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Assess.T.1 Mod.A,B,C
Health Assess. Ch.1-6 & 20, 22
| Question | Answer |
|---|---|
| Components of Health Assessment: | 1.health history 2.physical examination 3.documentation of data |
| The history component of health assessment is____. | subjective data |
| ___is subjective data. | History |
| The examination component of health assessment is____. | objective data |
| ___is objective data. | Examination |
| Signs & symptoms. | data |
| Data is___&___. | 1.signs 2.symptoms |
| What client feels & communicates. | symptoms |
| A symptom is___. | subjective data |
| A symptom is what the___&___. | 1.client feels 2.communicates |
| A clinical finding. | sign |
| A sign is___. | objective data |
| A sign is a____. | clinical finding |
| Signs &/or symptoms experienced by client. | clinical manifestations |
| Clinical manifestations are___. | objective data |
| A___&___is objective data. | 1.sign 2.clinical manifestation |
| A___is subjective data. | symptom |
| Nursing Process Steps: | 1.Assessment 2.Diagnosis 3.Outcome identification 4.Planning 5.Implementation 6.Evaluation |
| Assessment includes: | 1.collect data: 1.interview 2.health history 3.physical exam 4.functional assessment 5.consulatation 6.review of the literature |
| ___includes collecting data through interviews, health history, physical exam, functional assessment, consultation, & review of the literature. | Assessment |
| Type of questions used in assessment are___. | open-ended questions |
| Amount of information gained during a health assessment depends on factors such as: | 1.context of care 2.client need 3.expertise of the nurse |
| Every___is part of the nursing process. | interaction |
| A report of what the client experiences associated with a problem. | symptom |
| A symptom is a report of what the client___. | experiences |
| During a physical examination, the nurse obtains objective data using the techniques of: | 1.inspection 2.palpation 3.percussion 4.auscultation |
| During the physical examination the nurse also measures the clients: | 1.blood pressure 2.height 3.weight 4.temperature 5.respiratory rate |
| The nursing process: | 1.assessment 2.diagnosis 3.outcomes identification 4.planning 5.implementation 6.evaluation |
| The___identified by the__are based on the nursing process. | 1.Standards of Practice 2.ANA (American Nurses Association) |
| The Standards of Practice identified by the ANA are based on the___. | nursing process |
| The RN collects comprehensive data pertinent to the patient's health or the situation. | Assessment |
| Types of Health Assessment: | 1.comprehensive assessment 2.problem-based/focused assessment 3.episodic/follow-up assessment 4.screening assessment |
| The___of___to identify client's health characteristics. | 1.systematic method 2.data collection |
| The systematic method of data collection to identify client's___. | health characteristics |
| What you see, taste, touch, measure, & smell is___. | objective data |
| Objective Data: | what you: 1.see 2.touch 3.taste 4.smell 5.measure |
| The patient___a symptom. | says |
| You__a sign. | see |
| Clustering data that allows problems to be clearly apparent. | Data organization |
| Behavior motivated by desire to increase well-being & actualize health potential. | Health promotion |
| Behavior motivated by desire to avoid illness, detect illness early, & maintain functioning when ill. | Health protection |
| 3 levels of health promotion: | 1.primary preventing disease from developing; promoting health lifestyle. 2.secondary-screening to find early indicators of disese. 3.tertiary-minimizing disability from acute/chronic illness/injury & allowing for most productive life w/in limitations. |
| Nurses provide___&___to help meet health promotion needs. | 1.education 2.care |
| If a patient cannot speak English, who should the nurse get to translate that will maintain confidentiality? | Unfamiliar person/translator |
| If there is no translator, who should the nurse get to translate? | family |
| Vital signs should always be checked first except when assessing___. | the heart |
| When viewing the tympanic membrane, what equipment should be used? | largest equipment that fits the ear comfortably |
| Nurse should pay special attention to the abdomen when checking respiration of___. | infant |
| When checking the___of an infant, pay special attention to___. | 1.respiration 2.infant |
| Greatest bone differentiation between males and females during development? | adolescence |
| Transillumination shows: | different light degrees for tissues, fluids, etc. ? |
| Ringing in the ears. | Tinnitus |
| Largest endocrine gland. | Thyroid gland |
| Tinnitus is__in the__. | 1.ringing 2.ears |
| The thyroid gland is the___. | largest endocrine gland |
| There are 3 phases during an interview: | 1.introduction phase 2.discussion phase 3.summary phase |
| During an interview, the conversation is___. | client centered |
| Clients are free to share their concerns, beliefs, & values in their own words. | client centered |
| Client centered means that clients are free to share their___,___,&___in their own words. | 1.concerns 2.beliefs 3.values |
| A__condenses & orders data obtained during the interview to help clarify a sequence of events. | summary |
| A summary__obtained during an interview to help clarify a___. | 1.condenses/orders data 2.sequence of events |
