking too many questions
- Using clichés
What is the role of silence in therapeutic communication?
Allows the patient and the nurse to think over or feel what is being discussed.
What should a nurse do if a patient does not understand a question?
Obtain clarification.
What is the significance of using transitional statements during an interview?
To help redirect the interview to another topic.
What should nurses demonstrate when giving feedback to patients?
Honesty and respect.
What is the first step in patient communication?
Introduce yourself and call the patient by the appropriate surname.
What is the primary focus during the Working Phase of an interview?
Collect information about the patient.
What types of questions should be asked during the Working Phase?
Open- and closed-ended questions.
What should the nurse do if a patient does not understand English?
Explain the right to have a language interpreter.
True or False: It is recommended to use family members as interpreters during an assessment.
False.
What are some strategies for communicating with hearing-impaired patients?
Sit closer, ensure good lighting, speak slowly and clearly, face the patient.
What should a nurse do if a patient cannot hear?
Use written communication such as a whiteboard or paper and pencil.
What is crucial for visually impaired patients during assessments?
Introduce yourself and explain the purpose of the assessment.
What mnemonic is used to gather details about the history of present illness?
OLDCART.
What should be documented promptly regarding allergies?
The type of reaction the patient has had to an allergen.
What does a psychosocial assessment collect information about?
Psychological health and all aspects of the patient’s social life.
List the fundamental topics included in a psychosocial assessment.
- Behavioral
- Environmental
- Social
- Financial/economic
What is the purpose of a cultural assessment?
Identify specific cultural factors that affect a patient’s health.
What should nurses do to provide culturally competent care?
Develop increasing awareness about the similarities and differences of diverse cultures.
What is the General Survey in the Review of Systems (ROS)?
State of health and any current complaints/concerns.
What should be documented if a patient is unreliable or unable to answer questions?
The reason for their unreliability must be documented.
What are the components of the ROS?
- Integumentary
- HEENT
- Respiratory
- Cardiovascular
- Abdominal/GI
- GU/Reproductive
- Neuromuscular
- Neuro
What should be asked regarding the skin during the ROS?
Presence of rashes, lesions, redness, itching, or changes in moles.
Fill in the blank: The purpose of the OLDCARTS mnemonic is to document the specific details of _______.
[symptom(s)].
What should be assessed regarding the patient’s hair during the ROS?
Changes in hair distribution, brittleness, or hair loss.
What is the difference between dizziness and vertigo?
Dizziness is feeling light-headed; vertigo is a sensation of moving around.
What is recommended regarding cotton-tip applicators?
They are not recommended to clean the inner ear.
What should you avoid using to clean the inner ear?
Cotton-tip applicators
Cotton-tip applicators can push earwax farther into the ear canal.
What are common symptoms to assess in the nose and sinuses?
Nosebleeds, nasal drainage, loss of smell, allergy symptoms, sinus infections, sinus headaches
These symptoms can indicate underlying issues that require further evaluation.
What is a common question to ask regarding oral health?
Have you been to the dentist?
This helps assess the patient’s dental health and frequency of checkups.
What does dysphagia refer to?
Difficulty swallowing
What should you assess regarding neck health?
Lumps, limited range of motion, stiffness, history of neck injury
What are signs of respiratory issues to inquire about?
Cough, chest pain, shortness of breath, sputum production, hemoptysis, wheezing
What is important to document regarding a patient’s cardiac health?
Chest pain, palpitations, dyspnea on exertion, recent electrocardiogram
Documenting regular healthcare provider information is essential.
What percentage weight loss can indicate early risk of malnutrition?
5%
How is moderate protein-calorie malnutrition indicated?
10-20% weight loss
What is unplanned weight loss defined as?
Involuntary loss of greater than 5% of usual body weight in 1 month
What are signs of unplanned weight loss?
Loose fitting clothes, decreased food intake, reduced appetite, swallowing problems
What does malnutrition describe?
Deficiency, excess, or imbalance of nutrients
What are the two broad groups of malnutrition?
- Undernutrition
- Overnutrition
What is undernutrition?
Includes stunting, wasting, underweight, micronutrient deficiencies
What is overnutrition?
Being overweight or obese
What is the purpose of Kegel exercises?
To strengthen pelvic floor muscles to prevent leakage of urine
What are signs of depression to assess during a mental health evaluation?
