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Test 1 Review Flashcards

1
Q

What is the cornerstone of nursing care?

A

Health Assessment

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2
Q

In 1981, the World Health Organization adopted a program called what?

A

The Global Strategy for Health for All by Year 2000.

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3
Q

Assessment uses patient reports and ____ & _____ cues.

A

Verbal and nonverbal

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4
Q

Who defined health as being the state of complete physical, social, and mental well-being (not just the absence of disease)?

A

World Health Organization

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5
Q

Which theory looks at the balance of mind, body, and spirit?

A

The Balance Theory

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6
Q

Health is influenced by what factors?

A
  • external environment
  • physiological
  • biological
  • behavioral
  • economic
  • political
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7
Q

What are the 5 determinants of health the CDC identifies?

A
  1. Genetics/Biology
  2. Individual Behavior
  3. Social Environment
  4. Physical Environment
  5. Health Services
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8
Q

What is the science-based framework updated every 10 years by the US Dept of Health and Human Services that identifies health and risk factors for diseases?

A

Healthy People 2020

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9
Q

Who must take responsibility for a patient’s health?

A

The patient (oneself)

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10
Q

What is the framework for health education and coaching?

A

Healthy People 2020

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11
Q

Which organization’s goal was to use evidence-based practice to make evidence-based recommendations?

A

U.S. Preventative Services Task Force

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12
Q

What do preventative services include?

A
  • Screening for disease
  • Counseling
  • Meds to prevent disease
  • Immunizations
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13
Q

How many levels of prevention are there?

A

3 (Primary, secondary, tertiary)

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14
Q

What level of prevention is the prevention of disease/disability that focuses on improving the overall health?

A

Primary

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15
Q

What level of prevention encompasses early screenings and detection/treatments of diseases?

A

Secondary prevention

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16
Q

What level of prevention is the restoration of health after the disease has occurred?

A

Tertiary prevention

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17
Q

The _____ process is the way that nurses identify and solve problems.

A

Nursing

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18
Q

The American Nurse’s Association (ANA) identified what to be the essential core of practice?

A

The nursing process

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19
Q

A system and problem solving process that assists the nurse in organizing the assessment to identify patient health info, risk factors, and develop a plan.

A

The nursing process

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20
Q

What are the five steps of the nursing process?

A
  1. Assessment
  2. Diagnosis
  3. Planning/Outcomes
  4. Implementation
  5. Evaluation
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21
Q

What is the active/purposeful and organized cognitive process that involves: creativity, reflection, problem solving, rational/intuitive judgement, attitude of inquire, and a philosophical orientation towards thinking how a nurse thinks?

A

Critical thinking

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22
Q

How many techniques of physical assessment are there?

A

4 (inspection, percussion, palpation, auscultation)

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23
Q

What uses health history, physical signs/symptoms, lab data, and diagnosing imaging to arrive at a diagnosis and formulate a plan?

A

Clinical reasoning

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24
Q

What uses interpretation of a patient’s needs, concerns, health problems, and treatment plan or the need to take another approach?