| ___is used when you want to share with clients conclusions you have drawn from data they have given. | Interpretation |
| ___is used when you notice inconsistencies between what the client reports & your observations or other data about the client. | Confrontation |
| ___is repeating a phrase or sentence the client just said. | Reflection |
| ___involves repeating what client says using different words. | Restatement |
| ___is used to obtain more information about conflicting, vague, or ambiguous statements. | Clarification |
| ___uses phrases to encourage clients to continue talking. | Facilitation such as "go on", "uh-huh", or "then?" |
| __is performed by concentrating on what the client is saying & the subtleties. | Active Listening |
| ___is used when you notice inconsistencies between what the client reports & you observations or other data about the client. | Confrontation |
| The__includes biographic data, reason for seeking care, present health status, past medical history, family history, personal & psychosocial history, & a review of all body systems. | comprehensive health history |
| A comprehensive health history includes: | 1.biographic data 2.reason for seeking care 3.present health status 4.past medical history 5.family history 6.personal & psychosocial history 7.review of all body systems |
| A___may be done with a hospital admission, initial clinic or home visit, or when the client's reason for seeking care is for relief of generalized symptoms such as weight loss or fatigue. | comprehensive health history |
| A comprehensive health history may be done with a___,___or___,or when__is for___such as___or___. | 1.hospital admission 2.initial clinic 3.home visit 4.reason 5.seeking care of for relief of generalized symptoms 6.weight loss 7.fatigue |
| Collected at first visit & updated as changes occur. | Biographic data |
| Biographic data is collected at__& updated as changes occur. | first visit |
| Reason for seeking health care is also called___. | chief complaint (CC) or presenting problem (PP) |
| Brief statement of the client's purpose for requesting the services of a health care provider. | chief complaint or presenting problems |
| The client's reason for seeking health care is often recorded in___. | direct quotes |
| A loud, high-pitched sound heard over the abdomen. | Tympany |
| Tympany is a___heard over the___. | 1.loud, high-pitched 2.abdomen |
| Heard over normal lung tissue. | Resonance |
| Resonance is__over___. | 1.heard 2.normal lung tissue |
| Heard in overinflated lungs. | Hyperresonance -such as emphysema |
| Hyperresonance is heard in___. | overinflated lungs |
| Hyperresonance would be heard in patient with___. | emphysema |
| Heard over the liver. | Dullness |
| Dullness is heard over the__. | liver |
| Heard over the bones & muscle. | Flatness |
| Flatness is heard over the___&___. | 1.bones 2.muscle |
| Detecting sound changes is easier when moving from___to___. | 1.resonance 2.dullness or from the lung to the liver |
| Detecting___is easier when moving from the lung (resonance) to liver (dullness). | sound changes |
| A___is used for auscultation to block out extraneous sounds when evaluating the condition of the heart. | stethoscope |
| A stethoscope is used for___to block out___when evaluating condition of heart. | 1.auscultation 2.extraneous sounds |
| The act of listening to sounds within the body. | auscultation |
| Auscultation is the act of___to___within the body. | 1.listening 2.sounds |
| The__&___are the most common during the examination. | 1.sitting 2.supine positions |
| 2 most common thermometers used in health care settings are: | 1.electronic 2.tympanic |
| The___requires less than 5 seconds. | tympanic thermometer |
| The loudness of the sound. | Intensity |
| Intensity (loudness of sound) can be described as: | 1.soft 2.medium 3.loud |
| The frequency or number of sound waves generated per second. | pitch |
| Cariac sounds are___. | low-pitched |
| __are low-pitched. | Cardiac sounds |
| Pitch is the___of___generated___. | 1.#/frequency 2.sound waves 3.per second |
| High-pitched sounds have___. | high frequency |
| __have high frequency. | High-pitched sounds |
| Expected high-pitched sounds are__. | breath sounds |
| Expected___are breath sounds. | high-pitched sounds |
| ___is short, medium, or long. | Duration of sound vibrations |
| Duration of sound vibrations are___,___,or___. | 1.short 2.medium 3.long |
| Layers of soft tissue dampen the___from deep organs. | duration of sound |
| ___of___dampen the duration of sound from___. | 1.layers 2.soft tissue 3.deep organs |
| 2 common devices to measure temperatures in children: | 1.pacifier thermometers 2.chemical dot thermometers |
| Why is the tympanic thermometer normally used in health care settings? | b/c it provides reading very qickly |
| Whey assessing the rectum, what position? | knee-chest |
| When assessing the heart, what positon? | lateral recumbent |
| When assessing the musculoskeletal system, what position? | prone |
| When assessing the rectum & vagina, what position? | sims position |
| When assessing the female/male genitalia, what position? | lithotomy |
| When assessing the head & neck, thorax & lungs, breasts, axilla, heart, & abdomen, what position? | dorsal recumbent |
| When assessing the head & neck, anterior thorax & lungs, breasts, axilla, heart, abdomen, extremeties, & pulses, what postion? | supine |
