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2nd Sem > HA prelims > Flashcards

HA prelims Flashcards

1
Q

According to ANA, 2010, a nurse’s scope of practice puts emphasis on diagnosis and treatment of human response based on what?

A

Accurate Client Assessments

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2
Q

What is the standard 1 of Accurate client assessment?

A

Collects comprehensive data pertinent to the patient’s health or situation

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3
Q

How should you collect data?

A

In a systemic and ongoing process

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4
Q

True or False:
You should not involve the patient, family and other health care providers and environment in holistic data collection

A

False
You should involve the patient, family and other health care providers and environment in holistic data collection

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5
Q

How should you prioritize data collection activities?

A

Based on immediate condition, or anticipated needs

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6
Q

Standard 1 in accurate client assessment uses what assessment techniques and instruments?

A

Appropriate evidence-based and analytical models and problem-solving tools

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7
Q

Standard 1 synthesizes available data, information and knowledge relevant to the situation to do what?

A

Identify patterns

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8
Q

How do you document relevant data?

A

In a retrievable format

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9
Q

What is the standard 2 of Accurate client assessment?

A

Analyzes the assessment data to determine diagnoses or issues

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10
Q

What is the 3 steps in standard 2 of Accurate client assessment

A
  1. Derives the diagnosis based on assessment data
  2. Validates the diagnoses or issues with the client, family or health care providers
  3. Document diagnoses or issues to facilitate determination of outcomes and plans
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11
Q

The most marketable nurses will continue to be those with _____ and _____ as well as those who are ______

A

Strong assessment, client teaching abilities, and technologically savvy

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12
Q

Keep in mind the 5 trends

A
  1. Increased focus on primary care
  2. Increasing complexity of acute care
  3. Growing aging population
  4. Intensifying mental health issues
  5. Expanding service networks
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13
Q

The purpose of nursing assessment is to collect _______ to determine ______ in order to make a ______

A

Holistic subjective and objective data, overall level of functioning, professional clinical judgment

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14
Q

The nurse collects what 5 types of data about the client

A

Physiologic, psychological, sociocultural, developmental, and spiritual

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15
Q

Is used to organize information and promote the collection of holistic data

A

Framework

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16
Q

Generic/ basic sections of framework includes 5 what?

A
  1. History of present health concern
  2. Personal Health History
  3. Family History
  4. Lifestyle and Health Practices
  5. Physical Assessment
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17
Q

Types of Health Assessment

A
  1. Initial Comprehensive Assessment
  2. Ongoing/partial Assessment
  3. Focused/Problem-oriented Assessment
  4. Emergency Assessment
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18
Q

Identify the type of assessment:
1. Subjective data about the client’s perception of health
2. Past health history
3. Family history, lifestyle and health practices
4. Objective data gathered from physical examination

Depends on age, risk factors, health status, health promotion and lifestyle

A

Initial Comprehensive Assessment

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19
Q

Is needed when the client first enters a health care system and periodically thereafter

A

A total health assessment

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20
Q

Identify the type of assessment:
1. Consists of data collection that occurs after the comprehensive database established
2. Mini-overview of the client’s body systems and holistic patterns as a follow-up on health status
3. Reassessment of health problems detected to determine changes and detect any new problems
4. Performed whenever the nurse encounters a client
5. Determined by acuity of the client

A

Ongoing/ partial assessment

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21
Q

Identify the type of assessment:
1. Performed when a comprehensive database exists for a client who comes to a healthcare facility with a specific health concern
2. Consists of through assessment of a particular client problem and does not address areas not related to the problem

A

Focused/ Problem-oriented assessment

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22
Q

Identify the type of assessment:
1. Very rapid assessment performed in life-threatening situations to provide prompt treatment
2. Used to determine the status of the client’s life-sustaining physical functions

A

Emergency Assessment

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23
Q

What assessment should be done at this time:
Patient was admitted to the medical surgical ward for the first time in preparation for an abdominal surgery

A
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24
Q

What assessment should be done at this time:
Patient was admitted due to gunshot wound and bleeding profusely

A
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25
Q

What assessment should be done at this time:
Patient was admitted 3 days ago for evaluation of anti-cancer medication side effects

A
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26
Q

What assessment should be done at this time:
Patient was admitted to the medical surgical ward for monitoring of respiratory status

A
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27
Q

Is the first and most critical phase of the nursing process

A

Nursing Assessment

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28
Q

What are the steps of health assessment?

