Exam 1 Flashcards
(167 cards)
1
Q
5 Core competencies identified by Institute of Medicine (IOM) that are essential for all health care professionals to demonstrate in all areas of practice
A
1) Provide patient-centered care
2) Work in interdisciplinary teams
3) Use evidenced-based practice
4) Apply quality improvements
5) Use informatics
2
Q
Components of a health assessment
A
1) Conducting a health history
2) Performing a physical examination
3) Reviewing other data from the health record (as available)
4) Document findings
3
Q
A health history consists of
A
subjective data collected during an interview. Includes:
1) Information about the current state of health of patients
2) The medications they take
3) Previous illnesses and surgeries
4) A family history
5) Review of symptoms (ROS)
4
Q
Patients may report feelings or experiences associated with health problems. These patient reports are called?
A
Symptoms and are subjective
5
Q
Primary source data
A
Subjective data acquired directly from a patient
6
Q
Secondary source data
A
Data acquired from another individual (such as family member)
7
Q
During physical examination what is collected?
A
Objective data is collected using the techniques of: 1) Inspection 2) Palpation 3) Percussion 4) Auscultation for each body system. 5) Height 6) Weight 7) Blood pressure 8) Temp. 9) Pulse rate 10) Respiratory rate all measured
8
Q
Serves as the baseline for the evaluation of subsequent changes and decisions related to care
A
The patient’s health record
9
Q
What does the EHR include?
A
1) Data from the history
2) Physical examination
3) Laboratory and diagnostic tests
4) Surgical procedures
5) Progress notes
10
Q
Circumstances contributing to the context of care include?
A
Setting or environment physical psychological or socioeconomic circumstances involving the patient, and the expertise of the nurse.
11
Q
Types of data organization
A
1) body system format (e.g. cardiovascular, musculoskeletal, auditory, visual)
2) Conceptual format (e.g oxygenation, perfusion, mobility)
12
Q
Clinical judgement
A
An interpretation or conclusion about a patient’s needs, concerns, or health problems and/or the decision to take action (or not), use or modify standard approaches, or improvise new ones as deemed appropriate by the patient’s response.
13
Q
Process of clinical judgement include 4 components
A
1) Noticing
2) Interpreting
3) Responding
4) Reflecting
14
Q
A process in which the nurse uses patterns of reasoning (involving analysis of intuition) to gain an understanding of the situation
A
Interpreting
15
Q
Reflection-in-action
A
Reflecting on past experiences while in the midst of another situation
16
Q
Reflection-on-action
A
Thinking about a situation that has occurred and developing a better understanding of what happened & the appropriateness of the patient outcomes
17
Q
Primary prevention
A
Prevent a disease from developing through the promotion of healthy lifestyles
18
Q
Secondary prevention
A
Consists of screening efforts to promote the early detection of disease
19
Q
Tertiary prevention
A
Directed toward minimizing the disability from acute or chronic disease or injury & helping the patient to maximize his/her health.
20
Q
4 Overarching goals of Healthy People 2020
A
1) Attain high quality, longer lives free of preventable disease, disability, injury, & premature death
2) Achieve health equity, eliminate disparities, & improve health of all groups
3) Create social & physical environments that promote good health for all
4) Promote quality of life, healthy development, & healthy behaviors across all life stages
21
Q
What are the 4 foundational health measures that are indicators of progress towards goals for healthy people 2020?
A
1) General health status
2) health related quality of life & well being
3) determinates of health
4) Disparities
22
Q
A 52-year-old male patient is admitted to the hospital with a new diagnosis of rectal cancer. The nurse conducts which type of assessment on his admission?
A
Comprehensive assessment. The key words are new admission
23
Q
After collecting data, the nurse begins data analysis with which activity?
A
Organizing the data collected
24
Q
Components of health assessment include?
