Health Assessment in Nursing: Chapters 1-8 and 10
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| What does COLDSPA stand for? | Character
Onset
Location
Duration
Severity
Pattern
Associated factors/how it Affects the client
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| 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)
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| What is the difference between subjective and objective data? | Subjective comes from the client (includes pt hx), objective is observed by you.
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| What chart is used for testing distance vision? | Snellen chart
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| What instrument is used to test for red reflex, and examination of the retina? | Opthalmoscope
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| What is used to inspect the ear canal, and tympanic membrane? | Otoscope
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| What is used to inspect the internal nose? | Otoscope with wide-tip attachment
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| Which position includes lying face up with legs together | Supine Position (p. 33)
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| Which position includes lying face up with knees bent, legs separated, and feet flat on table / bed | Dorsal Recumbent Position (p. 33)
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| 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)
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| Which position involves lying face-down with head to the side | Prone Position (p. 32)
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| Which position involves keeling on the bed with the support of the body on the chest and knees. | Knee-chest Position (p. 32)
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| Which position involves lying on back with feet support by stirrups? | Lithotomy
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| Which part of the hand should one use to palpate fine discriminations? (think crepitus, texture, pulse) | Fingerpads
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| Which part of the hand should one use to palpate thrills, vibrations and fremitus? | Ulnar or palmar surface
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| Which part of the hand should one use to palpate temperature? | Dorsal (back) surface
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| What part of the stethoscope is used for high frequencies? | Diaphram
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| What part of the stethoscope detects low frequencies? | Bell
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| An __________________ form is called a nursing admission or admission database. | Initial Assessment (documentation; p. 42)
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| What is the form commonly used for frequent or ongoing assessments? | Flow chart (documentation; p. 42)
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| 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)
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| True or False? Married adults often report less stress than single or divorced adults? | True (mental health; p. 56)
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| 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)
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| 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)
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| True or False? In the older adult, purposeless movements, including wondering or aggressiveness may indicate neurological deficits? | True (mental status; p. 65)
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| _________ and black Africans have more sweat glands than Asians and Native Americans, thus they have increased body odor. | Caucasians
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| What scale is used if depression is suspected in the older adult? | Geriatric Depression Scale
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| 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)
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| What is aphasia? | Inability to express oneself, or understand others (mental status; p. 73)
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| 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)
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| If CO is increased, BP is _________. | Increased (vital signs; p. 78)
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| If blood volume is decreased, BP is _________. | Decreased (vital signs; p. 78)
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| When blood flow is slowed due to resistance is BP increased, or decreased? | Increased (vital signs; p. 78)
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| When blood is thinned is BP increased, or decreased? | Decreased (vital signs; p. 78)
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| 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)
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| 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)
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| 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)
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| Tachycardia is a pulse _____ than 100 bpm | greater (vitals p. 82)
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| 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)
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| 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)
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| A BP cuff that is too small will give a BP reading that is too ____. | high (vitals; p. 85)
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| 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)
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| 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)
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| What is the range of systolic pressures for someone with Stage I hypertension? | 140-159; diastolic 90-99 (vitals; p. 86)
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| What is the range of diastolic pressures for someone with prehypertension? | 80-89; systolic 120-139 (vitals; p. 86)
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| 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)
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| Chronic (nonmalignant) pain is characterized by persistence longer than _________. | 6 months (pain; p. 63)
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| Pain classifications include _______ pain (skin), ________ pain (abdomen, cranium, thorax) and ____ _______ pain (ligaments, tendons, etc) | Cutaneous, visceral, deep somatic (pain; p. 92)
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| 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
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| What kind of pain is manifested by previous damage to PNS and/or CNS? | Neuropathic; a result of sustained neurochemical levels (pain; p. 93)
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| What kind of pain is characterized by a high resistance to pain relief? | Intractable (pain; p. 93)
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| Which cultural group(s) might see pain as natural and / or honorable? | Asian and Asian American (pain; p. 95)
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| Which cultural groups might believe that pain is to be endured? | African-Americans, and Native-Americans (pain; p. 95-96)
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| 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)
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| Which cultural groups tend to shy away from "good eye contact?" | Some Native Americans, and those from Eastern countries (culture; p. 127)
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| Which cultural groups use silence before and after speaking, and may consider not doing so rude? | Eastern (culture; p. 127)
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| 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)
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| What is the leading cause of hearing loss in children? | Chronic middle-ear infection; considered completely avoidable (culture; p. 133)
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| What cultural group is least likely to experience hearing loss? | African Americans (culture; p. 133)
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| 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)
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| 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.
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| T/F: Incidence of breast cancer are similar across multiple cultural groups? | True (culture; p. 133)
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| 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)
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| 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)
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| 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)
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