Health Assess. Ch.1-6 & 20, 22
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| Components of Health Assessment: | 1.health history 2.physical examination 3.documentation of data
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| The history component of health assessment is____. | subjective data
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| ___is subjective data. | History
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| The examination component of health assessment is____. | objective data
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| ___is objective data. | Examination
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| Signs & symptoms. | data
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| Data is___&___. | 1.signs 2.symptoms
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| What client feels & communicates. | symptoms
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| A symptom is___. | subjective data
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| A symptom is what the___&___. | 1.client feels 2.communicates
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| A clinical finding. | sign
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| A sign is___. | objective data
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| A sign is a____. | clinical finding
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| Signs &/or symptoms experienced by client. | clinical manifestations
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| Clinical manifestations are___. | objective data
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| A___&___is objective data. | 1.sign 2.clinical manifestation
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| A___is subjective data. | symptom
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| Nursing Process Steps: | 1.Assessment 2.Diagnosis 3.Outcome identification 4.Planning 5.Implementation 6.Evaluation
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| Assessment includes: | 1.collect data: 1.interview 2.health history 3.physical exam 4.functional assessment 5.consulatation 6.review of the literature
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| ___includes collecting data through interviews, health history, physical exam, functional assessment, consultation, & review of the literature. | Assessment
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| Type of questions used in assessment are___. | open-ended questions
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| 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
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| Every___is part of the nursing process. | interaction
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| A report of what the client experiences associated with a problem. | symptom
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| A symptom is a report of what the client___. | experiences
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| During a physical examination, the nurse obtains objective data using the techniques of: | 1.inspection 2.palpation 3.percussion 4.auscultation
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| During the physical examination the nurse also measures the clients: | 1.blood pressure 2.height 3.weight 4.temperature 5.respiratory rate
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| The nursing process: | 1.assessment 2.diagnosis 3.outcomes identification 4.planning 5.implementation 6.evaluation
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| The___identified by the__are based on the nursing process. | 1.Standards of Practice 2.ANA (American Nurses Association)
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| The Standards of Practice identified by the ANA are based on the___. | nursing process
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| The RN collects comprehensive data pertinent to the patient's health or the situation. | Assessment
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| Types of Health Assessment: | 1.comprehensive assessment 2.problem-based/focused assessment 3.episodic/follow-up assessment 4.screening assessment
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| The___of___to identify client's health characteristics. | 1.systematic method 2.data collection
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| The systematic method of data collection to identify client's___. | health characteristics
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| What you see, taste, touch, measure, & smell is___. | objective data
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| Objective Data: | what you: 1.see 2.touch 3.taste 4.smell 5.measure
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| The patient___a symptom. | says
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| You__a sign. | see
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| Clustering data that allows problems to be clearly apparent. | Data organization
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| Behavior motivated by desire to increase well-being & actualize health potential. | Health promotion
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| Behavior motivated by desire to avoid illness, detect illness early, & maintain functioning when ill. | Health protection
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| 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.
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| Nurses provide___&___to help meet health promotion needs. | 1.education 2.care
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| If a patient cannot speak English, who should the nurse get to translate that will maintain confidentiality? | Unfamiliar person/translator
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| If there is no translator, who should the nurse get to translate? | family
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| Vital signs should always be checked first except when assessing___. | the heart
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| When viewing the tympanic membrane, what equipment should be used? | largest equipment that fits the ear comfortably
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| Nurse should pay special attention to the abdomen when checking respiration of___. | infant
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| When checking the___of an infant, pay special attention to___. | 1.respiration 2.infant
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| Greatest bone differentiation between males and females during development? | adolescence
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| Transillumination shows: | different light degrees for tissues, fluids, etc. ?
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| Ringing in the ears. | Tinnitus
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| Largest endocrine gland. | Thyroid gland
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| Tinnitus is__in the__. | 1.ringing 2.ears
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| The thyroid gland is the___. | largest endocrine gland
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| There are 3 phases during an interview: | 1.introduction phase 2.discussion phase 3.summary phase
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| During an interview, the conversation is___. | client centered
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| Clients are free to share their concerns, beliefs, & values in their own words. | client centered
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| Client centered means that clients are free to share their___,___,&___in their own words. | 1.concerns 2.beliefs 3.values
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| A__condenses & orders data obtained during the interview to help clarify a sequence of events. | summary
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| A summary__obtained during an interview to help clarify a___. | 1.condenses/orders data 2.sequence of events
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| ___is used when you want to share with clients conclusions you have drawn from data they have given. | Interpretation
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| ___is used when you notice inconsistencies between what the client reports & your observations or other data about the client. | Confrontation
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| ___is repeating a phrase or sentence the client just said. | Reflection
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| ___involves repeating what client says using different words. | Restatement
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| ___is used to obtain more information about conflicting, vague, or ambiguous statements. | Clarification
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| ___uses phrases to encourage clients to continue talking. | Facilitation such as "go on", "uh-huh", or "then?"