A
1) conducting a health history (the collection of subjective data)
2) performing a physical examination (the collection of objective data)
3) documenting the findings
Collection and analysis of data are components of formulating a nursing diagnosis and care plan.
25
Information gathered during a health history include
- how patients define health
- their beliefs about attaining and maintaining health (such as how they view their responsibility for their health, which health behaviors they currently practice, which unhealthy behaviors they are willing to change)
26
Patients expectations for health are based on?
His/her life experiences, experiences of family & friends, the culture in which they live.
27
Phases of an interview
Introduction
Discussion
Summary
28
How a nurse conducts him/her self in an interview includes
What is said to a patient
personal appearance
body language
tone of voice
29
Discussion phase of interview
Nurse collects health history by facilitating a discussion regarding various aspects of patients health. Conversation is patient-centered (patients free to share concerns, beliefs, values in own words).
During this phase, a variety of communication skills & techniques are used to enhance the conversation and data collection
30
Phases of an interview bullet points
Introduction phase
Nurse:
1) Introduces self to patient
2) Describes the purpose of the interview
3) Describes the interview process
Discussion phase
Nurse:
1) Faciliates & maintains a patient-centered discussion
2) Uses various communication techniques to collect data
Summary phase
Nurse:
1) Summarizes data w/patient
2) Allows patient to clarify the data
3) Communicates an understanding of the problems to the patient.
31
Numerous factors affect the interview
1) Physical setting
2) Nurses behavior
3) types of questions asked
4) how questions are asked
5) Personality/behavior of patient
6) how they are feeling during interview
7) nature of information being discussed or the problem confronted may affect the data revealed
32
Nurses ______ skills are instrumental in a successful interview
interpersonal
33
When conducting an interview consider patient variables such as?
Age & physical, mental & emotional status
34
When a patient is in physical or emotional distress what assessment should you conduct?
Focused assessment to limit the number and nature of questions to those which are absolutely necessary for the given situation, and save any additional questions for later.
35
Permission giving technique
The nurse communicates to the patient that it is safe to discuss such topics
36
Begin an interview with?
Open-ended questions
37
Directive questions lead patients to?
Focus on one set of thoughts. This type of question is most often used in reviewing symptoms or evaluating an individual's functional capabilities
38
The ____ is an essential tool in obtaining a patients history
question-answer format
39
Data collection can be facilitated by using the following techniques
1) Active listening
2) Facilitation
3) Clarification
4) Restatement
5) Reflection
6) Confrontation
7) Interpretation
8) Summary
40
Active listening involves?
Listening with a purpose to the spoken words as well as noticing nonverbal behaviors
41
Facilitation uses?
Phrases to encourage patients to continue talking. These include verbal responses such as "go on", "uh huh", "then" & nonverbal responses such as head nodding and shifting forward in your seat with increased attention.
42
When someone is overly talkative the use of ________ may help to maintain direction and flow of the conversation
Closed-ended questions
43
LEP
Limited english proficiency
44
Who mandates the provision of interpreting services for patients with LEP (Limited english proficiency); this is also an element w/in the accreditation guidelines for health care agencies
State and federal laws
45
Cultural differences: Patient-centered care is provided when nurses develop?
Cultural competence to accept and respect differences, & identify cultural factors that may influence patients' beliefs about health and illness
46
Who places accountability for cultural competence w/all health care professionals?
The health care system
47
Define cultural competence
The ongoing process in which the health care professional continuously strives to achieve the ability & availability to work effectively w/in the cultural context of the patient (individual, family, community)
48
To deliver culturally competent care, nurses must?
Interact w/each individual as a unique person who is a product of past experiences, beliefs, and values that have been learned and passed down from one generation to the next.
49
A comprehensive health history may be performed during?
1) A hospital admission
2) With an initial clinic
3) home visit
4) When the patient's reason for seeking care is for the relief of generalized symptoms such as weight loss or fatique
50
The history for a problem based/problem focused health assessment included data that is?
