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Health Assessment > Test 1 Review > Flashcards

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
Q

Who introduced the theory of intuitive thinking?

A

Patricia Benner

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26
Q

What skill level is intuitive thinking?

A

Expert level

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27
Q

Any reaction to stimulus is ______ response.

A

Human

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28
Q

What is the mnemonic for health assessment/the nursing process?

A

ADPIE

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29
Q

What kind of communication skill is goal-oriented, initiates change, and is patient-centered?

A

Therapeutic

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30
Q

What kind of communication is supportive, respectful, and social?

A

Interpersonal

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31
Q

The measurement to determine overall health and individual’s response to health and wellness.

A

Vital signs

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32
Q

What do vital signs measure?

A

Vital functions

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33
Q

How is the significance of vital signs is determined?

A

By comparing them to the baseline vital signs

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34
Q

How many hours of previous vitals should current vitals be compared against?

A

24 hours

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35
Q

What is TPR BP?

A

Temperature, Pulse, Respirations, Blood Pressure

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36
Q

What is the measurement of retained body heat called?

A

Temperature

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37
Q

What is the most sensitive and accurate measure of core body temperature?

A

The pulmonary artery (catheter)

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38
Q

What is the difference between core and surface temperatures?

A

Core=inside; Surface=skin

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39
Q

Under what circumstances is temperature measured?

A

Fever or pyrexia

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40
Q

What are the routes for measuring temperature?

A 
Oral
Axillary 
Tympanic 
Temporal 
Rectal
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41
Q

What is the limitation of using axillary temperature?

A

The least reliable in an adult.

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42
Q

What is the limitation of using rectal temperature?

A

-invasive and can potential puncture intestinal wall

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43
Q

What is the limitation with temporal temperature?

A

Not sensitive to small changes

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44
Q

How is the route of temperature chosen?

A
  • age of patient
  • physical status of patient
  • mental status/cognition
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45
Q

103 degrees Fahrenheit or higher

A

Pyrexia

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46
Q

105 degrees Fahrenheit or higher

A

Hyperpyrexia

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47
Q

Excessive body temperature (overheated)

A

Hyperthermia

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48
Q

Low body temperature (too cold)

A

Hypothermia

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49
Q

What happens in the body when the core temperature is out of range?

A

The body tries to compensate the difference

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50
Q

What routes is the blue probe of an electronic thermometer used for?

A

Oral/axillary

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51
Q

What route is the red probe on an electronic thermometer used for?

A

Rectal

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52
Q

How far inserted should the probe be when taking a rectal temperature? What position should the patient be in?

A

No further than 1 inch; Pt on his or her side

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53
Q

What are the three ways to evaluate the findings of measuring a temperature?

A
  1. Note if temperature was effected by anything
  2. Time of day
  3. Repeat if there are any abnormal findings
54
Q

What is the purpose of evaluating a pulse?

A

To measure the rate of heartbeat

55
Q

What causes the peripheral pulse to be palpable?

A

Contraction of the left ventricle sends blood into the aorta, which then sends wave through the peripheral circulation

56
Q

What site is the most commonly used site for counting pulse?

A

Radial artery

57
Q

What are two characteristics (other than rate) that are evaluated with the pulse?

A
  1. Rhythm

2. Amplitude

58
Q

What is the normal range for pulse?

A

60-100 bpm

59
Q

What age to children begin to exhibit normal range of pulse rate?

A

16 years old

60
Q

What is defined as irregular beats?

A

Arrhythmia

61
Q

Slow rate rate < 60 bpm

A

Bradycardia

62
Q

Fast heart rate > 100 bpm

A

Tachycardia

63
Q

What is defined as the strength of the pulse?

A

Amplitude

64
Q

What are the two ways to describe pulse irregularity?

A
  1. Regularly irregular

2. Irregularly irregular (more dangerous)

65
Q

When a pulse is given the grade of 0 what does it mean?

A

Pulse is absent

66
Q

When a pulse is given the grade of 1, what does it mean?

A

Pulse is weak

67
Q

When a pulse is given the grade of 2, what do it mean?

A

Pulse is normal

68
Q

When a pulse is given the grade of 3, what does it mean?

A

Pulse is bounding

69
Q

Respirations are controlled _______ and _______ ions.

A

CO2 and hydrogen

70
Q

What parts of the brain influence automatic respirations?

A

Medulla oblongata and pons

71
Q

What is the normal rate of respirations per minute for an adult?

A

12-20 RPM

72
Q

Why is it important to measure respiration rates accurately?

A

It is driven by carbon dioxide, not oxygen (especially important for oxygen administration)

73
Q

What is SPO2?

A

Peripheral capillary oxygen saturation

74
Q

The % of HgB in the capillary circulation that is saturated with oxygen?

A

SPO2

75
Q

What does the pulse oximeter measure?

A

The SPO2

76
Q

What is the normal range for pulse oximetry in an adult?

A

94-99%

77
Q

What factors might interfere with the accurate measure of pulse oximetry?

