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Health Assesment-RN > Test 1 > Flashcards

Test 1 Flashcards

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NCLEX-RN® flashcards
1
Q

Nursing process -steps

A

Assessment,

diagnosis,

outcome identification,

planning,

implementation,

evaluation

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2
Q

(*Perform the nursing actions identified in planning)- nursing process

Use community resources

Provide health teaching and health promotion

Document implementation and any modifications

Coordinate care delivery

Use evidence-based interventions

Implement in a safe and timely manner

A

Implement

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3
Q

Evaluate persons condition and compare actual outcomes with expected outcomes (progress toward outcomes)

Include patient and significant others

Ongoing assessment to revise plan or diagnoses

Communicate/inform results to patient and family

A

Evaluation

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4
Q

Review the clinical record

Health hx

Physical exam

Functional assessment

Cultural/spiritual assessment

Use evidence-based assessment techniques

A

Assessment

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5
Q

Compare clinical Findings of normal and abnormal variation in developmental events

Cluster associated data

Validate data

Confirm accuracy

Look for gaps

Interpret and Identify problem/data

Document the dx

A

Diagnosis

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6
Q

Identify expected outcomes

SMaRT components

Short term and long term goal measurement

Include a timeline

Cultural appropriate

Individualize to person

Realistic and measurable

A

Outcome identification

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7
Q

Establish priorities

Develop outcomes

Set timelines for outcomes

Identify interventions

Integrate evidence-based trends and research

Document plan of care

A

Planning

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8
Q

What are the components of evidence based decision making ?

A

Is there scientific evidence/research evidence

Patient preferences/values/circumstances

Clinicians experience and judgement

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9
Q

SMaRT components ?

A

Specific

Measurable

Attainable

Relevant

Time bound

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10
Q

Closed or open ?? Benefits of it

Tell me how you are feeling?

A

Open ended questions:

Narrative answers

Feelings and opinions

Develops rapport

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11
Q

Closed or open??

Do you have pain?

Benefits?

A

Closed ended questions

  • specific info
  • yes or no
  • limits rapport, neutral
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12
Q

Barriers to communication? Not to use

A

Providing false assurance or reassurance

Giving unwanted advice

Using authority (your dr knows best)

Avoidance language (they are in a better place)

Distancing (lump in “the breast”)

Adjust language to patient understanding

Leading questions (you don’t smoke do you?)

Interrupting

Don’t use why questions

Nonverbal skills (touch, voice,eye contact, gestures , facial expressions, posture , appearance

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13
Q

Reason for facilitation, cues, leads ?

Examples ?

A

Shows you are listening

Encourages to say more

  • nodding head yes
  • mmhmm
  • eye contact, shift forward
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14
Q

Gives the client time to think

A

Silence

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15
Q

Echos clients words to help patient identify feelings

“You have difficulty getting the day started?”

“It’s hard getting up in the morning”

A

Reflection

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16
Q

It must be difficult not being independent

A

Empathy

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17
Q

So you have difficulty lying down if you lie flat and you need pillows?

A

Clarification

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18
Q

Before you said you do not smoke but now you mentioned smoking with your friends?

A

Confrontation

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19
Q

I always take this blanket with me.

So this blanket must be very important to you

A

Interpretation

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20
Q

You cannot eat anything for 12 hours prior to surgery

A

Explanation

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21
Q

Condenses everything discussed allows plants to make corrections if needed

A

Summary

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22
Q

Lack of interest/attention

Door, curtain, computer, temp

Patient can not hear you

Safety- fear

Psychological barriers: Shocked, fear, embarrassed

Language Barrier

A

Barriers to communication

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23
Q

Types of pain

A 
Referred 
Phantom
Acute 
Chronic 
Breakthrough pain
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24
Q

Pain that is felt in a location other than where the pain originates

A

Referred pain

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25
Q

Feeling like the limb is still there after amputated due to damaged remaining nerve endings

A

Phantom pain/ sensation

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26
Q

Short term pain which is self limiting

Cause by ?Tissue damage

Less than 6 months

Mild moderate pain- sympathetic ns ?