Limited in scope to a specific problem. however, it must be detailed enough so the nurse is aware of other health related data that may affect the current problem. A focused interview is also used when a patient seeks help to address an urgent problem such as relief from asthma attacks or chest pain.
51
The history associated with an episodic or follow up assessment generally focuses on?
A specific problem or problems for which a patient has already been receiving treatment. It focuses on the changes that have taken place since the last visit, with an interest in disease management & the early detection of complications or a decline in health. Example is a cancer patient going for episodic visits for treatment.
52
A comprehensive health history includes the following components:
1) Biographic data
2) Reason for seeking care
3) History of present illness
4) Present health status
5) Past health history
6) Family history
7) Personal & psychosocial history
8) Review of symptoms (ROS)
53
What is biographic data?
1) Name
2) Gender
3) Address, telephone number, e-mail
4) Birthdate
5) Birthplace (important when born in foreign country)
6) Race/ethnicity
7) religion
8) marital status
9) occupation
10) contact person
11) source of data
54
Symptom analysis
A systematic method of collecting data about the history & status of symptoms
55
Symptom analysis: OLD CARTS
Onset: When did symptoms begin
Location: where are the symptoms
Duration: how long do symptoms last
Characteristics: Describe the characteristics of the symptoms
Aggravating and alleviating factors: What affects the symptoms
Related symptoms: are other symptoms present
Treatment: describe self Tx before seeking care
Severity: describe severity of the symptoms
56
The present health status focuses on?
The patient's conditions (acute & chronic), medications the patient is currently taking, and allergies the patient has experienced
57
What is included in past health history?
1) Childhood illnesses
2) Surgeries
3) Hospitalizations
4) Accidents or injuries
5) Immunizations
6) Last examinations
7) Obstetric history
58
When conducting family history ask about the presence of?
- Alzheimer's disease
- cancer (all types)
- diabetes mellitus (type 1 or 2)
- coronary artery disease (including myocardial infarction)
- hypertension
- stroke
- seizure disorders
- mental illness (including depression, bipolar, schizophrenia)
- substance abuse
- endocrine diseases (specify)
- kidney disease
59
Personal & psychosocial history: What is including in the personal history?
1) general statement of his/her feelings about self
2) cultural/religious affiliations & practices
3) Education
4) Occupational history
5) Work satisfaction
6) perception of having adequate time for leisure & rest
7) current hobbies/interests
60
What is included in a personal & psychosocial history?
1) Personal status
2) Family & social relationships
3) Diet/nutrition
4) Functional ability
5) Mental health
6) Tobacco, alcohol, illicit drug use
7) health promotion activities
8) environment
61
AUDIT
A screening questionnaire Alcohol Use Disorders Identification Test
62
General symptoms
Pain; general fatigue, weakness, fever; problems w/sleep; unexplained changes in weight
63
The nurse is assessing a patient’s activity level. Which question or comment best facilitates discussion with the patient regarding his or her level of activity?
“Do you exercise during the week?”
“Do you keep in shape?”
“Tell me what form of exercise you do on a daily basis?” Incorrect
“What do you do to get exercise?”
“What do you do to get exercise?”
64
```
In the introduction phase of the interview, the nurse asks why the patient came into the clinic. This is known as the __________________________.
history of present illness
biographic data
present health status
review of symptoms
```
history of present illness
It is not present health status because present health status includes the patient’s perception of his or her level of health
65
```
The nurse is focusing the interview for a patient who complains of headaches and nausea. Which interview format is based on body function as opposed to body system?
Review of systems
Functional health patterns
Health perception database
Nursing process
```
Functional health patterns
- Review of systems is very different from the body function format. Functional health patterns are based on body systems (e.g., respiratory and cardiovascular systems). Health perception database is an area of functional health patterns. Nursing process is the method used to identify patient problems and act on them.
