exam 1

Question 1

what is objective data and examples ?

Answer 1

observational data, vital signs

Question 2

what is subjective data and examples

Answer 2

data that the patient tells the nurse during history taking

Question 3

what are the 5 steps of the nursing process?

Answer 3

A: assessment, recognize cues
D: diagnosis, analyze the cues
P: planning, prioritize hypotheses and generate solutions
I: implementation, take action
E: evaluation, outcome of process

Question 4

what is the fasting growing minority population in the US?

Answer 4

hispanic/ latino

Question 5

describe elements of assessment phase of nursing process

Answer 5

recognize the cues

Question 6

definition of evidence-based practice, and type of info utilized for best

Answer 6

integration of research evidence, clinical expertise, clinical knowledge along with patients values and preferences
best evidence from literature review, patients own preference, clinicians experience

Question 7

definition of follow up bases

Answer 7

used to evaluate and document ongoing short and long term health problems

Question 8

elements of health data base, when it is appropriate to obtain

Question 9

culturally competent and appropriate care

Answer 9

develop cultural sensitivity, basic knowledge, applying knowledge to improve health outcomes, apply universal understanding to all contextual aspects of care, provide cultural care across cultural boundaries

Question 10

obtaining appropriate info as apart of health assessment

Answer 10

establish trust, teach the client, trusting rapport, focus on health promotion and disease prevention , gathering accurate/ complete data, gain understanding of persons belief system, concern, perception, subjective data and note

Question 11

how should the physical environment be in an interview?

Answer 11

“equal status” seating, nice temp.

Question 12

how do you start interviews?

Answer 12

hi my name is____, i need to ask you a few questions about ______.

Question 13

interview techniques ?

Answer 13

verbal communication: tone, vocalization
nonverbal: body language, unconscious messages may be more reflective of true messages
open ended and closed ended questions

Question 14

confrontation in an interview

Answer 14

clarifying inconsistent information

Question 15

non-therapeutic techniques

Answer 15

Providing false assurance or reassurance, Giving unwanted advice, Using authority, Using avoidance language, Engaging in distancing,Using professional jargon ,Using leading or biased questions, Talking too much, Interrupting, Using why questions

Question 16

teaching during interviews

Answer 16

informing person by sharing factual and objective information
(teaching materials such as for smoking cessation)

Question 17

biased/ leading questions definitions

Answer 17

be aware of your own self-awarenes ”implicit bias” set aside your own
personal prejudices to care for all types of clients

Question 18

anger- clarity in documenting

Answer 18

the nurse will want to assess the patient’s understanding about anger, their perceptions of their angry behavior, and their readiness to learn

Question 19

use of interpreters

Answer 19

safe and informed communication, trained certified medical interpreter, verbal and nonverbal ques, speaking patients language does not imply understanding of cultural diversity

Question 20

use of direct questions

Answer 20

target specific topics, vulnerable populations that need special attention include acutely ill person,
someone with drug/alcohol abuse, sexually aggressive, emotionally distraught
such as crying, angry/threatening violence and a person with anxiety

Question 21

interruptions during interviews

Answer 21

avoid interruptions, put cell phones on silence, inform staff of no interruptions

Question 22

active listening techniques

Answer 22

non-verbal communication, making sure you are paying attention

Question 23

what info should be included in documentation of health history?

Answer 23

Biographic data, History source, Reason for seeking care, History of present illness, Past health, Family history, ROS, Functional assessment including ADL’s

Question 24

purpose of health history?

Answer 24

reason for seeking care, patients own words

Question 25

what is the “history of the present illness”

Answer 25

collect all provided data, be as accurate and precise as possible, patients own words

Question 26

what may be an example of a patient’s symptom and an example of the quality of the symptom

Answer 26

symptom: subjective description from the patient sign: objective observation (abnormality) detected on the physical exam or in lab reports

Question 27

patient’s perception of present illness and the relationship to quality of life/functional assessment

Answer 27

self-esteem, Activity/exercise, Rest/sleep, Nutrition and elimination, IPR’s and resources, Spiritual resources, Coping/stress management, Personal habits, Illicit/street drugs, Environment/work hazards, Intimate partner violence, Occupational health