Severe pain- parasympathetic ns ?

A

Acute pain

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27
Q

Last longer than 6 months

Intermittent or continuous

Does not stop after injury heals

Abnormal processing of pain fibers ?

A

Chronic pain

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28
Q

How to assess pain? Physical changes with pain ?

A

Posture/behavior

Facial expression

Sounds

Palpation

Vitals (increased BP, Pulse, resp)

Pupil size dilation

Sweating/increased temperature

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29
Q

Pain that occurs between doses of pain medication

A

Breakthrough pain

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30
Q

Pain that is acute and starts outside NS

Results in actual or potential damage

Responds to opiated and inflammatories

A

Nociceptive pain

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31
Q

Abnormal processing of pain from injury to nerve fibers or CNS

Chronic

Numbness, tingling,shooting, burning, poorly responsive to pain meds

A

Neuropathic pain

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32
Q

The point at which a person feels pain

A

Pain threshold

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33
Q

Duration or intensity of pain a person will endure before outwardly responding

A

Pain tolerance

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34
Q

What is pain ?

A

Whatever the patient says it is and whenever they say it is occurring

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35
Q

PQRST pain assessment

A

Precipitating or palliative

Quality or quantity

Region or radiation

Severity scale

Timing

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36
Q

What consists of substance abuse assessment ?

Techniques to elicit (get) info from patient?

A

Learn terminology

Tolerance

Dependency vs addiction

Watch for withdrawal symptoms such as nausea, vomiting, anxiety, headache, tremor

???

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37
Q

CAGE questionnaire ?

A

Cut down, annoyed, guilty, eye opener

Questions to determine if your running is uncontrolled

Cut down (should you cut down?)

Are you annoyed of criticism you get about your drinking )

Have you ever felt guilty about your drinking?

Do you drink in the morning ?

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38
Q

Alcohol use disorders identification test

A

AUDIT- questionnaires with ? Such as how often do you have a alcoholic beverage?

Covers 3 domains: alcohol consumption, drinking behavior or dependence , and adverse consequences from alcohol

39
Q

Frequency of use of alcohol, tobacco, rx, for non-medical use, illicit drugs

A

Quick assessment (substance abuse)

40
Q

Who needs to be assessed for domestic violence ?

When to report??

A

Everyone

41
Q

What percent of women and men experience rape, physical violence and/or stalking ?

A

36% women and 29% men

42
Q

Types of violence or abuse

A 
Sexual 
Physical 
Threats 
Emotional 
Neglect 
Financial
43
Q

How to asses intimate partner abuse IPV

Scores?

A

Use your own words and be non- judgmental such as “domestic violence is so common I ask all my patient about abuse in the home.”

HITS
H-hurt
I- insult 
T-threaten 
S-scream

1-5 never to frequent

10 or more indicates IPV

44
Q

When to assess for IPV?

A

Assess at every visit

Abuse assessment screen

45
Q

S/s of abuse

A

Frequent UTIs

Chronic pelvic pain

STIs

Anxiety/depression

Back pain

PTSD

Failure to follow up

Frequent healthcare visits

46
Q

S/s of human trafficking

A

Injury/sign of abuse

Malnourished

Disoriented

Lack of ID

Few personal belongings

Fearful, anxious, submissive

Scared of the law

Can not freely contact friends and family

Avoids eye contact

47
Q

What to do if you see signs of human trafficking?

A

Must report

Call 911 if unsure

Contact national human trafficking resource center

48
Q

What are the characteristics and risks of human trafficking ?

A

Victims are usually white/black and US citizens

Risk factor:

Age 
Poverty 
Unemployed 
Gender inequality 
Sexual abuse 
Mental or health problems
49
Q

The degree of balance between nutritional intake and nutrient requirements

Intake sufficient for basic needs

A

Nutritional status

Optimal nutrition

50
Q

Two are two primary components of this :

Health history-subjective

Physical examination-objective

A

Health assessment

51
Q

Too much food energy or excess nutrients to the degree of causing disease or increasing risk of disease, a form of malnutrition (sedentary lifestyle)

Related conditions:

Heart disease
Diabetes 2
Stroke
Gallbladder disease

A

Overnutrition

52
Q

What fraction of kids are overweight or obese?

