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health assessment Test 1 > Chapter 10 * > Flashcards

Chapter 10 * Flashcards

1
Q

What is health history?

A

A comprehensive record of the client’s past and current health.

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2
Q

When is the heath history taken?

A

During the initial health assessment interview, which usually occurs at the client’s first visit to a healthcare facility.

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3
Q

What is included in a patients health history?

A

A wellness assessment covering questions on how the client optimizes health and well-being in such areas as nutrition, stress management, and social interactions.

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4
Q

T/F The health history performed by the nurse has a different focus from the medial history performed by the physician.

A

True
Both consists of subjective data, the focus of the medical history is to gather data about the cause and course of disease.

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5
Q

Health history is subjective or objective?

A

Subjective

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6
Q

What is communication?

A

The exchange of information between individuals.

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7
Q

What is encoding?

A

The process of formulating a message for transmission to another person.

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8
Q

Interactional skills include?

A
  • Listening
  • Attending
  • Paraphrasing
  • Leading
  • Questioning
  • Reflecting
  • Summarizing
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9
Q

What is listening?

A

Paying UNDIVIDED attention to what the client says and does.

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10
Q

When you are attending to a client what are you doing?

A

Giving full attention to verbal and nonverbal messages.

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11
Q

What is paraphrasing?

A

Restating the clients basic message

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12
Q

What is leading?

A

Used to encourage open communication

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13
Q

What is questioning?

A

Direct way of speaking with clients to obtain subjecting data for decision making and planning care.

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14
Q

What is reflecting?

A

Repeating the client’s verbal or nonverbal message for the client’s benefit to show that the nurse has empathy with the client’s thoughts, feelings, or experiences.

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15
Q

What is summarizing?

A

The process of gathering the ideas, feelings,and themes that clients have discussed throughout the interview and restating them in several general statements.

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16
Q

Name ways a nurse could create barriers that hinder the flow of information.

A
  • False reassurance
  • Interrupting or changing the subject
  • Passing judgment
  • cross-exmination
  • technical terms
  • sensitive issues
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17
Q

What is false reassurance?

A

Occurs when the nurse assures the client of a positive outcome with no basis for believing in it.

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18
Q

By interrupting or subject changing the nurse could show…

A

Insensitivity to the client’s thoughts and feeling and may occur when the nurse is not comfortable with the conversation .

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19
Q

Passing Judgement conveys messages to clients that…

A

they are not meeting the nurse’s values.

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20
Q

Explain cross-examination and what may happen if the nurse does this.

A

Asking questions during the interview may cause the client to feel threatened and reveal information.

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21
Q

Why should technical terminology be avoided?

A

Technical terminology should be avoided, as well as jargon, slang, or clinches, to facilitate client understanding.

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22
Q

When encountering sensitive issues the client may feel…

A

uncomfortable or defensive

23
Q

Factors that have a significant impact of the interaction that occur in the nurse-client relationship are…

A
  • Culture
  • Body Language
  • Ethnicity-Religion
  • Nationality
  • Education
  • Health status
  • Level of Intelligence
24
Q

When establishing the nurse-client relationship a translator should be used when…

A

for non-english-speaking clients.

25
Q

Characteristics that aid in establishing the nurse-client relationship are…

A
  • positive regard
  • Empathy
  • Genuineness
  • Concreteness
26
Q

What is positive regard?

A

Respect for another’s worth and dignity

27
Q

Explain what empathy is…

A

Capacity to respond to another’s feeling and experiences as if they were one’s own.

28
Q

Explain genuineness

A

Ability to present oneself honestly and spontaneously

29
Q

Concreteness is…

A

Speaking in specific terms

30
Q

What are the phases of the health history interview?

A
  • Per-interaction phase
  • Initial interview
  • Focused interview
31
Q

When does the pre-interaction phase occur?

A

Before the nurse meets the client, when data are collected from previous records.

32
Q

The initial interview is a planned meeting in which…

A

the nurse gathers information from the client.

33
Q

What is the importance of the focused interview?

A

To clarify previously obtained assessment data and gather missing information.

34
Q

What does OLDCART stand for?

A 
Onset
Location
Duration 
Characteristics 
Aggravating factors 
Relieving Factors 
Treatment
35
Q

What does ICE stand for?

A

Impact on ADLs
Coping strategies
Emotional response

36
Q

A planned, formal interaction between the nurse and the client is a…

A

Health history interview.

37
Q

The components of the health history include…

A
  • Biographic data
  • Present health or illness
  • Past history
  • Family history
  • Psychosocial history
  • Review of body systems
38
Q

The biographic data portion of the health history include the clients…

A
  • Name
  • Address
  • Age
  • Date of birth
  • Birthplace
  • Gender
  • Marital status
  • Race
  • Religion/Culture
  • Occupation
  • Insurance coverage
39
Q

The present health or illness history includes past and current health problems and concerns such as…

A
  • Reason for seeking care.
  • Health beliefs and practices
  • Health patterns
  • Medications
40
Q

Past history would include…

A
  • Childhood diseases
  • Immunizations
  • Allergies
  • Blood transfusions
  • Major illnesses
  • Injuries
  • Hospitalizations
  • Childbirths
  • Surgeries
  • Psychiatric problems
  • Use of alcohol, tobacco, and other substances.
41
Q

The family history determines whether genetic or familial patterns of health…

A

impact the client’s current or future health status.

42
Q

What is a genogram?

A

Pictorial representation of family relationships and medical history.

43
Q

Occupation, education, finances, roles and relationships, ethnicity and culture, family, spirituality, self-concept are all part of the ___ history.

A

Psychosocial

44
Q

A review of the body systems provides ___ information about each body system and its organs.

A

Subjective

45
Q

T/F The client is a secondary source.

A

False The client is a primary source.

46
Q

Secondary sources include…

A

Other individuals such as a spouse and client records.

47
Q

When reviewing the body system the nurse will review…

A
  • skin, hair, nails
  • Head, neck, and related lymphatics
  • Eyes
  • Ears, Nose, Mouth, and throat.
  • Respiratory system
  • Breast and Axillae
  • Cardiovascular system
  • Peripheral vascular system
  • Abdomen
  • Urinary system
  • Reproductive system
  • Musculoskeletal system
  • Neurologic system
48
Q

Give an example of an open ended question?

A

Anything that can not be answered with yes or no or a numeric value

49
Q

what is included in the health history format?

A

biographic data, present health or illness, past history, family history, psychosoical history, review of body systems

50
Q

What is some examples of “review of body systems” in the health history format?

A

skin,hair, and nails
head, neck, and lymphatics, eyes,
ears, nose, mouth and throat, respiratory, breasts and axillae cardiovascular peripheral vascular abdomen urinary male reproductive femociale reproductive musculoskeletal neurologic

51
Q

What is some examples of “ psychosocial history” in the health history format?

A

occupational history, education, financial background, roles and relationships, family, social structure/ emotional concerns self-concept

52
Q

What is some examples of past history in the health history format?

A

medical, surgical, hospitalization, outpatient care, childhood illnesses, immunzations, mental and emotional health, allergies, substance use

53
Q

Biographic Data

A

Name, address, age, date of birth, Birthplace, gender, Marital Status, Race, Ethnic Identity/Culture, Religion and spirituality, Occupation, Health Insurance, Source of Information/Reliability.

health assessment Test 1 (10 decks)

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