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test 1 Flashcards

1
Q

COLDSPA acronym

A

character
onset
location
duration
severity
pattern
associated factors

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2
Q

nursing open ended qeustions

A

can’t be answered with yes or no. requires more detail

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3
Q

what is health

A

a state of complete physical, mental, and social well being and not merely the absence of disease or infirmity

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4
Q

8 dimensions of health

A

physical, emotional, social, spiritual, environmental, intellectual, financial, occupational

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5
Q

health assessment

A

the process used to evaluate the health status of a person

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6
Q

nursing assessment

A

focus on patient response to diagnosis or disease

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7
Q

healthy people 2030

A

framework to improve overall health of induviduals

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8
Q

beginning the exam: set the stage

A

reflect on approach
adjust lighting
check equipment
use precautions

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9
Q

cardinal techniques of examination

A

close observation
auscultation
palpation
percussion

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10
Q

how to conduct an exam

A

move head to toe, starting with right side

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11
Q

ADPIE

A

assessment
diagnosis
planning
implementation
evaluation

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12
Q

objective data

A

what you see- signs
physical exam
lab reports
radiologic findings

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13
Q

subjective data

A

what patient tells you- symptoms
history
chief complaint
OLDCART

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14
Q

old cart: onset

A

when did symptom begin

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15
Q

old cart: location

A

where is the sign/symptom located

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16
Q

oldcart: duration

A

how long has this been going on

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17
Q

old cart: characteristic

A

what does it feel like? severity ?

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18
Q

old cart: associated manifestations

A

what else is happening when the patient experiences this? any other symptoms?

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19
Q

old cart: receiving factors

A

anything the patient tried to receive the symptoms? did it help

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20
Q

oldcart; treatments

A

any interventions the patient has already tried

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21
Q

what does OLDCART fall under in ADPIE

A

assessment

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22
Q

ADPIE - diagnosis

A

based on real or potential health problems
based on assessment data and problem list

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23
Q

ADPIE- planning

A

best course of action for patient
short term and long term goals
be realistic

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24
Q

ADPIE: implementation

A

can be completed by patient, family, or health care team
individualized for each patient
relates to nursing diagnosis and planned goals

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25
Q

ADPIE: evaluation

A

continues process toward goals
helps determine if plan needs revised

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26
Q

steps in clinical reasoning

A

identify
cluster
interpret
make
develop

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27
Q

manual heart rate

A

radius
30 secs multiply by 2
if irregular count for minute

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28
Q

resp rate

A

30 secs times 2
with stephoscope
labored or unlabored?
Even?
deep or shallow?

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29
Q

pulse ox

A

oxygen saturation.
wait until you get even waveform

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30
Q

convert F to C

A

Subtract 32 and multiply by 5/9

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31
Q

celsius to farenheit

A

multiply by 9/5 and add 32

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32
Q

assessment for pain

A

include vital signs
ask comfort level- get rating
can use quotes of patient

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33
Q

normal bp

A

<120 / <80

34
Q

prehypertension

A

120-139 / 80-89

35
Q

hypertension stage 1

A

140-159 / 90-99

36
Q

diabetes or renal bp

A

150-159 / 90-99

37
Q

hypertension stage 2

A

> 160 / >100

38
Q

ausculatory gap

A

don’t hear bp noise - gap

39
Q

occlusion point

A

when you stop hearing radial point- add 20-30

40
Q

normal temp

A

98.6 F / 37 C

41
Q

normal resp rate

A

12-20 no diff breathing

42
Q

normal oxygen sat

A

95-100%

43
Q

nociceptive or somatic pain

A

related to tissue damage

44
Q

neuropathic pain

A

related to injury of PNS or CNS

45
Q

Idiopathic pain

A

pain w out identifiable cause

46
Q

psychogenic pain

A

many factors influence pain

47
Q

pre interview HA

A

review medical and nursing records, set goals, adjust environment

48
Q

HA introduction

A

greet patient, put them at ease

49
Q

HA working phase

A

listen to patients story, identify and respond, clarify, test diagnostic hypothesis, negotiate a plan

50
Q

HA termination

A

summarize, discuss plan

51
Q

therapeutic communication techniques

A

active listening, guided questioning, nonverbal communication, empathic responses, validation, reassurance, summarizing, transitions, empowering the patient

52
Q

things not to do w angry patients

A

dont take things personally
dont isolate yourself w a angry person

53
Q

for the LGBTQ community

A

dont assume gender
establish birth general and gender identity

54
Q

for patients with language barrier

A

work with a qualified interpreter

55
Q

for patients with personal problems

A

dont give advice outside of nursing

56
Q

health history components

A

chief complaint, history of illness, allergies, medications, childhood illness, adult illness, health maintenance, health patterns

57
Q

for alcohol consumption

A

ask them what type of drink, how many they have, when was the last one

58
Q

when explaining things to patients

A

dont use medical words to patients, speak basic knowledge

59
Q

if a patient seems depressed

A

go into suicidal screening

60
Q

cultural competence

A

recognizes the need for a set of skills necessary to care for people of different cultures

61
Q

3 dimensions of cultural humility

A

self awareness
respectful communication
collaborative partnerships

62
Q

stolls guidelines for spiritual assessment

A

concept of god or diety
sources of hope and strength
religious practices
relation between spiritual beliefs and health

63
Q

four physical assessment techniques in order when initiating a health assessment

A

Inspection
palpation
percussion
auscultation

64
Q

what to do about silent patients

A

be attentive and encouraging

65
Q

what to do about confusing patients

A

possible mental status exam
check responses again
seek permission to speak with family members

66
Q

patients with altered capacity

A

dont have the ability to make healthcare decisions

67
Q

what to do about talkative patients

A

focus on what seems important to the patient
set limits where needed

68
Q

what to do about crying patients

A

be supportive

69
Q

helping deaf patient

A

find out there preferred method of communication

70
Q

assessing patients hard at hearing

A

see if they use a hearing aid and if its working
dont speak fast
eliminate background noise

71
Q

blind patient

A

establish contact
orient patient to surrounding

72
Q

poor vision patient

A

encourage glasses or contacts

73
Q

genogram

A

diagram for family history

female- circle
male- square
divorce- connected with 2 lines crossed
deeased- line through shape

74
Q

sensitive topics

A

sexual history, mental health history, family violence

75
Q

The nurse is conducting a physical examination of a client who is in the lying position. Place in order the areas the nurse will assess when completing this examination.
Shins and ankles
Groin, hips, and knees
Breasts
Chest and thorax
Cardiovascular

A

breast, chest & thorax, cardiovascular, groin + hips & knees, then shins and ankles

76
Q

Which equipment should the nurse use to validate the degrees of joint mobility?

A

goniometer

77
Q

far eye sight check

A

snellen chart

78
Q

A nurse is performing percussion on a client’s back to assess the lungs, and hears a loud, low-pitched, hollow sound, indicating normal lungs. What describes this finding

A

resonance

79
Q

One of the body’s normal physiologic responses to pain is

A

diaphoresis

80
Q

using the diaphragm, the nurse would expect to hear

A

high pitched sounds

81
Q

A nurse must assess a client’s red reflex. Which piece of equipment will the nurse need for this?

A

Ophthalmoscope

82
Q

FIFE

A

feelings
ideas
function
expectations

health assessment (4 decks)

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