A
  1. Collection of subjective Data
  2. Collection of objective Data
  3. Validation of Data
  4. Documentation of Data
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29
Q

True or False:
If data collection is inadequate or inaccurate, incorrect nursing judgements may be that adversely affect the remaining phases of the process: diagnosing, planning, implementation, and evaluation

A

True

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30
Q

Information collection/ gathering data

A

Assessment

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31
Q

Information interpretation, stating problems and strengths

A

Diagnosis

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32
Q

Setting nursing goals desired outcomes and planning interventions

A

Outcome/ Planning

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33
Q

Performing nursing interventions

A

Implementation

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34
Q

Patient’s status and effectiveness of nursing interventions

A

Evaluation

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35
Q

Based on the nursing scope of practice, the nurse “collects comprehensive data pertinent to the patient’s health or situation which include:

Collects data in

A

a systematic and ongoing process

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36
Q

Helps organize information and promotes collection of holistic data

A

A nursing framework

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37
Q

What is the first step of Health assessment?

A

Collection of subjective data

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38
Q

Before meeting the client, what should you do?

A

Review client’s medical record, if available

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39
Q

Sensations/ symptoms, perceptions, desires, preferences, beliefs, ideas, values and personal information that can be elicited and verified only by the client

A

Subjective data

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40
Q

Provides a focus for the physical exam and identify potential nursing diagnoses. It should begin with an explanation to the client of why the information is being requested

A

Health history

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41
Q

What does health history include?

A
  1. Biographic data
  2. Reasons for seeking health care
  3. History of present health concern
  4. Family health history
  5. Review of body systems
  6. Lifestyle and health practices profile
  7. Developmental Level
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42
Q

When students are collecting information and sharing in a form of academic discussion, what must be done?

A

Identifiable information must be deleted, and initials are used to protect the client’s privacy

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43
Q

The client is considered a _____ of biographic data and all others are _____

A

primary sources, secondary sources

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44
Q

To check for the reliability of the client as a source of information, what can you do?

A

Ask immediate family members or caregiver to give detailed data regarding the patient

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45
Q

The most significant health concern of a patient

A

Chief complaint

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46
Q

COLDSPA

A

Character
Onset
Location
Duration
Severity
Pattern
Associated factors/How it Affects the client

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47
Q

COLDSPA Symptom analysis:
- Describe the sign or symptom
- “What does the pain feel like?”

A

Character

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48
Q

COLDSPA Symptom analysis:
- when did it begin
- “when did this pain start?”

A

Onset

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49
Q

COLDSPA Symptom analysis:
- Where is it? Does it radiate? Does it occur anywhere else?
- “where does it hurt the most? Does it radiate or go to any other part of your body?”

A

Location

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50
Q

COLDSPA Symptom analysis:
- how long does it last? does it recur?
- “How does the pain last? Does it come and go or is it constant?”

A

Duration

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51
Q

COLDSPA Symptom analysis:
- How bad is it? How much does it bother you?
- “How intense is the pain? rate it on a scale of 1 to 10”

A

Severity

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52
Q

COLDSPA Symptom analysis:
- What makes it better or worse?
- “what makes your back pain worse or better? are there any treatments you’ve tried that relieve the pain”

A

Pattern

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53
Q

COLDSPA Symptom analysis:
- what other symptoms occur with it? how does it affect you?
- “what do you think caused it to start? do you have any other problems that seem related to you back pain? how does this pain affect your life and daily activities?”

A

Associated factors/ How it affects the client

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54
Q

PQRST

A

Provoking/Relieving, Quality, Region and radiation, Severity, Time

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55
Q

Personal Health History compromises of 4 what?

A
  1. Childhood illnesses and immunizations
  2. Adult co-morbidities
  3. Past surgeries/accidents
  4. Prolonged episodes of pain, allergies and prescription medications
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56
Q

Includes many genetic relatives as the client can recall. Includes maternal and paternal grandparents, aunts and uncles, parents, siblings ang children

A

Family history

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57
Q

What do you use in organizing family history of patient?