Question 28

patient drug allergies

Answer 28

make sure you get every allergy the patient knows of

Question 29

aspects of the Mental Health Assessment which can be gathered from observation

Answer 29

appearance, behavior, cognition, thought process, perform the exam when abnormality is noted

Question 30

delirium, dementia, cognition

Answer 30

delirium: a mental state that causes confusion, disorientation, and a reduced awareness of one's surroundings dementia: the loss of cognitive functioning thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities cognition: being able to be oriented to person, time, place,

Question 31

use of the MMSE tool in determining psychiatric mental illness versus other medical illnesses

Answer 31

test of cognitive functions of memory, orientation to time and place, naming, reading, copying or visuospatial orientation, writing, and the ability to follow a 3 stage command. quick and easy with 11 standard questions.

Question 32

information covered in the AUDIT questionnaire

Answer 32

how often one drinks alcohol, many drinks, last year containing anything fo alcohol, ijuries bc of alchol, higher the score more at risk

Question 33

older adult and alcoholic beverage use

Answer 33

decrease in metabolic functions, decrease muscle mass, rick of cognitive decline, falls, depression, GI disturbances

Question 34

use of TWEAK questionnaire

Answer 34

screening at risk women, especially pregnant

Question 35

intimate partner abuse

Answer 35

physical abuse, sexual abuse, stalking, psychological aggression

Question 36

registered Nurse and report of abuse

Answer 36

mandatory reporters, always include in interviews/assessments

Question 37

sounds that may be heard with the bell and diaphragm of the stethoscope

Answer 37

DIAPHRAGM—THE FLAT EDGE, USED TO LISTEN FOR HIGH PITCHED SOUNDS BELL—DEEP, HALLOW CUPLIKE SHAPE USED TO LISTEN FOR SOFT PITCHED SOUNDS

Question 38

what may be assessed with palpation

Answer 38

TEXTURE, TEMPERATURE, MOISTURE, SWELLING, ORGAN LOCATION AND SIZE, VIBRATION, PULSATION AND CREPITATION, RIGIDITY OR SPASTICITY, PRESENCE OF LUMPS OR MASSES, PRESENCE OF PAIN OR TENDERNESS

Question 39

correct order in performing the physical assessment

Answer 39

inspection, palpation, percussion, auscultation

Question 40

steps to help a patient be more comfortable before and during the exam

Answer 40

YOUR PATIENT WILL USUALLY BE ANXIOUS CONSIDERING THE ANTICIPATION OF THE EXAM (AND CONCERNS OF THE OUTCOME) AND THE ENVIRONMENT. REMEMBER—IF THIS IS THE FIRST TIME MEETING THIS PERSON—YOU ARE A STRANGER. TO DECREASE THE ANXIETY FOR THE PATIENT—APPEAR UNHURRIED AND CONFIDENT DURING THE EXAM REDUCING THE PATIENT’S ANXIETY MAY ALLOW THE PATIENT TO FEEL MORE COMFORTABLE WHICH WILL ASSIST IN ACCURATE GATHERING OF DATA.

Question 41

components of the general survey

Answer 41

physical appearance, body structure, mobility, behavior, measuring weight, measurements, waist circumference,

Question 42

charting a patient’s level of consciousness

Answer 42

is the person alert, oriented, responds to questions and responds appropriately?

Question 43

list what is included in obtaining a patient’s vital signs

Answer 43

blood pressure, RR, heart rate, temperature, o2 stats

Question 44

definition of spirituality

Answer 44

broader term that encompasses something larger than ones own existence with a belief in transcendence

Question 44

purpose of using a doppler

Answer 44

detect blood flow

Question 45

physiologic processes that can affect a patient’s vital signs

Answer 45

age, gender, infection, medication, pain, anxiety, stress, circadian rhythm, recent activity, menstrual cycle

Question 46

assessing and documenting a patient’s pain level

Answer 46

ask patient if they are in pain 0-10

Question 47

different levels of managing immediate priorities

Answer 47

first level: emergent, life threatening second level:next extend to this level to prevent further deterioration third level:important, but may be addresses after more urgent problems resolved

Question 48

definition of religion

Answer 48

organized system of beliefs as a shred experience that can assist in meeting ones individuals spiritual needs

Question 49

palpation techniques

Answer 49

fingertips, fingers/thumbs, dorsa, base of fingers