A

Clinical judgement

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25
Who introduced the theory of intuitive thinking?
Patricia Benner
26
What skill level is intuitive thinking?
Expert level
27
Any reaction to stimulus is ______ response.
Human
28
What is the mnemonic for health assessment/the nursing process?
ADPIE
29
What kind of communication skill is goal-oriented, initiates change, and is patient-centered?
Therapeutic
30
What kind of communication is supportive, respectful, and social?
Interpersonal
31
The measurement to determine overall health and individual’s response to health and wellness.
Vital signs
32
What do vital signs measure?
Vital functions
33
How is the significance of vital signs is determined?
By comparing them to the baseline vital signs
34
How many hours of previous vitals should current vitals be compared against?
24 hours
35
What is TPR BP?
Temperature, Pulse, Respirations, Blood Pressure
36
What is the measurement of retained body heat called?
Temperature
37
What is the most sensitive and accurate measure of core body temperature?
The pulmonary artery (catheter)
38
What is the difference between core and surface temperatures?
Core=inside; Surface=skin
39
Under what circumstances is temperature measured?
Fever or pyrexia
40
What are the routes for measuring temperature?
``` Oral Axillary Tympanic Temporal Rectal ```
41
What is the limitation of using axillary temperature?
The least reliable in an adult.
42
What is the limitation of using rectal temperature?
-invasive and can potential puncture intestinal wall
43
What is the limitation with temporal temperature?
Not sensitive to small changes
44
How is the route of temperature chosen?
- age of patient - physical status of patient - mental status/cognition
45
103 degrees Fahrenheit or higher
Pyrexia
46
105 degrees Fahrenheit or higher
Hyperpyrexia
47
Excessive body temperature (overheated)
Hyperthermia
48
Low body temperature (too cold)
Hypothermia
49
What happens in the body when the core temperature is out of range?
The body tries to compensate the difference
50
What routes is the blue probe of an electronic thermometer used for?
Oral/axillary
51
What route is the red probe on an electronic thermometer used for?
Rectal
52
How far inserted should the probe be when taking a rectal temperature? What position should the patient be in?
No further than 1 inch; Pt on his or her side
53
What are the three ways to evaluate the findings of measuring a temperature?
1. Note if temperature was effected by anything 2. Time of day 3. Repeat if there are any abnormal findings
54
What is the purpose of evaluating a pulse?
To measure the rate of heartbeat
55
What causes the peripheral pulse to be palpable?
Contraction of the left ventricle sends blood into the aorta, which then sends wave through the peripheral circulation
56
What site is the most commonly used site for counting pulse?
Radial artery
57
What are two characteristics (other than rate) that are evaluated with the pulse?
1. Rhythm | 2. Amplitude
58
What is the normal range for pulse?
60-100 bpm
59
What age to children begin to exhibit normal range of pulse rate?
16 years old
60
What is defined as irregular beats?
Arrhythmia
61
Slow rate rate < 60 bpm
Bradycardia
62
Fast heart rate > 100 bpm
Tachycardia
63
What is defined as the strength of the pulse?
Amplitude
64
What are the two ways to describe pulse irregularity?
1. Regularly irregular | 2. Irregularly irregular (more dangerous)
65
When a pulse is given the grade of 0 what does it mean?
Pulse is absent
66
When a pulse is given the grade of 1, what does it mean?
Pulse is weak
67
When a pulse is given the grade of 2, what do it mean?
Pulse is normal
68
When a pulse is given the grade of 3, what does it mean?
Pulse is bounding
69
Respirations are controlled _______ and _______ ions.
CO2 and hydrogen
70
What parts of the brain influence automatic respirations?
Medulla oblongata and pons
71
What is the normal rate of respirations per minute for an adult?
12-20 RPM
72
Why is it important to measure respiration rates accurately?
It is driven by carbon dioxide, not oxygen (especially important for oxygen administration)
73
What is SPO2?
Peripheral capillary oxygen saturation
74
The % of HgB in the capillary circulation that is saturated with oxygen?
SPO2
75
What does the pulse oximeter measure?
The SPO2
76
What is the normal range for pulse oximetry in an adult?
94-99%
77
What factors might interfere with the accurate measure of pulse oximetry?
- vasoconstriction of capillary beds - poor fit of the probe - disease (anemia, peripheral vascular disease)
78
What is the measure of heartbeats per minute?
Heart rate
79
What is the flow of blood through capillaries due to heartbeats?
Pulse rate
80
Where should a nurse auscultate the heart?
At the third intercostal space (ICS)
81
How is the apical-pulse rate measured?
Counting the heart rate while counting the pulse rate
82
The measurement of pressure of blood against vascular walls is __________.
Blood pressure
83
What is the normal range for systolic blood pressure for an adult?
90-120
84
What is the normal range of diastolic blood pressure for an adult?
60-90
85
How does venous congestion of the limb affect blood pressure readings?
Interferes with the ability to hear the Korotkoff sounds
86
Sounds audible by auscultation when blood returns to the occluded artery is called _______________.
Kortokoff sounds
87
The period between the first Korotkoff sound and the second and third sounds is called _______.
Ausculatory gap
88
What does pain is subjective mean?
Pain is individualized, every person perceives pain differently
89
How does a pain scale work?
0-10 (0 is no pain; 10 is worst)
90
What is acute pain?
Sudden onset, pain typically subsides after healing has taken place
91
What is chronic pain?
Pain that lasts 6 months or longer and can be lifelong
92
What are some common symptoms with acute pain?
- Grimacing - Guarding - Verbalization - Agitation - Restlessness - Diphorlesis
93
What are the three steps for evaluation abnormal vital signs?
1. Reverify vital signs 2. Always check for artifact 3. Knowing what to expect w/other symptoms
94
What is the mnemonic for assessing pain?
OPQRST | Onset, palliative/provocative, quality, radiation/region, severity, time
95
When a patient has a fever, how does this affect the pulse?
For every degree over baseline, the pulse increases by 10 BPM
96
When a patient has a fever, how does this effect respiration?
Every degree over the baseline, the respirations increase 4 RPM
97
What is the range for crisis level systolic BP?
>190
98
What is the range for crisis level diastolic BP?
>100
99
What is the first step the nurse should take if a patient has a crisis level BP reading?
Retake the measurement (manual BP should be taken)
100
What is the systolic range for hypotension?
<90
101
What is the diastolic range for hypotension?
<60
102
What is the minimum diastolic pressure required for perfusion of the tissue and organs?
30
103
What is the beginning o the nurse-patient relationship?
The interview
104
What kind of data does the interview gather?
Subjective data
105
Information that is derived from measurements
Objective
106
Information that is gather from the patient
Subjective data
107
What kind of data is getting a blood pressure reading from a blood pressure device?
Objective
108
What kind of data is getting a pain rating from a patient?
Subjective data
109
What kind of data is getting a pulse?
Objective
110
What are the three phases of an interview?
1. Introductory 2. Working 3. Summarization
111
In what phase of an interview is rapport established?
Introductory
112
In what phase of an interview is the mechanics of the interview explained?
Introductory
113
What phase of the interview is the longest?
Working
114
What phase of the interview is information collected on the patient?
Working
115
What is the last phase of the interview?
Summarization
116
What phase of the interview allows for patient feedback?
Summarization
117
What are the two forms of communication used in an interview?
1. Verbal | 2. Nonverbal
118
Communication that involves speech
Verbal communication
119
Communication that consists of appearance, facial expressions, eye contact, and gestures.
Nonverbal communication
120
Paying close attention, good eye contact, and willingness to listen are all example of _______ listening.
Active
121
Nurse concentrates on what they hear is _______ observing.
Active
122
Sounds and nonverbal behaviors that encourage the patient to talk
Facilitation
123
Allows patients to tell their story; allows the most disclosure of information
Broad opening questions
124
“Makes the murky clear”
Clarification
125
Gives space to allow patient to gather thoughts, clarify, and plan answers
Silence
126
_______ statements lead from one section of the interview to the next
Transitional
127
What is the normal temperature of an adult patient?
97.5-99.5 degrees Fahrenheit
128
What is the most sensitive indicator of a deteriorating condition?
Respiratory rate
129
What is the normal respiratory rate for a newborn?
40-60 rpm
130
What is the normal rate of pulse ox for patients with lung disease?
88-94%
131
What is the fifth vital sign?
Pain

Health Assessment (7 decks)

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