A

Genogram

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58
Q

In a genogram females are indicated by a _____ while males are a _____

A

circle, square

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59
Q

In a genogram if relatives has no problems, write_____, if deceased, they are noted by an _____

A

A/W (alive and well), X

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60
Q

True or false:
In review of systems, care must be taken to include only the client’s subjective information and not the nurse’s observations

A

True

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61
Q

Deals with human responses, which includes nutritional habits, activity and exercise patterns, sleep and rest patterns, self-concept and self- care activities, social and community activities, relationships, values and
beliefs system, education and work, stress level and coping style and environment

A

Lifestyle and health practices profile

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62
Q

11 Life style and health practices profile

A
  1. Description of typical day
  2. Nutrition and weight management
  3. Activity Level and Exercise
  4. Sleep and Rest
  5. Self-concept and self-care responsibilities
  6. Social Activities
  7. Relationship
  8. Values and Belief System
  9. Education and Work
  10. Stress Levels and Coping Styles
  11. Environment
63
Q

Overview of the client’s usual daily activity

A

Description of typical day

64
Q

Recalls 24-our intake with emphasis of what foods are eaten and in what amounts. This also considers how much fluid intake is consumed

A

Nutrition and Weight Management

65
Q

Assess how active the client is during an average week

A

Activity Level and Exercise

66
Q

What is the recommended exercise regimen of aerobic exercise?

A

20-30 mins

67
Q

Whether the client is getting enough quality sleep and rest

A

Sleep and Rest

68
Q

Sleep and Rest Screening tools:
Ten true/false questions

A

The sleep disorders screening survey (Division of sleep medicine, Harvard Medical School, 2007)

69
Q

Sleep and Rest Screening tools:

(Getbettersleep.com, 2009). A several-page list
of symptoms partitioned to address the following sleep disorders: insomnia;
exces- sive daytime sleepiness; depression; hypothyroidism; obstructive sleep
apnea; heartburn or reflux disease (GERD); nocturnal myoclonus (limb and leg
symptoms); nasal or sinus issues, allergies, asthma, or lung disease; circadian
rhythm disorder; hypersomnia; narcolepsy; and parasomnias

A

Sleep Disorder Screening Tests

70
Q

Sleep and Rest Screening tools:

A 17-item Likert-like scale with interpretation of results

A

The Insomnia Screening Questionnaire

71
Q

Assessment of how the client view herself including sexual responsibility, basic hygiene practices, regularity of health care checkups, breast/testicular self-exam, and accident and hazard protection

A

Self-Concept and Self-Care Responsibilities

72
Q

Helps the nurse discover outlets the client has for support and relaxation and if the client in involved in the community beyond the family and work

A

Social Activities

73
Q

Client describes the composition of the family into which they were born and about past and current relationships with these family members

A

Relationships

74
Q

Assesses the client’s values, philosophical, religious and spiritual beliefs. Note that not all clients are comfortable discussing their feelings and should be respected

A

Values and Belief System

75
Q

Identify areas of stress and satisfaction in the client’s life, should bring about kind and amount of education the client has, did the client enjoy school or what he/she perceives his/her education

A

Education and Work

76
Q

Investigate amount of stress the clients perceive they are under and how they cope, how they address events and how they usually respond

A

Stress Levels ang Coping Styles

77
Q

Asses health hazards unique to the client’s living situation and lifestyle
(Possible questions may include:
What risks are you aware of in your environment?
* What type of precautions do you take, if any, when playing
contact sports, using chemicals or operating machinery?
* Do you believe you are ever in danger of becoming a victim of
violence?)

A

Environment

78
Q

What is the second step of Nursing Assessment?

A

Collection of Objective Data

79
Q

Also known as the Physical Examination and the information about the client that the nurse directly observes during interaction and elicited through physical examination techniques

A

Objective Data

80
Q

To become proficient with physical assessment, the nurse should know what 3 things?

A
  1. Types and operation of equipment needed for the particular
    examination
  2. Preparation of the setting, oneself and the client for the
    physical assessment
  3. Performance of the four assessment techniques: Inspection,
    Palpation, Percussion and Auscultation
81
Q

To protect examiner in any part of the examination when the examiner may have contact with blood, bodily fluids, secretions, excretions, and contaminated items or when disease-causing agents could be transmitted to or from the client

A

Gloves and Gowns

82
Q

Used to measure diastolic and systolic blood pressure.

A

Sphygmomanometer

83
Q

Used to auscultate blood sounds when measuring blood pressure

A

Stethoscope

84
Q

To measure body temperature

A

Thermometer

85
Q

Who made the faces pain rating scale?