Depressed mood, decreased interest, difficulty sleeping, chronic fatigue, feelings of worthlessness
What is the first step in assessing for suicide risk?
Ask about thoughts of self-harm
What screening tool has been developed for suicide risk assessment?
ASQ - Ask Suicide-Screening Questions
What does a brief suicide safety assessment (BSSA) classify?
Risk of suicide (low, high, imminent)
What is a key principle of patient education during health assessments?
Allow plenty of time
What is the recommended action for patients regarding health screenings?
Discuss recommended health screenings and health promotion
What is malnutrition?
Malnutrition refers to deficiencies, excesses, or imbalances in a person’s intake of energy and/or nutrients.
What are the two broad groups of conditions covered by malnutrition?
- Undernutrition
- Overnutrition
Define undernutrition.
Undernutrition includes stunting, wasting, underweight, and micronutrient deficiencies.
What is overnutrition?
Overnutrition is being overweight or obese.
List common causes of undernutrition.
- Inadequate calorie consumption
- Inadequate intake of essential vitamins and minerals
- Improper absorption and distribution of foods
What factors may contribute to malnutrition?
- Low income
- Chronic illnesses
- Dietary restrictions
- Mental health problems
What are the six basic diagnostic criteria for malnutrition proposed by ASPEN and AND?
- Low energy intake
- Weight loss
- Loss of muscle mass
- Loss of subcutaneous fat
- Fluid accumulation
- Diminished hand grip strength
True or False: A diagnosis of malnutrition can be made if an individual has at least two of the five criteria.
True
What is the calorie surplus needed to gain 1 pound of body fat in a week?
500 calories or more per day.
What is the global epidemic related to overnutrition?
Obesity
List common causes of overnutrition.
- Physical inactivity
- Dietary patterns
- Genetic factors
- Sedentary lifestyle
- Medications that cause weight gain
- Food marketing and promotions
What does a balanced diet provide?
Necessary vitamins and minerals.
What is the purpose of a comprehensive nutritional assessment?
To evaluate a client’s nutritional status based on various data.
What are the components of a nutritional assessment?
- Physical examination
- Anthropometric measurements
- Laboratory data
- Food intake information
What is the purpose of a 24-Hour Diet Recall?
To identify baseline dietary patterns contributing to overnutrition or undernutrition.
Fill in the blank: A nutritional screening is a process to identify an individual who is __________ or at risk for malnutrition.
[malnourished]
What does Body Mass Index (BMI) measure?
The amount of body fat based on height and weight.
What are the BMI ranges for underweight, overweight, and obesity?
- Underweight: BMI < 18.5
- Overweight: BMI ≥ 25 to 29.9
- Obese: BMI ≥ 30
What does a hematocrit level indicate?
The proportion of blood volume that consists of red blood cells.
What is ferritin?
A protein that stores iron for release when the body needs it.
What is the role of serum albumin level in nutritional assessment?
It measures visceral protein status and serves as an indicator of long-term protein status.
What is the significance of a complete blood count (CBC) in nutritional assessment?
It is used for screening anemia and evaluating normal erythropoiesis.
True or False: Nutritional assessments can only be performed by dietitians.
False
What is the purpose of measuring abdominal circumference?
To assess abdominal fat distribution.
What are the normal findings for abdominal circumference in males?
≤ 102 cm (40 inches).
What are the normal findings for abdominal circumference in females?
≤ 88 cm (35 inches).
What indicates an abnormal abdominal circumference in males?
> 102 cm (40 inches).
What indicates an abnormal abdominal circumference in females?
> 88 cm (35 inches).
True or False: Abdominal circumference is diagnostic of body fatness.
False.
What does mid-upper arm circumference (MUAC) assess?
Body protein stores and skeletal muscle mass.
What are the normal findings for MUAC in males?
≥ 23 cm.
What are the normal findings for MUAC in females?
≥ 22 cm.
What measurement indicates malnutrition in males?
< 23 cm.
What measurement indicates malnutrition in females?
< 22 cm.
What is Body Mass Index (BMI)?
A screening tool that identifies the amount of body fat based on height and weight.
What BMI range indicates underweight?
Less than or equal to 18.
What BMI range indicates overweight?
25-29.9.
What BMI range indicates obesity?
30-39.
What BMI indicates morbid obesity?
40 or higher.
How is the waist-to-hip ratio calculated?
Waist (inches) / Hip (inches).
