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health assess. Final
Health assessment final
| Question | Answer |
|---|---|
| culturally sensitive implies that caregivers | possess some basic knowledge of and constructive attitudes toward the diverse cultural populations |
| culturally appropriate implies that the caregivers | apply the underlying background knowledge that must be possessed to provide a given person with the best possible health care |
| culturally competent implies that the caregivers | understand and attend to the total context of the individual's situation, including awareness of immigration status |
| religion is the belief in a | divine or superhuman power or powers to be obeyed and worshipped as the creator and ruler of the universe |
| socialization is the process of | being raised within a culture and acquiring the characteristics of that group |
| acculturation is the process of | adapting to and acquiring another culture |
| assimilation is the process of | a person develops a new cultural identity and becomes like the members of the dominant culture |
| biculturalism is the | dual pattern of identification and often of divided loyalty |
| subjective data | what the patient tells you |
| objective data | is what you observe |
| the nursing process includes | assessment, diagnosis, outcome identification, planning, implementation and evaluation |
| novice nurse has | no experience with specific patient populations and uses rules to guide performance. |
| competent nurse can | see actions in the context of arching goals or daily plans for patients, between 2-3 years |
| proficient nurse | understands a patients situation as a whole rather than as a list of tasks, can see long-term goals |
| expert nurses can | grasp a clinical situation an zero in on the accurate solution |
| First-level priority problems are | emergent, life-threatening, and immediate, such as establishing an airway or supporting breathing. |
| Second-level priority problems are | next in urgency. They require prompt intervention to prevent deterioration, and may include a mental status change or acute pain. |
| Third-level priority problems are | important to the patient’s health, but can be addressed after more urgent problems. Examples include lack of knowledge or family coping. |
| A complete (or total health) database | includes a complete health history and a full physical examination. |
| A focused (or problem-centered) database is | used for a limited or short-term problem. It is smaller in scope and more targeted than the complete database. |
| A follow-up database evaluates | the status of any identified problem at regular intervals to follow up on short-term or chronic health problems. |
| An emergency database calls | for rapid collection of data, which commonly occurs while performing lifesaving measures. |
| The biomedical model of Western medicine views health as the | absence of disease. It focuses on collecting data on biophysical signs and symptoms and on curing disease. |
| The holistic health model assesses the whole person because it views | the mind, body, and spirit as interdependent and functioning as a whole within the environment. Health depends on all these factors working together. |
| verbal communication is the | words you speak, vocalizations and the tone of voice |
| nonverbal communication is your | body language, posture, gestures, facial expression, eye contact, foot tapping, touch, even where you place your chair |
| empathy means | viewing the world from the other person's inner frame of reference while remaining yourself |
| Mental status is a person’s | emotional and cognitive functions and its functioning is inferred by assessing the individual’s consciousness, language, mood and affect, orientation, attention, memory, abstract reasoning, thought process, thought content, and perceptions. |
| The full mental status examination is a | systematic check of emotional and cognitive functioning. Its purpose is to determine mental health strengths and coping skills and to screen for dysfunction. |
| the close, careful observation of the patient as a whole and then of each body system. | Inspection |
| the use of touch to assess texture, temperature, moisture, and organ location and size | Palpation |
| tapping the patient’s skin with short, sharp strokes to create percussion sounds | Percussion |
| technique used to assess the location, size, and density of an organ, detect an abnormal mass, or elicit a deep tendon reflex. | Percussion |
| listening to sounds made by the body, usually using a stethoscope. | Auscultation |
| Use the stethoscope’s diaphragm for | high-pitched sounds, such as breath, bowel, and normal heart sounds |
| Use the stethoscope’s bell for | soft, low-pitched sounds, such as extra heart sounds or murmurs. |
| the otoscope funnels | light into the ear canal and onto the tympanic membrane |
| the ophthalmoscope illuminates the | internal eye structures |
| the single most important step to decrease risk of microorganism transmission is to | wash your hands promptly and thoroughly |
| The general survey is your overall impression of the patient and begins when you first encounter him or her. It covers four areas: | physical appearance, body structure, mobility, and behavior. |
| Physical appearance includes an assessment of the person’s | age, sex, level of consciousness, skin color, and facial features as well as any signs of distress |
| Body structure addresses In this area | stature, nutrition, symmetry, posture, position, and body build or contour. |
| Mobility is concerned with | gait and range of motion. |
| Behavior considers | facial expression, mood and affect, speech, dress, and personal hygiene. |
| Waiting less than 1 to 2 minutes before repeating the blood pressure reading on the same arm will result in a | falsely high diastolic pressure related to venous congestion in the forearm. |
| The blood pressure cuff bladder length should be about | 80% of the arm circumference. |
| The oral temperature route is | accurate and convenient. |
| insert a rectal thermometer | 2 to 3 cm or 1in into the adult rectum |
| the heart rate normally ranges from | 50 to 90 beats per minute, but varies with age and sex. |
| The pulse rhythm normally has an | even, regular tempo. |
| The force of the pulse shows the | strength of the heart’s stroke volume |
| The Doppler technique may be used to | locate peripheral pulse sites and for blood pressure measurement to augment Korotkoff sounds. |
| The tympanic membrane thermometer (TMT) is an | accurate measurer of core body temperature. |
| Endogenous obesity is caused by either | the administration of adrenocorticotropin (ACTH) or excessive production of ACTH by the pituitary. |