A

Wong-Baker

86
Q

Used to measure skinfold thickness of subcutaneous tissue

A

Skinfold calipers

87
Q

What are tools used for nutritional status examination

A
  1. Platform Scale
  2. Skinfold calipers
  3. Flexible tape measure
  4. Skin marking pen
88
Q

What are tools used for skin, hair, and nail examination

A
  1. Examination light
  2. Penlight
  3. Mirror
  4. Metric ruler
  5. Magnifying glass
  6. Wood’s light
89
Q

What are tools used for Eye examination

A
  1. Penlight
  2. Snellen Chart to test distant vision
  3. Newspaper to test near vision

For continued:
1. Opaque card
2. Ophthalmoscope

90
Q

What are tools used for ear examination

A
  1. Tuning fork
  2. Otoscope
91
Q

What are tools used for mouth, throat, nose, and sinus examination

A
  1. Penlight
  2. 4x4-inch small gauze pad
  3. Tongue depressor
  4. Otoscope
92
Q

What are tools for thoracic and lung examination

A
  1. Stethoscope to auscultate breath sounds
  2. Metric rules
  3. Skin marking pen
93
Q

What are tools used for heart and neck vessel examination

A
  1. Stethoscope
  2. Two Metric ruler
94
Q

What are tools used in peripheral vascular examination

A
  1. Sphygmomanometer and stethoscope
  2. Flexible metric measuring tape
  3. Tuning fork
  4. Doppler ultrasound device and conductivity gel
95
Q

What are tools used in abdominal examination

A
  1. Stethoscope
  2. Flexible metric measuring tape
  3. Skin marking pen
  4. Two small pillows
96
Q

What are tools used in Musculoskeletal Examination

A
  1. Flexible metric measuring tape
  2. Goniometer
97
Q

What are tools used in Neurologic Examination

A
  1. Cotton tipped applicator
  2. Newspaper
  3. Ophthalmoscope
  4. Flexible metric measuring tape
  5. Objects to feel
  6. Reflex hammer

Continued:
1. Cotton ball and paper clip
2. Substances to smell and taste
3. Snellen E chart
4. Penlight
5. Tongue depressor
6. Tuning fork

98
Q

What are tools used for male genitalia and rectum examination

A

1, Gloves and water-soluble lubricant
2. Penlight
3. Specimen card for occult blood (pwet blood ;-;)

99
Q

What are tools used for female genitalia and rectum examination

A
  1. Vaginal speculum and water soluble lubricant
  2. Bifid spatula, endocervical broom
  3. Large swabs for vaginal examination

continued:
1. Liquid pap medium
2. pH paper
3. Feminine napkins

100
Q

What are the steps in preparing for the examination?

A
  1. Preparing the physical setting
  2. Preparing oneself
  3. Approaching and preparing the client
101
Q

In preparing the physical setting ensure the room is

A
  1. Comfortable, warm room temperature and provide blanket if necessary
  2. Private area is free of interruptions. Close door/pull curtains if possible
  3. Quiet area free of distraction: Turn off the radio, television or other noisy equipment
  4. Adequate lighting: best to use sunlight
  5. Firm examination table or bed at a height that prevents stooping
  6. Bedside table/tray to hold equipment needed for examination
102
Q

In preparing oneself what should you do?

A
  1. Assess your own feelings and anxieties before examining the client
  2. Your thoughts and feelings may be easily conveyed to the client (Cross-Transference)
  3. Achieve self-confidence in performing PE by practicing with a classmate, friend or
    relative
  4. Prepare Personal Protective Equipment depending on the examination to be done
    (based on OSHA, CDC & DOH Guidelines)
  5. Wash hands (refer to lecture on Infection Control)
  6. If pin or other sharp object is used to assess, discard the pin and use a new one for
    your next client
103
Q

In approaching and preparing the client what should you do?