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| __is performed by concentrating on what the client is saying & the subtleties. | Active Listening
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| ___is used when you notice inconsistencies between what the client reports & you observations or other data about the client. | Confrontation
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| 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
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| 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
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| 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
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| 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
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| Collected at first visit & updated as changes occur. | Biographic data
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| Biographic data is collected at__& updated as changes occur. | first visit
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| Reason for seeking health care is also called___. | chief complaint (CC) or presenting problem (PP)
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| Brief statement of the client's purpose for requesting the services of a health care provider. | chief complaint or presenting problems
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| The client's reason for seeking health care is often recorded in___. | direct quotes
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| A loud, high-pitched sound heard over the abdomen. | Tympany
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| Tympany is a___heard over the___. | 1.loud, high-pitched 2.abdomen
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| Heard over normal lung tissue. | Resonance
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| Resonance is__over___. | 1.heard 2.normal lung tissue
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| Heard in overinflated lungs. | Hyperresonance -such as emphysema
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| Hyperresonance is heard in___. | overinflated lungs
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| Hyperresonance would be heard in patient with___. | emphysema
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| Heard over the liver. | Dullness
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| Dullness is heard over the__. | liver
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| Heard over the bones & muscle. | Flatness
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| Flatness is heard over the___&___. | 1.bones 2.muscle
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| Detecting sound changes is easier when moving from___to___. | 1.resonance 2.dullness or from the lung to the liver
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| Detecting___is easier when moving from the lung (resonance) to liver (dullness). | sound changes
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| A___is used for auscultation to block out extraneous sounds when evaluating the condition of the heart. | stethoscope
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| A stethoscope is used for___to block out___when evaluating condition of heart. | 1.auscultation 2.extraneous sounds
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| The act of listening to sounds within the body. | auscultation
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| Auscultation is the act of___to___within the body. | 1.listening 2.sounds
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| The__&___are the most common during the examination. | 1.sitting 2.supine positions
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| 2 most common thermometers used in health care settings are: | 1.electronic 2.tympanic
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| The___requires less than 5 seconds. | tympanic thermometer
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| The loudness of the sound. | Intensity
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| Intensity (loudness of sound) can be described as: | 1.soft 2.medium 3.loud
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| The frequency or number of sound waves generated per second. | pitch
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| Cariac sounds are___. | low-pitched
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| __are low-pitched. | Cardiac sounds
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| Pitch is the___of___generated___. | 1.#/frequency 2.sound waves 3.per second
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| High-pitched sounds have___. | high frequency
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| __have high frequency. | High-pitched sounds
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| Expected high-pitched sounds are__. | breath sounds
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| Expected___are breath sounds. | high-pitched sounds
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| ___is short, medium, or long. | Duration of sound vibrations
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| Duration of sound vibrations are___,___,or___. | 1.short 2.medium 3.long
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| Layers of soft tissue dampen the___from deep organs. | duration of sound
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| ___of___dampen the duration of sound from___. | 1.layers 2.soft tissue 3.deep organs
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| 2 common devices to measure temperatures in children: | 1.pacifier thermometers 2.chemical dot thermometers
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| Why is the tympanic thermometer normally used in health care settings? | b/c it provides reading very qickly
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| Whey assessing the rectum, what position? | knee-chest
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| When assessing the heart, what positon? | lateral recumbent
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| When assessing the musculoskeletal system, what position? | prone
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| When assessing the rectum & vagina, what position? | sims position
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| When assessing the female/male genitalia, what position? | lithotomy
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| When assessing the head & neck, thorax & lungs, breasts, axilla, heart, & abdomen, what position? | dorsal recumbent
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| When assessing the head & neck, anterior thorax & lungs, breasts, axilla, heart, abdomen, extremeties, & pulses, what postion? | supine
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| When assessing the head & neck, back, posterior thorax & lungs, anterior thorax & lungs, breasts, axilla, heart, vital signs, & upper extremities, what position? | sitting
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| ___have been shown to under measure body temperature compared to___& are not considered accurate. | 1.chemical dot thermometers 2.electronic thermometers
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| Abnormal lung sounds. | crackles
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| Crackles are___. | abnormal lung sounds