66
Two levels of infection control guidelines
Standard precautions & transmission based precautions
67
Standard precautions are?
Measures to reduce risk of transmitting infection from body fluids and non-intact skin
-standard precautions are applied in all aspects of care to all patients in all health care settings
68
Primary elements of standard precautions include?
hand hygiene, personal protective equipment (ppe), managing contaminated equipment, environmental control, respiratory hygiene/couch etiquette, & patient placement
69
Transmission based precautions
Guidelines designed for control of infections among patients w/known or suspected infections caused by certain pathogens of epidemiologic significance.
Include: contact, droplet, & airborne precautions
70
3 Categories of latex reaction
1) Irritant contact dermatitis (contact dermatitis of the skin, not involving the immune system)
2) Type IV dermatitis ( a delayed hypersensitivity involving the immune system in response to the chemicals in latex occurring 24-48 hours after contact
3) Type I system reaction (an immune based systemic reaction caused by an antigen-antibody reaction & resulting in the release of histamine
71
Patients at risk of latex allergy
Children with spina bifida and people who have had multiple medical procedures & surgeries, especially genitourinary surgery.
72
Tangential lighting
Penlight can be used to increase the light in a specific location or to create shadows by directing light at right angles to the area being inspected
73
what part of the hand is most sensitive to vibration?
the ulnar surface of the hand
74
Used to assess skin, pulsations, and tenderness
light palpation 1 cm
75
Used to determine size and contour of an organ
deep palpation 4cm using one or two hands
76
Bimanual palpation technique
Uses both hands, one anterior and one posterior, to entrap a mass or an organ between the fingertips to assess size and shape
77
Percussion is performed to?
Evaluate the size, borders, and consistency of internal organs; detect tenderness; determine the extent of fluid in a body cavity
78
two types of percussion
Direct & indirect
79
The diaphragm of the stethoscope
Used to hear high-pitched sounds such as breath, bowel, & normal heart sounds
80
The bell of the stethoscope
Used to hear soft, low-pitched sounds such as extra heart or vascular sounds (bruit)
81
LED
Light emitting diode
82
Used to detect fungal infections of the skin or corneal abrasions of the eye
Wood's lamp
83
Used to differentiate the characteristics of tissue, fluid, and air w/in specific body cavities
Transilluminator
84
Used to test for sensation on the lower extremities
Monofilament
85
Used to perform basic screening for hearing acuity
Audioscope
86
Estimate body fat
calipers
87
Used to determine the degree of flexion or extension of a joint
Goniometer
88
Auditory screening and assessment of vibratory sensation
Tuning fork
89
Inspection of external auditory canal & tympanic membrane
Otoscope
90
Inspection of the internal structures of the eye
Ophthalmoscope
91
Diversity refers to?
Differences in gender, age, culture, race, ethnicity, religion, sexual orientation, physical or mental disabilities, and social and economic status
92
Culture is defined as?
The thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups. Includes religious affiliation, language, physical size, gender, sexual orientation, age, disability, political orientation, socioeconomic status, occupational status, & geographic location, all of which influence a person's perception, behavior, & evaluation of the world
93
Ethnicity refers to?
The characteristics that a group may share in some combination such as a common geographic location; race; language and dialect; religious beliefs; a shared tradition and symbols; literature, folklore, & music; food preferences; settlement & employment patterns; & an internal sense of distinctiveness
94
Race is?
Genetic in origin & includes physical characteristics such as the skin color, bone structure, eye color, & hair color
95
Spirituality refers to
One's relationship with God, a spiritual being, a higher being, or a reality greater than oneself; an existential, not of the material world meaning & purpose in life; and the life force or integrating aspect of the person. Religion may or may not be apart of spirituality.
96
Religion refers to
The organized system of beliefs, rituals, and practices in which an individual participates; whereas spirituality is a broader concept
97
Spirituality practices may include?