A
  • vasoconstriction of capillary beds
  • poor fit of the probe
  • disease (anemia, peripheral vascular disease)
78
Q

What is the measure of heartbeats per minute?

A

Heart rate

79
Q

What is the flow of blood through capillaries due to heartbeats?

A

Pulse rate

80
Q

Where should a nurse auscultate the heart?

A

At the third intercostal space (ICS)

81
Q

How is the apical-pulse rate measured?

A

Counting the heart rate while counting the pulse rate

82
Q

The measurement of pressure of blood against vascular walls is __________.

A

Blood pressure

83
Q

What is the normal range for systolic blood pressure for an adult?

A

90-120

84
Q

What is the normal range of diastolic blood pressure for an adult?

A

60-90

85
Q

How does venous congestion of the limb affect blood pressure readings?

A

Interferes with the ability to hear the Korotkoff sounds

86
Q

Sounds audible by auscultation when blood returns to the occluded artery is called _______________.

A

Kortokoff sounds

87
Q

The period between the first Korotkoff sound and the second and third sounds is called _______.

A

Ausculatory gap

88
Q

What does pain is subjective mean?

A

Pain is individualized, every person perceives pain differently

89
Q

How does a pain scale work?

A

0-10 (0 is no pain; 10 is worst)

90
Q

What is acute pain?

A

Sudden onset, pain typically subsides after healing has taken place

91
Q

What is chronic pain?

A

Pain that lasts 6 months or longer and can be lifelong

92
Q

What are some common symptoms with acute pain?

A
  • Grimacing
  • Guarding
  • Verbalization
  • Agitation
  • Restlessness
  • Diphorlesis
93
Q

What are the three steps for evaluation abnormal vital signs?

A
  1. Reverify vital signs
  2. Always check for artifact
  3. Knowing what to expect w/other symptoms
94
Q

What is the mnemonic for assessing pain?

A

OPQRST

Onset, palliative/provocative, quality, radiation/region, severity, time

95
Q

When a patient has a fever, how does this affect the pulse?

A

For every degree over baseline, the pulse increases by 10 BPM

96
Q

When a patient has a fever, how does this effect respiration?

A

Every degree over the baseline, the respirations increase 4 RPM

97
Q

What is the range for crisis level systolic BP?

A

> 190

98
Q

What is the range for crisis level diastolic BP?

A

> 100

99
Q

What is the first step the nurse should take if a patient has a crisis level BP reading?

A

Retake the measurement (manual BP should be taken)

100
Q

What is the systolic range for hypotension?

A

<90

101
Q

What is the diastolic range for hypotension?

A

<60

102
Q

What is the minimum diastolic pressure required for perfusion of the tissue and organs?

A

30

103
Q

What is the beginning o the nurse-patient relationship?

A

The interview

104
Q

What kind of data does the interview gather?

A

Subjective data

105
Q

Information that is derived from measurements

A

Objective

106
Q

Information that is gather from the patient

A

Subjective data

107
Q

What kind of data is getting a blood pressure reading from a blood pressure device?

A

Objective

108
Q

What kind of data is getting a pain rating from a patient?

A

Subjective data

109
Q

What kind of data is getting a pulse?

A

Objective

110
Q

What are the three phases of an interview?

A
  1. Introductory
  2. Working
  3. Summarization
111
Q

In what phase of an interview is rapport established?

A

Introductory

112
Q

In what phase of an interview is the mechanics of the interview explained?

A

Introductory

113
Q

What phase of the interview is the longest?

A

Working

114
Q

What phase of the interview is information collected on the patient?

A

Working

115
Q

What is the last phase of the interview?

A

Summarization

116
Q

What phase of the interview allows for patient feedback?

A

Summarization

117
Q

What are the two forms of communication used in an interview?

A
  1. Verbal

2. Nonverbal

118
Q

Communication that involves speech

A

Verbal communication

119
Q

Communication that consists of appearance, facial expressions, eye contact, and gestures.

A

Nonverbal communication

120
Q

Paying close attention, good eye contact, and willingness to listen are all example of _______ listening.

A

Active

121
Q

Nurse concentrates on what they hear is _______ observing.

A

Active

122
Q

Sounds and nonverbal behaviors that encourage the patient to talk

A

Facilitation

123
Q

Allows patients to tell their story; allows the most disclosure of information

A

Broad opening questions

124
Q

“Makes the murky clear”

A

Clarification

125
Q

Gives space to allow patient to gather thoughts, clarify, and plan answers

A

Silence

126
Q

_______ statements lead from one section of the interview to the next

A

Transitional

127
Q

What is the normal temperature of an adult patient?

A

97.5-99.5 degrees Fahrenheit

128
Q

What is the most sensitive indicator of a deteriorating condition?

A

Respiratory rate

129
Q

What is the normal respiratory rate for a newborn?

A

40-60 rpm

130
Q

What is the normal rate of pulse ox for patients with lung disease?

A

88-94%

131
Q

What is the fifth vital sign?

A

Pain

Health Assessment (7 decks)

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