| When assessing the head & neck, back, posterior thorax & lungs, anterior thorax & lungs, breasts, axilla, heart, vital signs, & upper extremities, what position? | sitting |
| ___have been shown to under measure body temperature compared to___& are not considered accurate. | 1.chemical dot thermometers 2.electronic thermometers |
| Abnormal lung sounds. | crackles |
| Crackles are___. | abnormal lung sounds |
| The___of the stethoscope is constructed in concave shape. | bell |
| The bell of stethoscope is constructed in___. | concave shape |
| __should be used to hear soft, low-pitched sounds such as extra heart sounds or vascular sounds (bruit). | bell |
| The bell should be used to hear___. | soft, low-pitched sounds |
| The bell should be used to hear soft, low-pitched sounds such as___or___. | 1.extra heart sounds 2.vascular sounds (bruit) |
| Vascular heart sounds. | bruit |
| Bruit is___. | vascular heart sounds |
| When the bell is used, it should be pressed___to ensure that complete seal exists around the bell. | lightly (just enough pressure) |
| When the__is used, it should be pressed lightly, with just enough pressure to ensure that a complete seal exists around the bell. | bell |
| The__consists of a flat surface with a rubber or plastic ring edge. | diaphragm |
| The diaphragm consists of a__with a__or___. | 1.flat surface 2.rubber 3.plastic ring |
| The__is used to hear high-pitched sounds such as breath sounds, bowel sounds, & normal heart sounds. | diaphragm |
| The diaphragm is used to hear___such as___,___,&___. | 1.high-pitched sounds 2.breath sounds 3.bowel sounds 4.normal heart sounds |
| The structure of the___screens/blocks out low-pitched sounds. | diaphragm |
| The diaphragm screens/blocks out___. | low-pitched sounds |
| The___is held firmly against the client's skin, stabilizing it between the index & middle fingers. | diaphragm |
| The diaphragm is held___against the client's skin, stabilizing it between___&___. | 1.firmly 2.index 3.middle fingers |
| A___is used to ausculatate the fetal heart. | fetoscope |
| The head of the stethoscope consists of 2 components: | 1.bell 2.diaphragm |
| The___of the stethoscope should be heavy enough to lie firmly on the body surface without being held. | head |
| Blood pressure is most commonly measured indirectly (noninvasively) using a___or an___. | 1.sphygmomanometer 2.electronic noninvasive blood pressure (NIBP) monitor |
| The tubing of the stethoscope is usually a firm polyvinyl material that is no longer than___. | 12-18 inches (30-46cm) |
| A stethoscop is usually a___that is no longer than 12-18 inches (30-46 cm). | firm polyvinyl material |
| Several types of stethoscopes: | 1.acoustic 2.magnetic 3.electronic 4.stereophonic |
| The___is routinely used for health assessment. | acoustic stethoscope |
| The acoustic stethoscope is routinely used for___. | health assessment |
| ___for stethoscope tubing is a potential source of infection. | Fabric covers |
| Fabric covers for stethoscope tubing is a potential source of___. | infection |
| The gauge to measure the pressure. | manometer |
| The manometer is the___to___the___. | 1.gauge 2.measure 3.pressure |
| The___is an electronic device attached to a blood pressure cuff. | NIBP (noninvasive blood pressure) monitor |
| The___consists of the gauge to measure the pressure (manometer), a blood pressure cuff that encloses an inflatable bladder, & a pressure bulb with valve used to manually inflate & deflate the bladder within the cuff. | sphygmomanometer |
| The sphygmomanometer consists of the: | 1.gauge to measure pressure (manometer) 2.blood pressure cuff that encloses inflatable bladder 3.pressure bulb with valve used to manually inflate & deflate bladder within the cuff |
| A___is used in conjunction with the___to auscultate the blood pressure. | 1.stethoscope 2.sphygmomanometer |
| A stethoscope is used in conjunction with the sphygmomanometer to___the__. | 1.auscultate 2.blood pressure |
| The___recommends cuff sizes based on arm circumference. | American Heart Association |
| The American Heart Association recommends___based on___. | 1.cuff sizes 2.arm circumference |
| Ideally, the cuff width should be___of the circumference of the limb to be used. | 40% |
| Ideally, the___should be 40% of the___of the___to be used. | 1.cuff width 2.circumference 3.limb |
| If the cuff is too wide, it will___. | underestimate the blood pressure |
| If the cuff is___, it will underestimate the blood pressure. | too wide |
| If the cuff is too narrow, it will___. | overestimate the blood pressure |
| If the cuff is___, it will overestimate the blood pressure. | too narrow |
| Blood pressure cuffs come in a variety of___& are either___or___. | 1.sizes 2.reusable 3.disposable |
| Reusable blood pressure cuffs. | Occlusive cloth shell |
| Occlusive cloth shell cuffs are___. | reusable |
| Inexpensive vinyl material cuffs are___. | disposable |
| Disposable blood pressure cuffs. | Inexpensive vinyl material cuffs |
| Instrument that consists of a series of lenses, mirrors, & light apertures permitting inspection of the internal eye structures. | opthalmoscope |
| The opthalmoscope is an instrument that consists of___,___, &____. | 1.series of lenses 2.mirrors 3.light apertures |
| The opthalmoscope is used to inspect____. | internal structures of the eye |
| A noninvasive measurement of arterial oxygen saturation in the blood. | pulse oximetry |