A

Explain to the client that the physical assessment will follow and describe what
the examination will involve
* Respect client’s desires and requests related to the physical exam. Some
institutions need a consent form prior to any assessment
* PRIVACY CONCERNS
* Leave the room while the client changes into a gown and knock before re-
entering
* Allow the client to wear underwear until genitalia assessment is needed
* Lock doors, close curtains/ drapes
* Begin with less intrusive procedures
IF urine specimen is needed, explain and provide a container. Otherwise, ask
the client to urinate prior to the exam to promote easier and more
comfortable exam of the abdomen and genital area
* Continue explaining while the procedure is ease client’s anxiety
* It is helpful to integrate health teaching and promotion during examination
* Approach on the right-hand side (most procedures utilizes the right hand of
examiner)
* Prepare client for position changes and inquire if they would need assistance

104
Q

Identify the pe position:
This position is good for evaluating the head, neck, lungs, chest, back, breasts, axillae, heart, vital signs, and upper extremities. This position is also useful because it permits full expansion of the lungs and it allows the examiner to asses symmetry of upper body parts.

A

Sitting Position

105
Q

Identify the pe position:
A small pillow may be placed under the head to promote comfort. If the client has trouble breathing, the head of the bed may need to be raised. This position allows the abdominal muscles to relax and provides easy access to peripheral pulse sites. Areas assessed with the client in this position may include head, neck, chest, breasts, axillae, abdomen, heart, lungs, and all extremities

A

Supine

106
Q

Identify the pe position:
The client lies down on the examination table or bed with knees bent, the legs separated, and the feet flat on the table of bed. This position may be more comfortable than the supine position for clients with pain in the back or abdomen. Areas that may be assessed with the client in this position include head, neck, chest, axillae, lungs, heart, extremities, breasts, and peripheral pulses. The abdomen should not be assessed because the abdominal muscles are contracted in this position

A

Dorsal recumbent position

107
Q

Identify the pe position:
The client lies on the right or left side with the lower arm placed behind the body and the upper arm flexed at the should and elbow. The lower leg is slightly flexed at the knee while the upper leg in flexed at a sharper angle and pulled forward. This position is useful for assessing the rectal and vaginal areas. The client may need some assistance getting into this position. Clients with joint problems and elderly clients may have some difficulty assuming and maintaining this position

A

Sims’ position

108
Q

Identify the pe position:
The client stands still in a normal, comfortable, resting posture. This position allows the examiner to assess posture, balance, and gait. This position is also used for examining the male genitalia

A

Standing Position

109
Q

Identify the pe position:
The client lies down on the abdomen with head to the side. The prone position is used primarily to assess the hip joint. The back can also be assessed with the client in this position. Clients with cardiac and respiratory problems cannot tolerate this position

A

Prone

110
Q

Identify the pe position:
The client kneels on the examination table with the weight of the body supported by the chest knees. A 90-degrees angle should exist between the body and the hips. The arms are placed above the head, with the head turned to one side. This position is useful for examining the rectum.

A

Knee-chest

111
Q

Identify the pe position:
The client lies on the back with hips at the edge of the examination table and the feet supported by stirrups. This position is used to examine the female genitalia, reproductive tracts, and the rectum. The client may require assistance getting into this position. It is an exposed position, and clients may feel embarrassed. In addition, elderly clients may not be able to assume this position for very long or at all.

A

Lithotomy Position

112
Q

What are the 4 physical examination techniques?

A

1, Inspection
2. Palpation
3. Percussion
4. Auscultation

113
Q

Involves using the senses of vision, smell and hearing to observe and detect any normal or abnormal findings. Is usually done first since latter techniques can alter the appearance of the body part inspected

A

Inspection

114
Q

In inspection what 11 things should you take note of?

A
  1. Color
  2. Patterns
  3. Size
  4. locations
  5. consistency
  6. symmetry
  7. movement
  8. behavior
  9. odors
  10. sounds
  11. symmetry of paired body parts
115
Q

Consists of using parts of the hand to touch and feel

A

Palpation

116
Q

In palpation what are the descriptors of the following:
Texture

A

Rough/smooth

117
Q

In palpation what are the descriptors of the following:
Moisture

A

Dry/wet

118
Q

In palpation what are the descriptors of the following:
Consistency and degree of tenderness

A

Soft/hard/fluid filled

119
Q

In palpation what are the descriptors of the following:
Size

A

small/medium/large

120
Q

In palpation what are the descriptors of the following:
Temperature

A

Warm/cold

121
Q

In palpation what are the descriptors of the following:
Mobility

A

Fixed/movable/still vibrating

122
Q

In palpation what are the descriptors of the following:
Strength of pulses

A

Strong/weak/thready/bounding

123
Q

In palpation what are the descriptors of the following:
Shape

A

well defined/irregular

124
Q

In palpation for the following what is used:
Fine discriminations: pulses, texture, size, consistency, shape, crepitus

A

Fingerpads

125
Q

In palpation for the following what is used:
Vibrations, thrills, fremitus

A

Ulnar or palmar surface

126
Q

In palpation for the following what is used:
Temperature

A

Dorsal (back) surface

127
Q

What are the 4 palpation types?