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| The___of the stethoscope is constructed in concave shape. | bell
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| The bell of stethoscope is constructed in___. | concave shape
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| __should be used to hear soft, low-pitched sounds such as extra heart sounds or vascular sounds (bruit). | bell
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| The bell should be used to hear___. | soft, low-pitched sounds
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| The bell should be used to hear soft, low-pitched sounds such as___or___. | 1.extra heart sounds 2.vascular sounds (bruit)
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| Vascular heart sounds. | bruit
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| Bruit is___. | vascular heart sounds
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| When the bell is used, it should be pressed___to ensure that complete seal exists around the bell. | lightly (just enough pressure)
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| When the__is used, it should be pressed lightly, with just enough pressure to ensure that a complete seal exists around the bell. | bell
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| The__consists of a flat surface with a rubber or plastic ring edge. | diaphragm
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| The diaphragm consists of a__with a__or___. | 1.flat surface 2.rubber 3.plastic ring
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| The__is used to hear high-pitched sounds such as breath sounds, bowel sounds, & normal heart sounds. | diaphragm
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| The diaphragm is used to hear___such as___,___,&___. | 1.high-pitched sounds 2.breath sounds 3.bowel sounds 4.normal heart sounds
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| The structure of the___screens/blocks out low-pitched sounds. | diaphragm
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| The diaphragm screens/blocks out___. | low-pitched sounds
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| The___is held firmly against the client's skin, stabilizing it between the index & middle fingers. | diaphragm
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| The diaphragm is held___against the client's skin, stabilizing it between___&___. | 1.firmly 2.index 3.middle fingers
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| A___is used to ausculatate the fetal heart. | fetoscope
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| The head of the stethoscope consists of 2 components: | 1.bell 2.diaphragm
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| The___of the stethoscope should be heavy enough to lie firmly on the body surface without being held. | head
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| Blood pressure is most commonly measured indirectly (noninvasively) using a___or an___. | 1.sphygmomanometer 2.electronic noninvasive blood pressure (NIBP) monitor
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| The tubing of the stethoscope is usually a firm polyvinyl material that is no longer than___. | 12-18 inches (30-46cm)
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| A stethoscop is usually a___that is no longer than 12-18 inches (30-46 cm). | firm polyvinyl material
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| Several types of stethoscopes: | 1.acoustic 2.magnetic 3.electronic 4.stereophonic
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| The___is routinely used for health assessment. | acoustic stethoscope
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| The acoustic stethoscope is routinely used for___. | health assessment
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| ___for stethoscope tubing is a potential source of infection. | Fabric covers
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| Fabric covers for stethoscope tubing is a potential source of___. | infection
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| The gauge to measure the pressure. | manometer
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| The manometer is the___to___the___. | 1.gauge 2.measure 3.pressure
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| The___is an electronic device attached to a blood pressure cuff. | NIBP (noninvasive blood pressure) monitor
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| 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
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| 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
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| A___is used in conjunction with the___to auscultate the blood pressure. | 1.stethoscope 2.sphygmomanometer
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| A stethoscope is used in conjunction with the sphygmomanometer to___the__. | 1.auscultate 2.blood pressure
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| The___recommends cuff sizes based on arm circumference. | American Heart Association
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| The American Heart Association recommends___based on___. | 1.cuff sizes 2.arm circumference
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| Ideally, the cuff width should be___of the circumference of the limb to be used. | 40%
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| Ideally, the___should be 40% of the___of the___to be used. | 1.cuff width 2.circumference 3.limb
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| If the cuff is too wide, it will___. | underestimate the blood pressure
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| If the cuff is___, it will underestimate the blood pressure. | too wide
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| If the cuff is too narrow, it will___. | overestimate the blood pressure
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| If the cuff is___, it will overestimate the blood pressure. | too narrow
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| Blood pressure cuffs come in a variety of___& are either___or___. | 1.sizes 2.reusable 3.disposable
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| Reusable blood pressure cuffs. | Occlusive cloth shell
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| Occlusive cloth shell cuffs are___. | reusable
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| Inexpensive vinyl material cuffs are___. | disposable
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| Disposable blood pressure cuffs. | Inexpensive vinyl material cuffs
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| Instrument that consists of a series of lenses, mirrors, & light apertures permitting inspection of the internal eye structures. | opthalmoscope
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| The opthalmoscope is an instrument that consists of___,___, &____. | 1.series of lenses 2.mirrors 3.light apertures
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| The opthalmoscope is used to inspect____. | internal structures of the eye
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| A noninvasive measurement of arterial oxygen saturation in the blood. | pulse oximetry
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| Pulse oxymetry is a___of___in the___. | 1.noninvasive measurement 2.arterial oxygen saturation 3.blood