| Pulse oxymetry is a___of___in the___. | 1.noninvasive measurement 2.arterial oxygen saturation 3.blood |
| A large wall chart hung at a distance of 20 feet from client. | Snellen's chart |
| A Snellen's chart is a large all chart hung at distance of___from client. | 20 feet |
| Chart that consists of 11 lines of letters of decreasing size. | Snellen's Chart |
| Chart hung at 20 feet distance & consists of___of___of___is a Snellen's Chart. | 1.) 11 lines 2.) letters 3.) decreasing size |
| 2 charts commonly used to evaluate near vision: | 1.Jaeger 2.Rosenbaum |
| Jaeger & Rosenbaum are commonly used charts to evaluate___. | near vision |
| The___consists of a series of numbers, E's, X's, & O's in graduated sizes. | Rosenbaum chart |
| The Rosenbaum chart consists of a___,___,____,&____in____. | 1.) series of numbers 2.) E's 3.) X's 4.) O's 5.) graduated sizes |
| The client should hold the___14 inches away from face. | Rosenbaum chart |
| The Rosenbaum chart should be held by client___away from___. | 1.) 14 inches 2.) face |
| With the Snellen's Chart, the letter size indicates the___of___when read from distance of 20 feet. | 1.degree 2.visual acuity |
| With the___, the___indicates the degree of visual acuity when read from distance of 20ft. | 1.Snellen's chart 2.letter size |
| The top number of the recording indicates the___between the___&___. | 1.distance 2.chart 3.client |
| The___of the recording indicates the distance between the chart & client in___. | 1.top number 2.Snellen's chart |
| For young children or non-English speaking individuals, the___should be used. | "E" chart |
| The nurse describes the___as a table with legs & asks the client to point in the direction that the legs of the table point. | "E" chart |
| The "E" chart may be used for___&___. | 1.young children 2.non-speaking individuals |
| The nurse describes the "E" chart as a table with legs & asks the client to point in the___the legs of the table point. | direction |
| To inspect the external auditory can & tympanic membrane is the purpose of___. | Otoscope |
| The Otoscope purpose is to inspect the___&____. | 1.external auditory canal 2.tympanic membrane |
| The traditional otoscope consists of 2 primary components: | 1.head 2.handle |
| The traditional___consists of 2 primary components, the head & the handle. | Otoscope |
| A focused light source to facilitate inspection. | penlight |
| A penlight is a focused is a___to facilitate___. | 1.focused light source 2.inspection |
| With an otoscope, choose the___. | largest sized speculum that fits comfortably in the ear |
| With an___, choose the largest sized speculum that fits comfortably in the ear. | otoscope |
| The tuning fork has 2 purposes in physical assessment: | 1.auditory screening 2.assessment of vibratory sensation |
| The___has 2 main purposes of physical assessment including auditory screening & assessment of vibratory sensation. | tuning fork |
| For neurologic vibratory evaluation, a tuning fork with a pitch between__&__should be used. | 100 & 400 Hz |
| For___, a tuning fork with a pitch between 100 & 400 Hz should be used. | neurologic vibratory evaluation |
| To engage a tuning fork with a pitch between 100 & 400 Hz for neurologic vibratory examination,___the tuning fork on the___of the___. | 1.sharply strike 2.heel 3.hand |
| For auditory evaluation, a___with a frequency of 500-1,000 Hz should be used. | high-pitched tuning fork |
| For___, a high-pitched tuning fork with a frequency of___should be used. | 1.) auditory evaluation 2.) 500-1,000 Hz |
| The range of normal speech. | 300-3,000 Hz |
| 300-3,000 Hz is the range of___. | normal speech |
| A tuning fork that vibrates with a frequency of___can estimate___in the range of___. | 1.) 500-1,000 Hz 2.) hearing loss 3.) normal speech (300-3,000 Hz) |
| The___is used to spread the opening of the nares so the internal surfaces of the nose may be inspected. | Nasal speculum |
| The___is used to spread the walls of the vaginal canal so that the vaginal walls & cervix can be inspected. | Vaginal Speculum |
| The vaginal speculum is used to spread the walls of the___so that the___&___can be inspected. | 1.vaginal canal 2.vaginal walls 3.cervix |
| The___is used to perform basic screening of hearing acuity. | Audioscope |
| The audioscope is used to perform basic screening of___. | hearing acuity |
| The___is used to determine the degree of flexion or extension of a joint. | Goniometer |
| The goniometer is used to determine the degree of___or___of a___. | 1.flexion 2.extension 3.joint |
| A___is used to amplify sounds that are difficult to hear with an acoustic stethoscope. | doppler |
| A doppler is used to___sounds that are difficult to hear with an___. | 1.amplify 2.acoustic stethoscope |
| There are 3 types of vaginal specula: | 1.Graves' speculum 2.Pederson speculum 3.Pediatric or virginal speculum |
| All of the vaginal specula are composed of___& a___. | 1.) 2 blades 2.) handle |
| All___are composed of 2 blades & a handle & are either___or___. | 1.vaginal specula 2.reusable metal 3.disposable plastic models |
| The__is available in a variety of sizes with blades ranging from 3.5 to 5.0 inches in length & 0.75 to 1.25 inch in width. | Graves' speculum |
| ___are used to measure the thickness of subcutaneous tissue to estimate the amount of body fat. | Calipers for Skinfold Thickness |