What ages?

A

1/3

Ages 6-19

53
Q

Occurs when nutritional reserves or depleted or when nutrient intake is in adequate to meet day today needs or added metabolic demands

  • impaired growth
  • lowered resistance to disease
  • delayed wound healing
A

Undernutrition

54
Q

How to asses food intake ? What methods??

A

24 hour recall

Food diary (most comprehensive)

Food frequency

Typical food intake

Direct observation

55
Q

Difference between 24 hour food recall and food diary ??

A

Food diary may be more accurate - write down everything consumed for a certain period of time. Write down immediately after eating.

24hour recall- questionnaire to recall everything eaten within the last 24 hours. Can evoke Specific information about dietary intake.

56
Q

Factors what can affect nutritional status?

A

Problem based hx:
Weight loss, weight gain (when it started, intentionally ?

Difficulty chewing or swallowing
(Types of food you eat)

Loss of appetite/nausea

57
Q

Normal vs for an adult:

Bp:

P:

R:

O2:

T:

A

Bp:systolic- 90-120
Diastolic- 60-80

P:radial, apical, carotid , brachial 60-100 bpm

3+ is full, bounding
2+ is normal
1+ is weak
0 is absent

R:10-20 count for 30 sec x 2

T:98.6

O2:95-100%

58
Q

How to take-

pulse:

Bp:

A

30 seconds and times by 2

59
Q

What affects vital signs?

A

Stress, pain, drinking fluids, temperature, position, wrong cuff size …

??

60
Q

What can influence a normal body temp ? What is being assessed?

A 
Drinking hot or cold fluids
Exercise 
Stress
Age
Gender - mensuration in women  
Time of day 
Smoking 
Chewing gum
61
Q

Characteristics assessed for pulse?

A

Pulse strength , Rhythm, BPM

62
Q

R-

What does a normal breathing pattern look
Like?

A

relaxed, regular rhythm, quiet, 12-20 per minute

63
Q

Temperature methods? Accuracy of them? Trouble shooting?

A 
Tympanic ear - accurate 
Oral - most convenient and accurate 
Temporal- fast and accurate 
Rectal -most accurate to core temp 
Axillary- arm pit - kids
64
Q

What do the bp numbers mean?

Systolic ?

Diastolic?

A

Bp is the force of blood pushing against the side of the vessel wall. (The strength charges with the event in the cardiac cycle)

S-the maximum pressure felt in the artery during left ventricular contraction

D-blood pressure flow when heart is relaxed or resting between each contraction

65
Q

What is orthostatic bp?

A

A change in bp after standing up after laying down.

Person may feel faint or dizzy

66
Q

Types of assessments to screen for pt history?

A

Comprehensive health hx

Complete total health

Focused or problem- centered database

Primary, secondary, and tertiary prevention

General survey

67
Q

Comprehensive health hx

A

A detailed examination that typically includes a thorough health history and comprehensive head-to-toe physical exam.

Also includes an examination of social and behavioral influences, health risks and information needs of patients and/or families/caregivers.

68
Q

Complete total health

A

Complete health hx and a full physical examination

Yields the first diagnosis

69
Q

Focused or problem- centered database

A

Limited or short term problem. Mainly one problem or one body system

70
Q

Primary, secondary, and tertiary prevention

A

Primary- prevents health problems (safety glasses, vaccines, exercise)

Secondary- screening, catch problems early

Tertiary- cardiac rehab, support groups

71
Q

General survey - what is it and what things to look for in patient?

A

A study of the whole person, covering the general health state and any obvious physical characteristics

Age sex, loc, skin color
Posture , body build
Gait, ROM
Facial expression, mood , speech, dress, hygiene

Intro for the physical , objective parameters which apply to the whole person

How the person stands at their name , so they look sick?, make eye contact? Smile, shake hand firmly? Health hx, measurements , vs

**Physical appearance , body structure, mobility, and behavior

72
Q

How and when to use tools/equipment?