| Respirations should be counted for | 30 seconds (if regular) and multiplied by two. The respirations should be counted after the pulse assessment. |
| To assess respirations, count them while | your hand is still in position for taking the pulse. |
| Blood pressure is the | pressure of the blood against the blood vessel walls |
| Systolic pressure is the maximum pressure felt on the artery during | left ventricular contraction (or systole). |
| Diastolic pressure is the | elastic recoil (or resting) pressure the blood exerts constantly between contractions. |
| Pulse pressure is the difference between | the systolic and diastolic pressures and reflects the stroke volume. |
| Mean arterial pressure is the | pressure forcing blood into the tissues, averaged over the cardiac output. |
| A cuff that is too narrow yields a | falsely high pressure. |
| A cuff that is too wide yields a | falsely low pressure. |
| BP has a false high measurement when the | legs are crossed versus uncrossed |
| a drop of in systolic pressure of more than 20mm Hg | orthostatic hypotension |
| thigh pressure is normally | higher than that in the arm |
| the pulse oximeter is a | noninvasive method to assess arterial oxygen saturation |
| the light on the pulse ox measures the | relative amount of light absorbed by oxyhemoglobin and unoxygenated hemoglobin |
| Nociceptive pain develops when | nerve fibers in the peripheral and central nervous systems are functioning and intact. |
| nociceptors are designed to | detect painful sensations from the periphery and transmit them to the CNS |
| Neuropathic pain does not | adhere to typical and predictable phases |
| 1st phase of pain is transductions which | occurs when a noxious stimulus in the form of traumatic or chemical injury, burn, incision, or tumor takes place in the periphery |
| 2nd phase of pain is the transmission where the | pain impulse moves from the level of the spinal cord to the brain |
| 3rd phase of pain is the modulation where | neurons from the brainstem release neurotransmitters that block the pain impulse |
| Visceral pain originates from | Large internal organs, such as the kidneys, stomach, intestines, gallbladder, and pancreas. |
| Deep somatic pain comes from | sources such as blood vessels, joints, tendons, muscles, and bone. |
| Cutaneous pain is derived from | the skin and subcutaneous tissues. |
| Referred pain is felt at a | particular site, but originates from another location. |
| Acute pain is | short-term and self-limiting, often follows a predictable track, and ends after the injury heals. |
| Persistent (or chronic) pain continues for | 6 months or longer and can last for years. |
| A numeric scale is used for | adults and older children. |
| used for young children in determining pain | the Oucher Scale and the Faces Pain Rating Scale, are |
| the descriptor scale of pain lists | words that describe different levels of pain intensity |
| PAINAD scale is called | pain assessment in advanced dementia |
| nonverbal behaviors of pain, such as | guarding, grimacing, moaning, agitation, restlessness, stillness, diaphoresis, or vital sign changes |
| nutritional status refers to the | degree of balance between nutrient intake and nutrient requirements |
| optimal nutritional status is achieved | is achieved when sufficient nutrients are consumed to support dat to day body needs |
| undernutrition occurs when | nutritional reserves are depleted and or when nutrient intake is inadequate to meet day to day needs |
| over nutrition is caused by | the consumption of nutrients, especially calories, sodium and fat in excess of body needs |
| nutrition screening is the | first step in assessing nutritional status and is required for all patients in all health care settings within 24 hours |
| normal hemoglobin level is | 14-18 g/dl for men and 12-16 g/dl for women |
| normal hematocrit level is | 37%- 49% for men and 36%-46% for females |
| LDL cholesterol is the | bad cholesterol |
| good cholesterol is the | good cholesterol |
| Marasmus is due to | inadequate intake of protein and calories or prolonged starvation |
| Kwashiorkor is due to | diets high in calories but contain little or no protein, low protein diets |
| rickets is a | sign of vitamin D and calcium deficiencies in children |
| the body’s largest organ system. | The skin |
| The epidermis is the | thin, tough outer layer. |
| The dermis is the | inner supportive layer, consisting mostly of collagen or connective tissue |
| The subcutaneous layer is the | adipose tissue below the dermis. |
| fine, faint hair that covers most of the body is called | vellus hair |
| hair that is darker, thicker and grows on the scalp and eyebrows, pubic area, chest and face are called | terminal hair |
| sebaceous glands produce a | protective lipid substance called sebum |
| eccrine glands are | coiled tubules that open directly onto the skin surface and produce a dilute saline solution called sweat |
| apocrine glands produce a | thick milky secretion and open into the hair follicles |
| vitiligo is the | complete absence of melanin pigment |
| Common causes of pruritus include | dry skin, aging, drug reactions, allergy, obstructive jaundice, uremia, and lice. |
| in a newborn a bluish color around the lips, hands, and fingernails, may last for a few hours and disappears with warming is called | acrocyanosis |
| erythema toxicum is a | common rash that appears in the first 3 to 4 days of life, also called a flea bite |
| stage 1 skin appears | red but unbroken, skin will not blanch |
| stage 2 skin is | partial thickness with loss of epidermis or also the dermis. |
| stage 3 skin is | full-thickness pressure ulcer extending into the subcutaneous tissue and resembling a crater |
| stage 4 skin is | full-thickness pressure ulcer that involves all skin layers and exposes muscles, tendons, bones |
| a rigid, bony box that protects the brain and special sense organs | the skull, |
| immovable joints are called | sutures |
| highly vascular endocrine gland synthesizes and secretes thyroxine and triiodothyronine | the thyroid gland |
| the adam's apple is also known as the | thyroid cartilage |
| tension headaches tend to be | occipital, frontal and bandlike tightness |
| a bruit occurs with | accelerated or turbulent blood flow |
| the pupillary light reflex is the | normal constriction of pupils when bright light shines on the retina |
| accommodation is the | adaptation of the eye for near vision. |
| pupil loses elasticity, becomes hard and glasslike, loses it's ability to change shape to accommodate for near vision | presbyopia |
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