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| A large wall chart hung at a distance of 20 feet from client. | Snellen's chart
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| A Snellen's chart is a large all chart hung at distance of___from client. | 20 feet
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| Chart that consists of 11 lines of letters of decreasing size. | Snellen's Chart
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| Chart hung at 20 feet distance & consists of___of___of___is a Snellen's Chart. | 1.) 11 lines 2.) letters 3.) decreasing size
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| 2 charts commonly used to evaluate near vision: | 1.Jaeger 2.Rosenbaum
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| Jaeger & Rosenbaum are commonly used charts to evaluate___. | near vision
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| The___consists of a series of numbers, E's, X's, & O's in graduated sizes. | Rosenbaum chart
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| The Rosenbaum chart consists of a___,___,____,&____in____. | 1.) series of numbers 2.) E's 3.) X's 4.) O's 5.) graduated sizes
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| The client should hold the___14 inches away from face. | Rosenbaum chart
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| The Rosenbaum chart should be held by client___away from___. | 1.) 14 inches 2.) face
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| With the Snellen's Chart, the letter size indicates the___of___when read from distance of 20 feet. | 1.degree 2.visual acuity
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| With the___, the___indicates the degree of visual acuity when read from distance of 20ft. | 1.Snellen's chart 2.letter size
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| The top number of the recording indicates the___between the___&___. | 1.distance 2.chart 3.client
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| The___of the recording indicates the distance between the chart & client in___. | 1.top number 2.Snellen's chart
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| For young children or non-English speaking individuals, the___should be used. | "E" chart
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| 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
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| The "E" chart may be used for___&___. | 1.young children 2.non-speaking individuals
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| 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
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| To inspect the external auditory can & tympanic membrane is the purpose of___. | Otoscope
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| The Otoscope purpose is to inspect the___&____. | 1.external auditory canal 2.tympanic membrane
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| The traditional otoscope consists of 2 primary components: | 1.head 2.handle
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| The traditional___consists of 2 primary components, the head & the handle. | Otoscope
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| A focused light source to facilitate inspection. | penlight
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| A penlight is a focused is a___to facilitate___. | 1.focused light source 2.inspection
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| With an otoscope, choose the___. | largest sized speculum that fits comfortably in the ear
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| With an___, choose the largest sized speculum that fits comfortably in the ear. | otoscope
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| The tuning fork has 2 purposes in physical assessment: | 1.auditory screening 2.assessment of vibratory sensation
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| The___has 2 main purposes of physical assessment including auditory screening & assessment of vibratory sensation. | tuning fork
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| For neurologic vibratory evaluation, a tuning fork with a pitch between__&__should be used. | 100 & 400 Hz
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| For___, a tuning fork with a pitch between 100 & 400 Hz should be used. | neurologic vibratory evaluation
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| 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
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| For auditory evaluation, a___with a frequency of 500-1,000 Hz should be used. | high-pitched tuning fork
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| For___, a high-pitched tuning fork with a frequency of___should be used. | 1.) auditory evaluation 2.) 500-1,000 Hz
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| The range of normal speech. | 300-3,000 Hz
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| 300-3,000 Hz is the range of___. | normal speech
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| 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)
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| The___is used to spread the opening of the nares so the internal surfaces of the nose may be inspected. | Nasal speculum
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| The___is used to spread the walls of the vaginal canal so that the vaginal walls & cervix can be inspected. | Vaginal Speculum
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| 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
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| The___is used to perform basic screening of hearing acuity. | Audioscope
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| The audioscope is used to perform basic screening of___. | hearing acuity
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| The___is used to determine the degree of flexion or extension of a joint. | Goniometer
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| The goniometer is used to determine the degree of___or___of a___. | 1.flexion 2.extension 3.joint
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| A___is used to amplify sounds that are difficult to hear with an acoustic stethoscope. | doppler
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| A doppler is used to___sounds that are difficult to hear with an___. | 1.amplify 2.acoustic stethoscope
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| There are 3 types of vaginal specula: | 1.Graves' speculum 2.Pederson speculum 3.Pediatric or virginal speculum
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|
||||
| All of the vaginal specula are composed of___& a___. | 1.) 2 blades 2.) handle
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|
||||
| 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
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|
||||
| ___are used to measure the thickness of subcutaneous tissue to estimate the amount of body fat. | Calipers for Skinfold Thickness
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|
||||
| 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
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|
||||
| The Graves' speculum is used in a variety of___, with blades ranging from___in__. | 1.) sizes 2.) 3.5-5.0 inches 3.) length
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|
||||