Prayer, meditation, walking in the woods, listening to music, painting, journaling, intentional appreciation of beauty, or being present in the world w/others
98
______ and ______ _____ may influence interpersonal behaviors and expectations
Spiritual and religious beliefs
99
OMH
Office of Minority Health; Issue national standards to ensure that all people entering the health care system receive equitable and effective treatment.
100
CLAS
Culturally and linguistically appropriate services.
| Helps eliminate racial and ethnic health disparities & improve the health of all people living in the US.
101
CLAS (culturally and linguistically appropriate services) are organized around 3 themes
1) Culturally competent care
2) Access to language services
3) Organizational support for cultural competence
102
Requires a spiritual history to be documented on every patient admitted to a hospital, nursing home, or home health agency
The Joint Commission (TJC)
103
Improving cultural awareness and meeting Standard 1 of CLAS (Culturally and linguistically appropriate services) require nurses to take several steps:
1) Develop cultural competence through developing a sensitivity to differences between their own culture & that of the patient
2) Avoid stereotyping and assuming the meaning of the behavior of others
3) Develop a template that can be used for cultural and spiritual assessment of patients and their families
104
Culturally competent involves
The mastering of 5 interrelated components: cultural desire, cultural awareness, cultural knowledge, cultural skill, & cultural encounters
105
FICA
Faith, Importance, Community, Apply, Address
106
IASP
International Association for the Study of Pain, they state that pain is an unpleasant sensory and emotional experience associated w/actual or potential tissue damage.
107
A decrease in perfussion interrupts oxygen supplied to the tissues and can lead to pain and impaired tissue integrity
.
108
A persons' pain perception and responses are affected by?
cognitive factors and cultural influences, including spiritual and ethnic beliefs
109
What are considered cultural factors for pain?
The attention people give to their pain, their expectation/anticipation of pain, and their judgement/explanation of it
110
A person's _____ ______ may lead to different behavioral responses of pain.
Cognitive interpretation
111
Cognitive patterns
Uniquely defined by one's cultural and environmental background, are constantly changing as new and repeated perceptions of pain are experienced.
112
To provide culturally acceptable pain management, nurses should?
Ask patients about their unique cultural, spiritual, and ethnic beliefs; values; and behaviors about pain and its management
113
Types of pain include
Acute, persistent (chronic), nociceptive, and nuropathetic
114
What does acute pain cause?
Results from tissue damage, usually self limiting, ends when the tissue heals. It is a stressor initiating a generalized stress response and may cause physiological signs associated w/pain such as an increase in blood pressure (BP), pulse rate, and respiration
115
What does persistent (chronic) pain cause?
It does not cause physiological stress because people adapt to it but it can cause, irritability, depression, and insomnia
116
Nociceptive pain
Arises from stimulation of somatic structures such as bone, joint, muscle, skin and connective tissue or from stimulation of visceral organs such as the gastrointestinal tract or pancreas
117
Neuropathic pain
Occurs from an abnormal processing of sensory input by the central or peripheral nervous system
118
Referred pain
Pain felt in an area away from the area of tissue injury or disease. Often occurs when visceral pain is experienced because many abdominal organs do not have pain receptors.
119
Phantom pain
Pain that a person feels in an amputated extremity after the residual limb has healed. Occurs in a person who experienced pain in that limb before the amputation.
120
Set a standard for patients to have the right to appropriate assessment and management of pain
The Joint Commission (TJC)
121
Standards for pain (TJC)
1) Initial assessment of pain and regular assessment therafter, taking into account the patients personal, cultural, spiritual, & ethnic beliefs
2) Education of all relevant health care personnel in pain assessment & management
3) Education of patients & families on their roles in managing pain & potential limitations and adverse effects of the Tx of pain.
122
Expectations for nurses implementing pain standard include?