| Calipers for skinfold thickness are used to measure the thickness of___to estimate the amount of___. | 1.subcutaneous tissues 2.body fat |
| The___is used to test the deep tendon reflexes. | percussion or reflex hammer |
| The Graves' speculum is used in a variety of___, with blades ranging from___in__. | 1.) sizes 2.) 3.5-5.0 inches 3.) length |
| The___is available in a variety of sizes, with blades ranging from 3.5-5.0 inches in length. | Graves' speculum |
| The Grave's speculum comes in a variety of sizes, ranging from 3.5 to 5.0 inches in lenth &___in___. | 1.) 0.75-1.25 inches 2.) width |
| With___, the bottom blade is slightly longer than the top blade. | Graves' speculum |
| With Graves' spculum, the___is slightly longer than the___. | 1.bottom blade 2.top blade |
| With the Graves' speculum, the bottom blade is___than the top blade because it conforms to the___& aids with____. | 1.slightly longer 2.longer posterior vaginal wall 3.visualization |
| The___has blades that are as long as the Graves' speculum but are much narrower & flatter. | Pederson speculum |
| The Pederson speculum has blades that are as___as the___but are much narrower & flatter. | 1.long 2.Graves' speculum |
| The Pederson speculum has blades that are as long as the Graves' speculum but are much___&___. | 1.narrower 2.flatter |
| The___is smaller in all dimensions of width & lenth. | pediatric or virginal speculum |
| The pediatric or virginal speculum is___in all dimensions of___&___. | 1.smaller 2.width 3.length |
| The purpose of the___is to detect fungal infections of the skin or to detect corneal abrasions. | Wood's lamp |
| The Wood's lamp is used to detect___of the__or to detect___. | 1.fungal infections 2.skin 3.corneal abrasions |
| The wood's lamp may be used to detect___. | ringworm |
| The___may be used to detect ringworm. | wood's lamp |
| The wood's lamp produces a___. | black-light effect |
| The___produces a black-light effect. | wood's lamp |
| The___is used to assist with the identification of skin lesions. | magnification device |
| The magnification device is used to assist with the identification of___. | skin lesions |
| The monofilament is used to test for___on___. | 1.sensation 2.lower extremities |
| The___is used to test for sensation on lower extremities. | monofilament |
| Tentatively explains a set of cues. | Hypothesis |
| Evaluate the hypothesis to arrive at a____. | Diagnosis |
| Evaluate the___to arrive at a diagnosis. | hypothesis |
| Pieces of information such as signs or symptoms. | cueset |
| A cueset is pieces of____such as____or____. | 1.information 2.signs 3.symptoms |
| Checking data to ensure accuracy. | validation |
| Process of gathering cues & data to make hypothesis & diagnoses. | diagnostic reasoning |
| Diagnostic reasing is the process of____&_____to make hypothesis & diagnoses. | 1.gathering cues 2.data |
| Diagnostic reasoning is the process of gathering cues & data to make____&____. | 1.hypothesis 2.diagnoses |
| Refers to a systematic method of collecting data. | Health assessment |
| Health assessment refers to a____of____. | 1.systematic method 2.collecting data |
| The Standards of Practice are identified by____& are based on the___. | 1.ANA (American Nurses Association) 2.nursing process |
| The___are identified by the ANA (American Nurses Association) & are based on the nursing process. | Standards of Practice |
| Comprehensive data pertinent to the patient's health or the situation. | assessment |
| Assessment is___pertinent to the___or the___. | 1.comprehensive data 2.patient's health 3.situation |
| Components of health assessment: | 1.health history 2.physical examination |
| Health history & physical examination are 2 components of____. | health assessment |
| Subjective data nurses collect while interviewing clients. | health history |
| Objective data the nurse collects using the techniques of inspection, palpation, percussion, & ausculatation. | physical examination |
| During the physical examination,___is taken as the nurse obtains the____of____,____,____,&_____. | 1.objective data 2.techniques 3.inspection 4.palpation 5.percussion 6.auscultation |
| A___consists of information about client's current state of health, meds. they take, their previous illnesses/surgeries, family histories, & review of systems. | health history |
| A health history consists of information such as: | 1.client's current state of health 2.meds. they take 3.previous illnesses/surgeries 4.family histories 5.review of systems |
| If the data is acquired from another individual (such as a family member), it is____. | secondary source of data |
| The amount of information collected by the nurse during a health history depends on: | 1.setting 2.context of care 3.client needs 4.experience of the nurse |
| Types of Health Assessment: | 1.Comprehensive assessment 2.Problem-based/focused assessment 3.Episodic/follow-up assessment 4.Screening assessment |
| Refers to the circumstance or situation related to the health care delivery. | context of care |
| The context of care refers to the___or___related to the___. | 1.circumstance 2.situation 3.health care delivery |
| Type of health assessment depends on several factors including: | 1.context of care 2.setting 3.patient needs 4.experience of the nurse |
| If you are initiating care for a client in a well-client setting, you will collect___&___. | 1.comprehensive subjective 2.objective information |