Oximeter ?

Thermometers?

Stethoscope ?

Etc.

A

Have all equipment at easy reach and laid out in an organized fashion

Make sure they care cleaned after using with sanitizer whipe

73
Q

What are the 4 techniques of assessment?

What information will each technique tell you?

A
  1. inspection
  2. palpation
  3. percussion
  4. Auscultation
74
Q

Why to use assessment techniques?

A

to know your patient and identify their real needs

Forms the basis of the care plan

75
Q

Direct vs indirect percussion?

A

direct, which uses only one or two fingers, Immediate or Blunt Percussion; Percussing hand directly strikes the body wall (done w/ sinuses)

indirect, which uses the middle/flexor finger. striking a punch-like object with a hammer or percussor. Mediate Percussion; Involves 2 hands

76
Q

Know medical terminology- from packet??

A

??

77
Q

Know definitions in culture

From crossword-mod 3

A

Snsn

78
Q

What are some cultural competence methods?

A

Explore patients beliefs , values, and needs to build effective relationships with them.

Understand that each patient is unique

79
Q

Causes/types of illness in culture?

A

Biomedical illness

Naturalistic illness

Magiocoreligious illness

80
Q

What is a material vs non material cultural characteristic?

A

Material: dress, tools, art

Non material: verbal, religion, customs, beliefs

81
Q

What are the components of a mental assessment?

ABCT:

A

Detailed mental status exam

Assess through health hx

Be aware of:

Meds taken
Hx of alcohol or drug use
Stress levels
Sleep disorders

Appearance
Behavior
Cog function
Thought process

82
Q

What are expected age related changes? When it comes to memory/mind?

A

? Normal aging is associated with a decline in various memory abilities in many cognitive tasks; the phenomenon is known as age-related memory impairment (AMI)

May need more time to learn new material or tasks

83
Q

A condition which is Sudden onset, interrupting the bodies homeostasis

Orientation:

Altered consciousness

Rapid mood swings/emotions

Reversible

A

Delirium

84
Q

delirium?

What can affect it?

A

start of delirium is usually rapid — within hours or a few days. Delirium can often be traced to one or more contributing factors, such as a severe or chronic illness, changes in metabolic balance (such as low sodium), medication, infection, surgery, or alcohol or drug intoxication or withdrawal

85
Q

This condition has a slow gradual onset (organic)

Orientation:

Consciousness is not altered

Flat, agitated

Incoherent , slow, repetitive

Not reversible

A

Dementia

86
Q

What can affect dementia :

A

Can be caused by vascular disease, HIV, Alzheimer’s disease

87
Q

how to Assess ones orientation?

A

Test attention span

Recent memory

Remote memory (long term)

New learning

88
Q

Components of the mental exam status ?

A

MMSE (mini-mental state examination

Set of 11 questions that tests orientation to time and place , naming , reading, copying orientation , writing, and following three stage command. Can also test for dementia or mental illness

89
Q

Performing mini-cog? What is it?

A

A newly developed, reliable , quick and easy available instrument to screen for cognitive impairment in healthy older adults

Takes 3-5 minutes- ask adult to listen carefully to, then repeat the 3 words that you will say. (Short And unrelatedly words) Make sure there are no distractions. Have them do something else and then repeat again later.

90
Q

Disease caused by bacteria, virus, etc

A

Biomedical illness

91
Q

Illness caused when there is loss of natural balance

Ting/yang
Hot/cold

A

Naturalistic illnesses

92
Q

Illness caused by supernatural forces

Folk remedies

A

Magiocoreligious

93
Q

What is normal gait?

A

Walk is smooth and even

Balance with out assistance

Movement of arm symmetry are present

94
Q

WT and height in 80s and 90s ?

A

Prominent bony areas

Muscle shrinkage and weight and height decreases- especially in males

Fat loss from face , forearms, abd and hips (even with good nutrition)

Health Assesment-RN (7 decks)

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