1) Assessing intensity of pain
2) location
3) quality
4) duration
5) alleviating and aggravating factors
6) determining effects of pain on patients life (daily functioning)
7) patients goal for pain relief
123
Describe the pain process
Begins when nociceptors respond to stimuli causing tissue damage. Nociceptors are primary sensory nerves located in tendons, muscles, subcutaneous tissue, epidermis, dermis and skeletal muscles. Once nociceptors are stimulated they initiate the 2nd phase of the journey, which stimulates sensory peripheral nerves. These sensory nerve fibers carry pain impulses and include the large A-delta and the small C fibers. The A-delta fibers are associated w/sharp, pricking, acute, well localized pain of short duration. The C fibers associated w/dull, aching, throbbing, or burning sensation that is diffuse, has slow onset, relatively long duration.
- When these fibers are stimulated by nociceptors they initiate an action potential that travels along peripheral nerves to dorsal horn of spinal cord.
- located in dorsal horn is substantia gelatinosa (gate) which controls the stimulation of sensory tracts w/in spinal cord.
- gate theory of pain: when gate is open, pain impulses enter spinal cord & ascend in the spinothalamic tract to the thalamus, resulting in perception of pain.
- Third phase of journey: Thalamus receives impulses from spinothalamic tract & sends them to the parietal lobe in the cerebral cortex and on to the limbic system. When impulses reach the parietal lobe, pain is felt.
124
Stimulation of the limbic system generates what?
The emotional response to the pain such as crying or anger
125
The pain journey ends when?
The body produces substances to reduce the perception of pain.
126
As sensory nerve fibers travel through the brainstem, they stimulate?
Descending nerves that inhibit nociceptor stimuli. These nerves travel down to the dorsal horn of the spinal cord, where they release substances such as endogenous opioids (endorphins & enkephalins) that inhibit the transmission of noxious stimuli and produce analgesia.
127
Pain threshold
The point at which a stimulus is perceived as pain
128
Pain tolerance
The duration or intensity of pain that a person endures or tolerates before responding outwardly.
- Person's culture, experience of pain, expectations, role behaviors, & physical & emotional health influence tolerance of pain.
129
Pleuritic chest pain
Sharp pain when they take a deep breath
130
During low-to-moderate acute pain intensity the sympathetic nervous system may cause?
Palpitations, diaphoresis (profuse sweating), or increasing respiratory rate
131
During severe or deep pain the parasympathetic nervous system may cause?
Pallor; rapid, irregular breathing; nausea, vomiting
132
NRS
Numeric Rating Scale
133
CPG & AHCPR
The Clinical Practice Guidelines
&
The Agency for Health Care Policy and Research
state that pain should be reassessed 30 minutes after administering a parenteral analgesic and w/in 1 hour of oral analgesic drug administration
134
FLACC Pain assessment tool
```
Facial expression
Leg movement
Activity
Cry
Consolability
```
135
NVPS
adult Nonverbal Pain Scale was patterned after FLACC, but modified to reflect assessment of adults
136
A patient complains of chest pain. Which question has the highest priority to obtain additional information?
What does the pain feel like?
137
Nutrition has a close relationship with
```
elimination
hormonal regulation
immunity
tissue integrity
sensory perception
```
138
Basal metabolic rate (BMR) is influenced by several factors
```
Activity levels
illness
injury
infection
ingestion of food
starvation
```
139
Nutrients are classified into one of 3 groups
Macronutrients
Micronutrients
water
140
Macronutrients
Carbohydrate, proteins, fats.
| They are required in large amounts
141
Carbohydrate
Main source of energy and fiber in the diet.
- two main sources of carbs are plant based (fruits, vegies, and grains) and lactose (from milk)
- small amounts stored in liver & muscle in the form of glycogen (to serve as energy reserves between meals)
- moderate amounts must be ingested at regular intervals to meet energy demands
- excess stored as adipose tissue
- RDA (Recommended daily allowance) 130g/day children/adults, 175g/day pregnancy, 210g/day lactating women
- should account for 55-60% total calories
- many carb sources are high energy, nonnutrient dense (desserts, candy, etc.)
