Exam 1

Question 1

subjective data

Answer 1

health history, in pt words

Question 2

objective data

Answer 2

physical assessment, lab results, pt record

Question 3

what is the client’s database?

Answer 3

sub and obj data, nursing diagnosis, problem list

Question 4

nursing diagnosis

Answer 4

clinical judgment about pt response to problems, which are addressed through nursing interventions

Question 5

problem list

Answer 5

priorities

Question 6

biomedical model

Answer 6

absence of disease, health to disease continuum, physicians focus, assess s/s, medical diagnosis

Question 7

holistic health

Answer 7

nursing approach of mind body and spirit

Question 8

complete assessment

Answer 8

total health database, complete health history, full physical exam, on admission

Question 9

episodic assessment (or problem centered)

Answer 9

used in all settings for focused assessment in regards to problems at hand

Question 10

follow-up assessment

Answer 10

re-assessment of the problems

Question 11

emergency assessment

Answer 11

rapid, same time as life sustaining measures: ABCD

Question 12

validate data as reliable or accurate

Answer 12

ask sig. other, check history

Question 13

first-level priority

Answer 13

immediate, ABCs and vital signs

Question 14

Second-level priority

Answer 14

immediate after first level, mental status change, acute pain, untreated medical problems, abnormal lab values

Question 15

third-level priority

Answer 15

health problems related to lack of knowledge, activity, rest, or family coping

Question 16

results of successful interview

Answer 16

obtain description and chronology of symptoms, establish rapport and trust, teach the pt about health state and problems, build rapport for future, begin teaching for health promotion and prevention

Question 17

how to establish a contract during interview

Answer 17

time and place for physical to follow, introduce self and role, explain purpose of interview, length it will take, expectation of participation, ask permission for others to be in for interview, explain confidentiality, and any costs

Question 18

empathy

Answer 18

recognizing a feeling and putting it into words, permits expression from pt/ family

Question 19

physical environment for interview

Answer 19

quiet, private, well-lit setting, pt comfort

Question 20

challenges of note taking

Answer 20

breaks eye contact, shifts attention, interrupts pt flow, can’t see pt nonverbal, inhibits pt from sensitive topics

Question 21

what can we do to facilitate the interview process?

Answer 21

be familiar with tool for the history, minimize notes, write when there is a pause

Question 22

communication techniques

Answer 22

facilitation, silence, reflection, clarification, conformation, summary

Question 23

facilitation

Answer 23

encourages pt to continue “please go on”

Question 24

silence

Answer 24

helps pt continue talking and organize thoughts

Question 25

reflection

Answer 25

question to get more specific information "you know you have an ulcer?"

Question 26

clarification

Answer 26

used to clarify vague statements "what do you mean by..."

Question 27

conformation

Answer 27

makes sure on the same path "if I understand you correctly you said..."

Question 28

summary

Answer 28

brief restate of what pt told you, lets them know interview is coming to end

Question 29

10 traps

Answer 29

unwanted advise, avoidance, distance, interruptions, biased ?, false assurance, using authority, professional jargon, too much talking, interrupting, why questions

Question 30

what gets included when documenting history source

Answer 30

reliability of information

Question 31

"what makes the headache worse?" example of:

Answer 31

aggravating factors

Question 32

CAGE test is for:

Answer 32

excessive or uncontrolled drinking

Question 33

the 'review of systems' in history is for:

Answer 33

an evaluation of past and present health state of body systems

Question 34

when recording information for the 'review of systems' interviewer must document

Answer 34

the presence or absence of all symptoms under the systems heading

Question 35

PQRSTU is address characteristics of

Answer 35

symptoms

Question 36

effects of alcohol on traumatic conditions:

Answer 36

cirrhosis (final stage of alcohol liver disease), cancers of mouth liver and esophagus, breast cancer in women, heart damage, vehicle accident

Question 37

most abused opioid

Answer 37

oxycodone, hydrocodone, methadone

Question 38

AUDIT questionnaire

Answer 38

quantitative form w/ 10 questions that cover alcohol consumption, drinking behavior, and adverse consequences

Question 39

increase GGT level

Answer 39

chronic alcohol abuse

Question 40

increase AST level

Answer 40

months of chronic drinking

Question 41

increase MCV level

Answer 41

heavy alcohol consumption for 4 to 8 weeks

Question 42

CAGE means

Answer 42

cut down, annoyed, guilty, eye opener

Question 43

abuse is

Answer 43

intent to harm

Question 44

neglect has

Answer 44

no intent to harm

Question 45

inspection

Answer 45

first done in physical assessment to examine general

Question 46

palpation

Answer 46

touch to determine texture size consistency of body parts

Question 47

auscultation

Answer 47

listening to parts for problems

Question 48

percussion

Answer 48

sharp taps to find location size and density of underlying parts, thorax and abdomen

Question 49

what order should be used for physical assessment?

Answer 49

inspection, percussion, palpation, auscultation except for on the abdomen it is auscultation then palpation

Question 50

direct percussion

Answer 50

used on sinuses, strike directly on body

Question 51

indirect percussion

Answer 51

fingers of one hand on the area and strike with middle finger of dominant hand

Question 52

components of percussion note

Answer 52

amplitude, pitch, and quality or timbre

Question 53

tympany

Answer 53

loud high pitch... organ filled with air, air bubble over stomach

Question 54

resonance

Answer 54

loud low pitch normal over lungs

Question 55

hyperresonance

Answer 55

abnormal loud low tone last longer, pt with emphysema

Question 56

dullness

Answer 56

high pitched tone soft and short, solid organs like liver and spleen, problem over bladder (full and can't empty)

Question 57

flatness

Answer 57

high pitched tone very soft, over muscle or bone

Question 58

Bimanual palpating

Answer 58

Use of both hands to capture parts like kidneys

Question 59

Diaphragm

Answer 59

High pitched sounds, breath bowel and normal heart

Question 60

Bell

Answer 60

Soft low pitched sounds, murmurs and extra heart sounds

Question 61

Laceration

Answer 61

Cut from pressure (ring) split and tear skin

Question 62

Ecchymosis

Answer 62

Excessive blood under skin, not bruise