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Assess.T.1 Mod.A,B,C

Health Assess. Ch.1-6 & 20, 22

QuestionAnswer
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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