142
Protiens
Plays an essential role in facilitating growth & repair of body tissues
- can be source of energy
- 20 diff. amino acids 10 are essential in diet because our bodies can't make them they are called complete proteins (high biologic value proteins)
- foods containing the highest quality proteins (complete proteins) come from animal sources (meat, fish, poultry, eggs, milk)
- foods that contain incomplete proteins come from cereals, legumes, some veggies.
- extra used to supply energy or stored as fat
- RDA adult 0.8g/kg body weight, 56g/day adult male, 46g/day adult female, 71g/day pregnant or lactating females
- should account for 12-20% total kcal
143
Fat
Main source of fatty acids, which are essential for normal growth and development.
- Other functions include; synthesis and regulation of certain hormones, tissue structure, nerve impulse transmission, energy, insulation, protection of vital organs
- Two essential fatty acids for metabolic processes; linoleic (omega 6) alpha-linolenic (omega 3) acids
- Major form of stored energy in the body
- limit saturated fatty acid intake to less than 7% of total calories & dietary cholesterol to less than 300 mg/day
144
Micronutrients
Nutrients required in small quantities
- two groups: vitamins and minerals, they are essential for growth, development, and metabolic processes that occur continuously throughout body
- vitamins classified as water soluble (cannot be stored in body, ingested daily) and fat soluble (can be stored in body, toxicity can happen)
- Deficiencies or toxicities result in nutritionally based diseases; usually late sign of depletion
- Minerals: major minerals, trace minerals
- major minerals: present in body in large amounts, required intake over 100mg/day
- trace minerals present in body in smaller amounts; 10 essential and required intake of under 100mg/day
145
Water
Comprises 60-70% total body weight
- body required fluid for metabolic and cellular processes; cells depend on a well hydrated environment for optimal functioning.
- water intake through ingestion of fluids/food
- lost from body in various ways: urine, insensible fluid losses (lungs, skin, feces)
- fluid loss continuously so fluid replacement in ongoing
- average adult: 2.5-3L/day from foods/fluid
146
Who is at a greater risk for malutrition
Those with GI disease
147
Normal BMI range
18.5-24.9
148
Serum Albumin
Measures circulating protein; levels can be affected by fluid status, blood loss, liver function, trauma, and surgery. Fluctuations in albumin levels occur over a 3-4 week period
149
Hemoglobin (Hgb) and Hematocrit (Hct)
Provide info. regarding erythrocytes. Clinically useful to screen for anemia caused by dietary deficiency such as iron, folate, and vitamin B12.
-Hematocrit is also useful in evaluation of hydration
150
Blood glucose
Reflects carbohydrate metabolism. A fasting glucose level is used to screen for the presence of diabetes mellitus or glucose intolerance
151
BUN/Creatinine Ratio
Blood test is used as an indication of hydration
152
Why does the nurse ask a patient which medications he takes as part of a nutritional assessment?
The absorption and bioavailability of some medications are affected by food
153
A patient states that he has experienced "a lot" of unintentional weight loss over the past 4 months. Nurse measures his height/weight & determines his body mass index is 22.7 What is the most appropriate action to better evaluate his recent weight loss?
Ask what is your usual body weight
154
The nurse is assessing a patient’s dietary intake to help the patient lose weight. What is the easiest way to assess the patient’s normal dietary intake?
- Comparing established eating habits with Dietary Reference Intakes
- Asking the nurse to fill out a food plan
- Comparing the recommended dietary allowances to the USDA MyPlate
- Asking the patient to do a 24-hour dietary recall
Asking the patient to do a 24-hour dietary recall
155
The nurse is teaching adult male healthy eating guidelines. How many servings of dairy should the nurse recommend for this patient?
