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Nurs 228 Week 1

Health Assessment in Nursing: Chapters 1-8 and 10

QuestionAnswer
What does COLDSPA stand for? Character Onset Location Duration Severity Pattern Associated factors/how it Affects the client
In terms of self-care, what is the scale used to determine how alert you are feeling? The Stanford Sleepiness Scale (p.25); from 1 (alert) to 7 (having dream-like thoughts)
What is the difference between subjective and objective data? Subjective comes from the client (includes pt hx), objective is observed by you.
What chart is used for testing distance vision? Snellen chart
What instrument is used to test for red reflex, and examination of the retina? Opthalmoscope
What is used to inspect the ear canal, and tympanic membrane? Otoscope
What is used to inspect the internal nose? Otoscope with wide-tip attachment
Which position includes lying face up with legs together Supine Position (p. 33)
Which position includes lying face up with knees bent, legs separated, and feet flat on table / bed Dorsal Recumbent Position (p. 33)
Which position involves lying on side with lower arm placed behind the body, and upper arm flexed at the shoulder and elbow SIM's Position (p. 32)
Which position involves lying face-down with head to the side Prone Position (p. 32)
Which position involves keeling on the bed with the support of the body on the chest and knees. Knee-chest Position (p. 32)
Which position involves lying on back with feet support by stirrups? Lithotomy
Which part of the hand should one use to palpate fine discriminations? (think crepitus, texture, pulse) Fingerpads
Which part of the hand should one use to palpate thrills, vibrations and fremitus? Ulnar or palmar surface
Which part of the hand should one use to palpate temperature? Dorsal (back) surface
What part of the stethoscope is used for high frequencies? Diaphram
What part of the stethoscope detects low frequencies? Bell
An __________________ form is called a nursing admission or admission database. Initial Assessment (documentation; p. 42)
What is the form commonly used for frequent or ongoing assessments? Flow chart (documentation; p. 42)
What is the second step of the nursing process? (hint: the purpose, and end-result of an assessment) Analysis of the data (documentation; p. 42)
True or False? Married adults often report less stress than single or divorced adults? True (mental health; p. 56)
Which of the following could have an affect on mental status? a) head injury b) meningitis c) encephalitis d) stroke e) all of the above All of the above (mental status; p. 57)
How might inquiring about eating habits help in diagnosing a mental disorder? Poor appetite may help identify depression, eating disorders, or substance abuse (mental status; p. 58)
True or False? In the older adult, purposeless movements, including wondering or aggressiveness may indicate neurological deficits? True (mental status; p. 65)
_________ and black Africans have more sweat glands than Asians and Native Americans, thus they have increased body odor. Caucasians
What scale is used if depression is suspected in the older adult? Geriatric Depression Scale
One's ability to joke and/or use puns is an indicator of one's ability to use ________ reasoning? Abstract reasoning; important when interviewing one with a low level of education (mental status; p.68)
What is aphasia? Inability to express oneself, or understand others (mental status; p. 73)
When palpating a pulse, amplitude is quantified as 1+, 2+, and 3+. What are the descriptions of these values? 1+ - Thready or weak (easy to obliterate); 2+ - Normal; 3+ - Bounding (unable, or nearly unable to obliterate)
If CO is increased, BP is _________. Increased (vital signs; p. 78)
If blood volume is decreased, BP is _________. Decreased (vital signs; p. 78)
When blood flow is slowed due to resistance is BP increased, or decreased? Increased (vital signs; p. 78)
When blood is thinned is BP increased, or decreased? Decreased (vital signs; p. 78)
What is a normal oral temperature? (according to our text for 228) 36.5 to 37.0 deg C; 96.0 to 99.9 deg F (according to our text for 228)
T/F: The axillary temperature is 0.5 degrees C higher than oral? False: Axillary temperature s/b about 0.5 degrees Celsius LOWER than oral (vitals; p. 81)