What are the normal findings for waist-to-hip ratio in males?
< 0.95.
What are the normal findings for waist-to-hip ratio in females?
< 0.80.
What waist measurement indicates increased risk for cardiovascular disease in males?
> 40 inches.
What waist measurement indicates increased risk for cardiovascular disease in females?
> 35 inches.
What is neuropathic pain?
Pain caused by injury or damage to nerves.
What type of pain is characterized as diffuse, sharp, or well-localized?
Somatic pain.
What is visceral pain?
Vague or poorly localized pain originating from internal organs.
What characterizes colicky pain?
Fluctuates in intensity and occurs in waves.
What type of headache is characterized by unilateral, pulsatile pain?
Migraine.
What is the gold standard for assessing pain?
The patient’s self-report of pain.
What does the OLDCARTS acronym stand for in pain assessment?
Onset, Location, Duration, Characteristics, Aggravating, Relieving, treatment, severity
What is the numeric rating scale used for?
Patients rate pain from 0-10.
What are standard precautions in healthcare?
Minimum infection prevention practices that apply to all patient care.
What are the five moments for hand hygiene according to WHO?
- Before touching a patient
- Before clean/aseptic procedures
- After body fluid exposure/risk
- After touching a patient
- After touching patient surroundings.
What sequence is followed in physical assessment?
Inspection, Palpation, Percussion, Auscultation (IPPA).
What regulates body temperature?
The thermoregulatory center in the hypothalamus.
What is the term for the number of times the heart beats in a minute?
Pulse Rate
Pulse rate is a vital sign that reflects the heart’s activity.
Define Respiratory Rate.
Breathing frequency of respiratory cycles
One increase and one decrease counts as 1 towards the respiratory rate.
What does Blood Pressure measure?
The force of blood being exerted on the walls of the arteries
Blood pressure is critical for assessing cardiovascular health.
How is Cardiac Output calculated?
Stroke volume (mL) x heart rate
Cardiac output is an important measure of heart function.
What is Stroke Volume?
The amount of blood that is forced out of the heart with each heartbeat
Stroke volume is a key component of cardiac output.
Define Peripheral Vascular Resistance.
Resistance in the circulatory system that is used to create blood pressure
Peripheral vascular resistance is important for maintaining blood flow.
What is the normal appearance of tonsils?
Soft masses of lymphoid tissue, symmetric in size and grade 1+ bilaterally
Tonsils play a role in the immune system.
Describe the normal findings of the thyroid gland.
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.
What are normal nasal findings?
Nose located centrally, septum midline, bilateral nares pink and moist
These findings indicate a healthy nasal structure.
What does a normal cephalic finding indicate?
The head is normocephalic, with no signs of trauma
Normocephalic means the head is of normal shape and size.
What characterizes Acromegaly?
Enlargement of the bones of the hands, feet, and face due to growth hormone excess
Acromegaly is caused by pituitary gland dysfunction.
What features are assessed in a dilated eye examination?
Internal structures including the fundus, macula, and optic disc
This examination is vital for detecting eye diseases.
What is Conjunctivitis?
A bacterial or viral infection causing erythema of the sclera and yellow-green drainage
It is a common eye condition requiring medical attention.
What defines a Hordeolum?
Inflammation of an eyelash follicle causing redness, inflammation, and a lump
Commonly known as a stye.
What does Blepharitis entail?
Inflammation and infection of the eyelid margins, leading to redness and crusting
Associated with overproduction of oil by eye glands.
What are normal ear findings during hearing tests?
Tests include Rinne, Weber, Whisper, and Darwin test
These tests help assess hearing function.
What is Tinnitus?
Ringing sound in the ears
Tinnitus can indicate underlying auditory issues.
What is presbycusis?
Gradual loss of hearing in both ears
It is often associated with aging.
What tool measures visual acuity?
Snellen chart
This chart is commonly used in eye examinations.
What is the purpose of an Otoscope?
To examine the ear canal and eardrum
It is essential for diagnosing ear conditions.
What does Healthy People 2030 recommend for TBI prevention?
Health promotion efforts including recreational safety, fall prevention, and car safety
Focus on safety measures to reduce the risk of traumatic brain injury.
What is the prevalence of open-angle glaucoma in African Americans?
Affects three to six times more often than whites, six times more likely to cause blindness
Diabetics are also at higher risk for glaucoma.