Between 2 and 3 servings is the recommended daily intake of dairy. 3 to 5 servings would be recommended for children and pregnant and lactating women. 5 to 6 servings of dairy is not a standard recommendation for any age category. 0 to 2 servings is not a standard recommendation for any age category.
156
Motor development
Has 2 components: gross and fine
- Gross motor behavior: refers to postural reactions such as head balance, sitting, creeping, standing, walking.
- Fine motor behavior: use of hands and fingers in the prehensile approach to grasping and manipulating an object.
157
Social adaptive behavior
Interactions of the infant or child w/other people & the ability to organize stimuli, perceive relationships between objects, dissect a whole into its component parts, reintegrate these parts in a meaningful fashion, & solve practical problems. Examples include smiling @ other people and learning to feed self
158
Language behavior
Include visible & audible forms of communication, whether facial expression, gesture, postural movements, or vocalizations (words, phrases, sentences). Includes comprehension of communication by others
159
Erik Erikson
Believed that the ego was the primary seat of personality functioning. Believed that society and culture influenced behavior. Believed people developed through a predetermined unfolding of their personalities. (rosebud unfolding)
160
Each stage (8) of Erik Erikson involves
certain developmental tasks that are psychosocial in nature and described as polar opposites or conflicts.
- example the first stage, during infancy the conflict is trust vs. mistrust
- accomplishing each successive task provides foundation for healthy self identity. Each stage builds on previous stages & must be accomplished for person to successfully complete next stage
161
8 stages of development according to erik erikson
1) infancy, trust vs mistrust, drive and hope
2) toddlerhood, autonomy vs shame/doubt, self-control & will power
3) preschool, initiative vs. guilt, direction & purpose
4) middle childhood (school age), industry vs, inferiority, method & competence
5) adolescence, identity vs role confusion, devotion & fidelity
6) young adult, intimacy vs isolation, affiliation & love
7) middle adult, generativity vs stagnation, production & care
8) older adult, ego integrity vs despair, renunciation & wisdom
162
Jean Piaget
Stages of cognitive development from birth to approximately 15yrs.
- Believed child's main goal was to establish equilibrium between self & environment
- believed that child's view developed from simple reflex behavior to complex logical & abstract thought.
- child needs a functioning neurologic system & sufficient environmental stimuli
- has 4 sequential levels of cognitive development
163
Piaget's levels of cognitive development
1) Sensorimotor, 0-2, thought dominated by physical manipulation of objects/events
2) Preoperational, 2-7, function is symbolical, using language as major tool
3) Concrete operations, 7-11, mental reasoning processes assume logical approaches to solving concrete problems
4) formal operations, 11-15, true logical thought and manipulation of abstract concepts emerge
164
2 types of adult intelligence
1) Fluid: ability to perceive complex situations & engage in short term memory, concept formation, reasoning, abstraction. Develops through CNS function & declines w/age & physiological change
2) Crystallized: associated w/skills & knowledge learned as a part of growing up in a given culture such as verbal comprehension, vocab, ability to evaluate life experiences. Develops through life experiences & education & remains stable or increases w/maturity.
165
Which finding is expected when assessing an 11 yr old child?
Five-pound 2.3kg weight gain & beginning of growth spurt
166
A nurse is assessing an infant who is able to pull up to a sitting position, turn from prone to side position, laugh & babble, & show interest in surroundings. These behaviors are consistent with?
3 month old
167
The nurse is assessing a 5-month-old infant to determine if the infant is meeting typical milestones. Which observation should be considered an expected finding for a 5-month-old infant?
Stands while holding onto furniture
Sits alone
Head lags when pulled to sitting position
Rolls over independently
Rolls over independtly
A 5-month-old also can push up from a prone position and maintain weight on his or her forearms. Stands while holding onto furniture usually is not achieved until 10 months of age. Sits alone usually is not achieved until 7 months of age. Head lags when pulled to sitting position is a typical finding for a 1-month-old infant.