| You will collect comprehensive subjective & objective information during a____. | well-client setting |
| If you are working in Emergency dept., & client has minor burns on arm, a____should be conducted to ensure subjective & objective data are collected which may have direct or indirect impact on the management of the client's burn & risk for future injury. | problem-based or focused assessment |
| A short, usually inexpensive examination focused on disease detection. | Screening assessment |
| Screening assessment is a___, usaully___focused on___. | 1.short 2.inexpensive 3.disease detection |
| ___ex. include___blood pressure, glucose, cholesterol, & colorectal. | 1.screening assessment 2.screening |
| Screening assessment ex.: | screening: 1.blood pressure 2.glucose 3.cholesterol 4.colorectal screening |
| A patient may be asked to return for a___after completion of antibiotics. | episodic or follow-up assessment |
| Involves a detailed history & physical examination performed at the onset of care in a primary care setting or upon admission to a hospital or long-term care facility. | comprehensive assessment |
| Variables that impact client need: | 1.client's age 2.general level of health 3.(pp) presenting problems 4.knowledge level 5.support sytstems |
| A healthy 17 yr. old male presenting for a sports physical on football team has different___that 78 yr. old, recently widowed, diabetic client presenting to clinic w/ shortness of breath. | client needs |
| A nurse working in adult ICU has expertise assessing hemodynamic instability is an ex. of specialization within a given area of practice which defines___. | expertise of the nurse |
| Levels of Health Promotion: | 1.primary prevention 2.secondary prevention 3.tertiary prevention |
| Primary, secondary, & tertiary prevention are all levels of___. | health promotion |
| Protection to prevent occurrence of disease. | primary prevention |
| Immunizations, pollution control, nutrition, & exercise are all___. | primary prevention |
| Primary prevention ex.: | 1.immunizations 2.pollution control 3.nutrition 4.exercise |
| The nurse must analyze & interpret the___of a____before initiating a plan of care. | 1.outcome 2.health assessment |
| Examples of nonverbal data: | 1.touch 2.gestures 3.posture 4.facial expressions |
| Communication can be___or___. | 1.verbal 2.nonverbal |
| ____can be verbal or nonverbal. | Communication |
| ___are collected through spoken or written words. | Verbal Data |
| Verbal data may be collected through___or___. | 1.spoken 2.written words |
| During assessment, data must be___,___,&____. | 1.collected 2.verified 3.communicated |
| What should the nurse always do when taking a rectal temp.? | lubricate the thermometer |
| Sources of Data: | 1.primary source 2.secondary source 3.tertiary source |
| The primary source. | patient |
| The patient is the___. | primary source |
| A___produces info. from someplace other than the patient. | secondary source (such as family) |
| A___provides info. from outside the specific patient's frame of reference. | tertiary source |
| Ex. of tertiary sources: | 1.textbooks 2.nurse's experience 3.accepted commonalities among patients with similar adaptations 4.nurse's or health team members' responses to the patient |
| textbooks are ex. of___. | tertiary sources |
| The nurse's or other health care team members' responses to the patient are ex. of___. | tertiary sources |
| The nurse's experience & accepted commonalities among patients with similar adaptations are ex. of___. | tertiary sources |
| After data is collected, it must be___. | verified |
| To___is to confirm info. by collecting additional data, questioning orders, obtaining judgments &/or conclusions from other team members when approriate, & by collecting data oneself rather than relying on technology. | verify data |
| ___ensure authenticity & accuracy. | Verifying data |
| The nurse takes the patient's blood pressure & records a diastolic pressure of 120. What should the nurse do first? | retake the blood pressure |
| ___groups related info. together. | Clustering data |
| The nurse understands that pressure ulcers are most often associated with patients who___. | are immobilized |
| Brain attack or CVA (cerebrovascular accident) is also called____. | Stroke |
| A stroke is also called a___or___. | 1.brain attack 2.(CVA) cerebrovascular accident |
| The single most effective tool used to prevent the spread of microorganisms. | Hand washing |
| When administering medications, the safest way for the nurse to identify the patient is to___. | check the identification bracelet |
| To provide aseptically safe perineal care to all female patients, what should the nurse do? | use different parts of the washcloth with each stroke |
| The RN delegates the implementation of a nasogastric tube feeding to a LPN, what should the RN be aware of? | The RN is responsible for delegated care (supervising & evaluating delivery of care) |
| An adult patient's respiratory rate should be between____. | 14 & 20 effortless & noiseless |
| A__reduces resistance when the thermometer is inserted past the___. | 1.lubricant 2.anal sphincters |
| A lubricant___when the___is inserted past the anal sphincters. | 1.reduces resistance 2.thermometer |
| When the nurse determines if a person's body weight is ideal, it is important to assess the person's: | 1.height 2.age 3.extent of bone structure |
| Holding hands is an ex. of___. | nonverbal communication |