| The___is available in a variety of sizes, with blades ranging from 3.5-5.0 inches in length. | Graves' speculum
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|
||||
| 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
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|
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| With___, the bottom blade is slightly longer than the top blade. | Graves' speculum
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|
||||
| With Graves' spculum, the___is slightly longer than the___. | 1.bottom blade 2.top blade
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|
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| 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
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|
||||
| The___has blades that are as long as the Graves' speculum but are much narrower & flatter. | Pederson speculum
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|
||||
| The Pederson speculum has blades that are as___as the___but are much narrower & flatter. | 1.long 2.Graves' speculum
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|
||||
| The Pederson speculum has blades that are as long as the Graves' speculum but are much___&___. | 1.narrower 2.flatter
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|
||||
| The___is smaller in all dimensions of width & lenth. | pediatric or virginal speculum
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|
||||
| The pediatric or virginal speculum is___in all dimensions of___&___. | 1.smaller 2.width 3.length
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|
||||
| The purpose of the___is to detect fungal infections of the skin or to detect corneal abrasions. | Wood's lamp
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|
||||
| The Wood's lamp is used to detect___of the__or to detect___. | 1.fungal infections 2.skin 3.corneal abrasions
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|
||||
| The wood's lamp may be used to detect___. | ringworm
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|
||||
| The___may be used to detect ringworm. | wood's lamp
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|
||||
| The wood's lamp produces a___. | black-light effect
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|
||||
| The___produces a black-light effect. | wood's lamp
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|
||||
| The___is used to assist with the identification of skin lesions. | magnification device
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|
||||
| The magnification device is used to assist with the identification of___. | skin lesions
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|
||||
| The monofilament is used to test for___on___. | 1.sensation 2.lower extremities
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|
||||
| The___is used to test for sensation on lower extremities. | monofilament
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|
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| Tentatively explains a set of cues. | Hypothesis
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|
||||
| Evaluate the hypothesis to arrive at a____. | Diagnosis
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|
||||
| Evaluate the___to arrive at a diagnosis. | hypothesis
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|
||||
| Pieces of information such as signs or symptoms. | cueset
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|
||||
| A cueset is pieces of____such as____or____. | 1.information 2.signs 3.symptoms
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|
||||
| Checking data to ensure accuracy. | validation
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|
||||
| Process of gathering cues & data to make hypothesis & diagnoses. | diagnostic reasoning
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|
||||
| Diagnostic reasing is the process of____&_____to make hypothesis & diagnoses. | 1.gathering cues 2.data
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|
||||
| 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
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|
||||
| 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
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|
||||
| The___are identified by the ANA (American Nurses Association) & are based on the nursing process. | Standards of Practice
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|
||||
| Comprehensive data pertinent to the patient's health or the situation. | assessment
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|
||||
| Assessment is___pertinent to the___or the___. | 1.comprehensive data 2.patient's health 3.situation
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|
||||
| Components of health assessment: | 1.health history 2.physical examination
🗑
|
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| Health history & physical examination are 2 components of____. | health assessment
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|
||||
| Subjective data nurses collect while interviewing clients. | health history
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|
||||
| Objective data the nurse collects using the techniques of inspection, palpation, percussion, & ausculatation. | physical examination
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|
||||
| 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
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|
||||
| 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
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|
||||
| 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
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|
||||
| 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
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|
||||
| 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
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|
||||
| 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
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|
||||
| A short, usually inexpensive examination focused on disease detection. | Screening assessment
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|
||||
| 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
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|
||||
| Protection to prevent occurrence of disease. | primary prevention
🗑
|
||||
| Immunizations, pollution control, nutrition, & exercise are all___. | primary prevention
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|
||||
| 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
🗑
|
Review the information in the table. When you are ready to quiz yourself you can hide individual columns or the entire table. Then you can click on the empty cells to reveal the answer. Try to recall what will be displayed before clicking the empty cell.
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If you know all the data on any row, you can temporarily remove it by tapping the trash can to the right of the row.
To hide a column, click on the column name.
To hide the entire table, click on the "Hide All" button.
You may also shuffle the rows of the table by clicking on the "Shuffle" button.
Or sort by any of the columns using the down arrow next to any column heading.
If you know all the data on any row, you can temporarily remove it by tapping the trash can to the right of the row.
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