T/F: The rectal temp s/b about 1/2 degree Celsius higher than oral? True: The rectal temperature is between .4-.5 deg C higher than oral (.7-1.0 deg F) (vitals; p. 81)
Tachycardia is a pulse _____ than 100 bpm greater (vitals p. 82)
Orthostatic hypotension is characterized by a drop in BP greater than ____ mmHg when comparing supine vs sitting, stting vs standing, etc 20 mmHg (vitals; p. 84)
An ideal BP cuff has a length that is at __% of the length, and __% of the circumference of the arm. 80% and 40% (vitals; p. 85)
A BP cuff that is too small will give a BP reading that is too ____. high (vitals; p. 85)
When taking a BP, inflate about __mmHg past the point at which the radial pulse disappears 30mmHg; this is to ensure that one doesn't miss the auscultatory gap. (vitals; 85)
When taking a BP, the mercury collumn should be DEFLATED at a rate of __ to __ mmHg per second. 2 to 3 mmHg; deflating too slowly or quickly can affect results (vitals; p. 85)
What is the range of systolic pressures for someone with Stage I hypertension? 140-159; diastolic 90-99 (vitals; p. 86)
What is the range of diastolic pressures for someone with prehypertension? 80-89; systolic 120-139 (vitals; p. 86)
What is a normal finding for pulse pressure in mmHg? 30 to 50 mmHg; typically gets wider with age due to diminished elasticity of the periphery (vitals; p. 87)
Chronic (nonmalignant) pain is characterized by persistence longer than _________. 6 months (pain; p. 63)
Pain classifications include _______ pain (skin), ________ pain (abdomen, cranium, thorax) and ____ _______ pain (ligaments, tendons, etc) Cutaneous, visceral, deep somatic (pain; p. 92)
T/F: Pain perceived at both the source, and extending to other tissues is called referred pain. False: radiating is felt in both places; referred is only felt in areas away from the source
What kind of pain is manifested by previous damage to PNS and/or CNS? Neuropathic; a result of sustained neurochemical levels (pain; p. 93)
What kind of pain is characterized by a high resistance to pain relief? Intractable (pain; p. 93)
Which cultural group(s) might see pain as natural and / or honorable? Asian and Asian American (pain; p. 95)
Which cultural groups might believe that pain is to be endured? African-Americans, and Native-Americans (pain; p. 95-96)
T/F: Both the Numeric Pain Intensity Scale, and the Wong-Baker Facial Grimace Scale measure pain on a scale from 0 to 10? True; "0 being no pain, and 10 being the worst possible pain" (pain; p. 101)
Which cultural groups tend to shy away from "good eye contact?" Some Native Americans, and those from Eastern countries (culture; p. 127)
Which cultural groups use silence before and after speaking, and may consider not doing so rude? Eastern (culture; p. 127)
What is the leading cause of blindness in non-developing nations? Cataracts, followed by glaucoma and age-related macular degeneration--leading cause in developed countries (culture; p. 133)
What is the leading cause of hearing loss in children? Chronic middle-ear infection; considered completely avoidable (culture; p. 133)
What cultural group is least likely to experience hearing loss? African Americans (culture; p. 133)
Which cultural group has even higher rates of oral cancer than the US (five times higher)? Inhabitants of South Asia--from ritualistic tobacco usage (oral cancer is inflamed by all tobacco, and alcohol use) (culture; p. 133)
T/F: African Americans are more likely to develop COPD than other cultural groups? False: However, they are more at risk for nearly every other respiratory related illness, including asthma, chronic RIs and lung cancer.
T/F: Incidence of breast cancer are similar across multiple cultural groups? True (culture; p. 133)
T/F: All CVDs are of higher incidence in the Southern United States, than elsewhere in the country? True; called the "stroke belt." (culture; p. 133)
T/F: Osteoporosis is less common in small frame people, such as Asians? False; it is more common in small frame people (culture; p. 134)
T/F: Alzheimer's is found more readily in the United States than any where else? True; developing countries show a higher incidence of Alzheimer's, as it is a "disease of longevity." (culture; p. 134)
Created by: scottheadrick