| ___is an ex. of nonverbal communication. | Holding hands |
| Refers to the normal skin fullness or ability of the skin & underlying tissue to return to their regular position after being pinched & lifted. | Skin turgor |
| When there is decreased skin turgor due to___,the skin remains__for a longer period of time than___after it is released. | 1.dehydration 2.pinched & "tented" 3.well-hydrated skin |
| 1.035 reflects concentrated urine which indicates that the patient has a___. | fluid volume deficit |
| An increased heart rate. | Tachycardia |
| Tachycardia is an___. | increased heart rate |
| A compensatory mechanism to increase oxygen to all body cells & is associated with hemmorrhage. | Tachycardia |
| Tachycardia is a compensatory mechanism to___to all body cells & is associated with___. | 1.increase oxygen 2.hemmorrhage |
| The nurse is caring for a patient experiencing loss of appetite (anorexia) & nausea. Which statement includes an expected outcome? The patients: | intake will be 50% of every meal during the next week |
| A patient has just returned from surgery with an IV & does not have a gag reflex. Which planned intervention takes priority? | ensure adequacy of air exchange |
| An___is made for a patient on complete bed rest; this patient is not permitted out of bed. | occupied be |
| An occupied bed is made for a patient on___; this patient is___. | 1.complete bed rest 2.not permitted out of bed |
| Patients on bed rest mut remain in bed when the linens are changed; this is called____. | making an occupied bed |
| A nurse is caring for a patient with a large pressure ulcer that has not responded to common nursing interventions. To best deal with this problem, the nurse should consult with the___. | clinical nurse specialist |
| The primary nurse assigns a staff nurse to insert an indwelling urinary (Foley) catheter. What is the first thing the staff nurse should do? | check the physician's order |
| Out of milk, fruit, celery, & vegetables, what has the least amount of sodium? | fruit |
| Encompasses health problems experienced by the client, as well as health promotion, diesease prevention, & assessment for problems associated with known risk factors, or assessment for age & gender specific health problems. | Comprehensive assessment |
| Comprehensive assessment encompasses: | 1.health probs. experienced by client 2.health promotion 3.disease prevention 4.assessment for problems asscociated with known risk factors 5.assessment for age & gender specific probs. |
| This type of assessment is most commonly used in a walk-in clinic or emergency department or other outpatient settings. | Problem-based/focused assesment |
| A problem-based/focused assessment is most commonly used in a___or___, but may also be applied in other___. | 1.walk-in clinic 2.emergency department 3.outpatient settings |
| An individual treated for an ongoing condition such as diabetes is asked to make regular visits to the clinic for___. | Episodic/follow-up assessment |
| Another type of__is the shift assessment performed by nurses in acute care facilities. | Episodic/follow-up assessment |
| Another type of episodic/follow-up assessment is the___performed by nurses in____. | 1.shift assessment 2.acute care facilities |
| The purpose of the shift assessment is to identify___in condition from___; thus the focus is largely based on the condition or problem the client is experiencing. | 1.changes 2.baseline |
| The purpose of the___is to identify changes in condition from baseline; thus the focus is largely based on the condition or problem the client is experiencing. | shift assessment |
| A screening assessment may be performed in a___or at a___. | 1.health care provider's office (as part of comprehensive examination) 2.health fair |
| A___may be performed in a health care provider's office (as part of a comprehensive examination) or a health fair. | screening assessment |
| A rash, enlarged lymph nodes, & swelling are ex. of___. | signs |
| Ex. of signs: | 1.rash 2.enlarged lymph nodes 3.swelling |
| Ex. of symptoms: | 1.nausea 2.pain 3.itching |
| Pain, itching, & nausea are ex. of___. | symptoms |
| Occasionally, data may fall into categories of both signs & symptoms. For ex.,___. | she/he "feels sweaty" |
| She/he "feels sweaty" is an ex. of____. | symptom |
| Excessive sweating. | Diaphoresis |
| Diaphoresis is___. | excessive sweating |
| The nurse may observe excessive sweating. This is an ex. of____. | sign |
| Using an___&___during the encounter facilitates documentation & increases accuracy. | 1.outline 2.taking brief notes |
| A portrait of the client's physical status, strengths, weaknesses, abilities, support systems, health beliefs, activities to maintain health, health problems, & lack of resources for maintaining health. | outcome of a health assessment |
| The implementation for implementing identified plan includes: | 1.coordination of care 2.health teaching & health promotion 3.consultation 4.presriptive authority & treatment |
| The___uses prescriptive authority, procedures, referrals, treatments, & therapies in accordance with state & federal laws & regulations. | APRN |
| The APRN uses: | 1.prescriptive authority 2.procedures 3.referrals 4.treatments 5.therapies -in accordance w/ state & fed. laws & regulations |
| Coordination of care, health teaching & health promotion, consultation, & prescriptive authority & treatment are all steps of___. | implementation |