A

Light, moderate, deep, bi-manual(Using two hands)

128
Q

True or False:
When palpating, use finger pads and not tips of fingers to palpate

A

True

129
Q

Involves tapping body parts to produce sound waves

A

Percussion

130
Q

For percussion what should be done to identify the following:
Detect inflamed structures

A

Eliciting pain

131
Q

For percussion what should be done to identify the following:
Changes between borders of an organ

A

Determine location, size and shape

132
Q

For percussion what should be done to identify the following:
If filled with are/fluid/solid structure

A

Determining density

133
Q

For percussion what should be done to identify the following:
can detect superficial abnormal structures or _____

A

Detecting abnormal masses

134
Q

For percussion what should be done to identify the following:
Through percussion hammer

A

Eliciting reflexes

135
Q

What are the 3 types of percussions

A

Direct, Blunt, Indirect

136
Q

Identify the type of percussion:
Tapping of a body part with 1 or 2 fingers

A

Direct

137
Q

Identify the type of percussion:
Placing hand on the body surface and using fist of the other hand to strike the back of the hand flat

A

Blunt

138
Q

Identify the type of percussion:
Most common type produces a sound/tone that varies with density of the structures

A

Indirect

139
Q

Requires the use of stethoscope to listen for heart sounds, movement of blood through the cardiovascular, movement of bowel and movement of air through respiratory tract

A

Auscultation

140
Q

What is the 3rd step of health assessment

A

Validating of Data

141
Q

The process of confirming the subjective and objective data you have collected are reliable and accurate

A

Validation

142
Q

What is the 4th step of nursing assessment?

A

Documenting and reporting data

143
Q

What are the guidelines for documentation

A
  1. Keep confidential all documented information in the client record
  2. Document legibly and print neatly in nonerasable ink
  3. Use correct grammar and spelling. Use only abbreviations that are acceptable
    and approved by the institution
  4. Avoid wordiness that creates redundancy
  5. Use phrases instead of sentences to record data
  6. Record data findings, not how they are obtained
  7. Write entries objectively without making premature judgments or diagnoses
  8. Record the client’s understanding and perception
  9. Avoid recording the word “normal” for normal findings
  10. Record complete information and details for all client symptoms or
    experiences
  11. Include additional assessment content when applicable
  12. Support objective data with specific observations obtained during physical
    examination
144
Q

In signing nurses’ notes to discourage others from adding information the the nurses’ notes, what should you do?

A

Draw a line through any blank spaces and sign you name at the far right of the column

145
Q

Anytime one health care provider is transferring client care responsibilities to another healthcare provider

A

Handoff

146
Q

What is another word for handoff

A

Endorsement

147
Q

Verbal communication of data

A
  1. Use standardized method of data communication (SBAR)
  2. Communicate with good eye contact and face-to-face
  3. Allow time for the receiver to ask questions
  4. Provide documentation of the data you are sharing
  5. Validate what the receiver has heard by questioning or asking to summarize
    report
  6. Telephone reports: record time, receiver, sender and information shared
148
Q

What is SBAR

A

Situation, Background, Assessment, Recommendation

149
Q

What part of SBAR:
States concisely why you need to communicate the client data that you have assessed (example: Mary Lorno, age `8, is experiencing a sudden onset of periumbilical pain

A

Situation

150
Q

What part of SBAR:
Describes the events that led up to the current situation (Example: client first noticed periumbilical pain at 10:30. She denies any precipitating factors)

A

Background

151
Q

What part of SBAR:
State the subjective and objective data you have collected

A

Assessment

152
Q

What part of SBAR:
Suggest what you believe needs to be done for the client based on your assessment findings (example: suggest that the primary care provider come to further assess the client and intervene)

A

Recommendations

153
Q

What is the first step of the nursing process?

A

Nursing Assessment

154
Q
A

2nd Sem (13 decks)

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