| The RN analyzes the assessment data to determine the___or___. | 1.diagnoses 2.issues |
| The RN___the___to determine the diagnoses or issues. | 1.analyzes 2.assessment |
| The RN identifies___for a plan individualized to the patient or the situation. | expected outcomes |
| An adaptation of Gordon's functional health patterns. | NANDA (North American Nursing Diagnosis Association) Taxonomy II |
| ___is based on 13 domains. | NANDA Taxonomy II (North American Nursing Diagnosis Association) |
| The NANDA Taxonomy II is based on___. | 13 domains |
| The NANDA Taxonomy II Domains: | 1.health promotion 2.nutrition 3.elimination/exhange 4.activity/rest 5.perception/cognition 6.self-perception 7.role relationship 8.sexuality 9.coping/stress tolerance 10.life principles 11.safety/protection 12.Comfort 13.growth/development |
| ___&___are classification systems for data & nursing diagnoses. | 1.functional health patterns 2.NANDA Taxonomy II |
| An interpretation or conclusion about a patient's needs, concerns, or health problems, &/ or the decision to take action (or not), use or modify standard approaches, or improvise new ones as deemed appropriate by the patient's response. | clinical judgment |
| Noticing, Interpreting, Responding, & Reflecting are the steps of___. | clinical judgment |
| A perceptual grasp of situation. | Noticing |
| Although clinical judgment requires accurate collection of assessment data, it is the___of data by the___that impacts the decisions made. | 1.interpretation 2.nurse |
| A perceptual grasp of the situation, understanding the situation, & determining appropriate actions, if any & considering the appropriateness of patient outcomes is___. | clinical judgment -accord. to Tanner |
| According to Tanner, clinical judgment is: | 1.Noticing 2.Interpreting 3.Responding 4.Reflecting |
| Understanding the situation. | Interpreting |
| Determining appropriate actions. | Responding |
| Considering the appropriateness of patient outcomes. | Reflecting |
| if 2 nurses had same patient with same signs/symptoms, but different analysis or interpretation, they have differing___. | clinical judgment |
| The process of assessment does not automatically lead to___although it is___to it. | 1.Noticing 2.linked |
| Noticing is based on expectations of the nurse associated with___including___,____,&___. | 1.multiple variables 2.clinical experience 3.knowledge 4.clinical context |
| ___is based on___of the___associated with multiple variables including clinical experience, knowledge, & the clinical context. | 1.Noticing 2.expectations 3.nurse |
| A central component of nursing is____. | health promotion |
| Health promotion is a____of___. | 1.central component 2.nursing |
| Health promotion begins with___. | health assessment |
| ___begins with health assessment. | Health promotion |
| Through the process of health assessment, the nurse assesses a client's___,___,&___. | 1.current health status 2.health practices 3.risk factors |
| Through the process of___, the nurse assesses a client's current health status, health practices, & risk factors. | health assessment |
| Behavior motivated by the desire to increase well-being & actualize human health potential. | Health promotion |
| Health promotion is___motivated by the__to___& actualize___. | 1.behavior 2.desire 3.increase well-being 4.human health potential |
| Behavior motivated by a desire to actively avoid illness, detect it early, or maintain functioning within the constraints of illness. | health protection |
| Health protection is behavior motivated by desire to___,___,or___within the____. | 1.actively avoid illness 2.detect it early 3.maintain functioning 4.constraints of illness |
| Primary, secondary, & tertiary prevention address the promotion of health regardless of a client's____. | health status |
| Focus is to prevent a disease from developing through the promotion of a healthy lifestyle. | primary prevention |
| Consists of screening efforts to promote early detection of disease. | secondary prevention |
| ___is directed toward minimizing the disability from acute or chronic disease or injury & helping the client to maximize his/her health. | tertiary prevention |
| The framework for health promotion efforts in the U.S. is found in the____. | Healthy People 2010:Understanding and Improving Health |
| Healthy People 2010:Understanding and Improving Health if the framework for___in the___. | 1.health promotion efforts 2.U.S. |
| This document contains the national health objectives that address the most significant preventable threats to health, & national goals to reduce such threats. | Healthy People 2010: Understanding and Improving Health |
| Healthy People 2010: Understanding & Improving Health is a document that contains the___that address the most___to___. | 1.national health objectives 2.significant preventable threats to health 4.national goals to reduce such threats |
| The 2 overarching goals of Healthy People 2010 are: | 1.increase the yrs. of healthy life 2.eliminate health care disparities |
| Healthy People 2010: Understanding & Improving Health has___. | 28 focus areas |
| A 52 yr. old client is admitted to the hospital with a new diagnosis of rectal cancer. The nurse will conduct what following admission? | comprehensive assessment |
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allicox
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