Exam 1 Flashcards
(97 cards)
1
Q
: Age, gender, skin color, LOC, facial features, overall appearance
A
Physical Appearance
2
Q
Which of the following has been found to influence pain sensitivity in women?
- Age
- Hormonal changes
- Parity
- weight
A
Hormonal changes
3
Q
Symptom Analysis that includes
How does it look, feel, sound? How intense/severe is it?
A
Quality or Quantity.
4
Q
The most familiar rhythm is the 24-hour, day-night cycle known as the ________ or circadian rhythm
A
diurnal
5
Q
Data collection for the general survey begins:
- at the first encounter.
- at the beginning of the physical examination.
- while taking vital signs.
- during the mental status examination
A
at the first encounter
6
Q
Symptom Analysis that includes
Where is it? Does it spread anywhere?
A
Region or Radiation.
7
Q
Symptom Analysis that includes
. What do you think it means?
A
Understand Patient’s Perception of the problem
8
Q
When recording information for the review of systems, the interviewer must document:
- physical findings, such as skin appearance, to support historic data.
- “negative” under the system heading.
- the presence or absence of all symptoms under the system heading.
- objective data that support the history of present illness.
A
the presence or absence of all symptoms under the system heading.
9
Q
The most appropriate introduction to use to start an interview with an older adult patient is:
- “Mr. Jones, I want to ask you some questions about your health so that we can plan your care.”
- “David, I am here to ask you questions about your illness; we want to determine what is wrong.”
- “Mr. Jones, is it okay if I ask you several questions this morning about your health?”
- “Because so many people have already asked you questions, I will just get the information from the chart.”
A
“Mr. Jones, I want to ask you some questions about your health so that we can plan your care.”
10
Q
: (To creep!) Focus eyes on the patient, use lighting appropriately, remember the other senses - scents and odors
A
Inspection
11
Q
An example of an open-ended question or statement is:
- “Tell me about your pain.”
- “On a scale of 1 to 10, how would you rate your pain?”
- “I can see that you are quite uncomfortable.”
- “You are upset about the level of pain, right?”
A
“Tell me about your pain.”
12
Q
What is the source of deep somatic pain?
- Skin and subcutaneous tissues
- Bones and joints
- Pancreas
- Intestine
A
Bones and joints
13
Q
While discussing the treatment plan, the nurse infers that the patient is uncomfortable asking the physician for a different treatment because of fear of the physician’s reaction. In this situation, the nurse’s verbal interpretation:
- affects the nurse-physician relationship.
- impedes further discussion.
- helps the patient understand personal feelings in relation to his or her verbal message.
- helps the nurse understand his or her own feelings in relation to the patient’s verbal message.
A
helps the patient understand personal feelings in relation to his or her verbal message.
14
Q
Verbal Responses-Assisting in interview that
- Clarifying inconsistent information
- Focusing client’s attention on an observed behavior, action, or feeling
- You look sad, or You sound angry.
- Earlier you said that you didn’t drink, but just now you said you go out every night after work for 1-2 beers.
- When I press here you grimace, but you said it doesn’t hurt.
A
Confrontation
15
Q
What type of pain is short and self-limiting and dissipates after the injury heals?
- Chronic
- Persistent
- Acute
- Breakthrough
A
Acute
16
Q
10 Traps of Interviewing
A
Providing false assurance or reassurance Giving Unwanted Advice Using Authority Using Avoidance Language Distancing Using professional jargon Using Leading or Biased Questions Talking Too Much Interrupting Using “Why” Questions
17
Q
What information is included in greater detail when taking a health history on an infant?
- Nutritional data
- History of present illness
- Family history
- Environmental hazards
A
Nutritional data
18
Q
Parents or caretakers accompany children to the health care setting. Starting at ___ years of age, the interviewer asks the child directly about his or her presenting symptoms.
- 5
- 7
- 9
- 11
A
7
19
Q
Deep palpation is used to:
- identify abdominal contents
- evaluate surface characteristics.
- elicit deep tendon reflexes.
- determine the density of a structure
A
identify abdominal contents
20
Q
Verbal Responses-Assisting in interview that
- Names a feeling and allows its expression
- Allows person to feel accepted and strengthens rapport
- Useful in instances when client hasn’t identified the feeling or isn’t ready to discuss it
- Client (sarcastically): This is just great! I own a business, direct my employees; now I can’t even go to the bathroom without help.
- Response: It must be hard—one day having so much control and now feeling dependent on someone else.
- Other responses include: This must be very hard for you or just placing hand on person’s arm (see Fig. 3-4)
A
Empathy
21
Q
Fine tactile discrimination is best achieved with:
- opposition of the fingers and thumb.
- fingertips
- base of fingers
- back of hand
A
Fingertips
22
Q
The tympanic membrane thermometer (TMT):
- provides an accurate measurement of core body temperature.
- senses the infrared emissions of the cerebral cortex.
- is not used in unconscious patients.
- accurately measures temperature in 20 to 30 seconds.
A
-provides an accurate measurement of core body temperature.
23
Q
Doppler technique:
- is used to assess the apical pulse.
- augments Korotkoff sounds during blood pressure measurement.
- provides an easy and accurate measurement of the diastolic pressure.
- measures arterial oxygenation saturation
A
augments Korotkoff sounds during blood pressure measurement.
24
Q
A medical diagnosis is used to evaluate:
A. a person’s state of health.
B. the response of the whole person to actual or potential health problems.
C. a person’s culture.
D. the cause of disease.
A
the cause of disease.
25
The nurse questions the reliability of the history provided by the patient. One method to verify information within the context of the interview is to:
- review previous medical records.
- rephrase the same questions later in the interview.
- ask the patient if there is someone who could verify information.
- call a family member to confirm information.
rephrase the same questions later in the interview.
26
The use of euphemisms to avoid reality or to hide feelings is known as:
- distancing language.
- sympathetic language.
- avoidance language.
- ethnocentric language.
avoidance language.
27
Symptom Analysis that includes
How long did it last? Frequency—How often does it occur?
Timing. Duration
28
part of complete health history that includes
```
Name
Address and phone number
Age and birth date
Birthplace
Sex
Relationship status
Race
Ethnic origin
Occupation: Usual and present
```
Biographical Data
29
A common error in blood pressure measurement is:
- taking the blood pressure in an arm that is at the level of the heart.
- waiting less than 1 to 2 minutes before repeating the blood pressure reading on the same arm.
- deflating the cuff about 2 mm Hg per heart beat
- using a blood pressure cuff whose bladder length is 80% of the arm circumference.
waiting less than 1 to 2 minutes before repeating the blood pressure reading on the same arm.
30
part of complete health history that includes
What a person says is the reason for seeking care is recorded and enclosed in quotation marks to indicate person’s exact words
Reason for Seeking Care
Present Health
31
An example of subjective data is:
A. decreased range of motion.
B. crepitation in the left knee joint.
C. left knee has been swollen and hot for the past 3
days.
D. arthritis.
left knee has been swollen and hot for the past 3
| days.
32
ALWAYS count the _______ for ONE full minute!!
apical heart rate
33
Pain signals are carried to the central nervous system by way of:
- perception.
- afferent fibers.
- modulation.
- referred pain.
afferent fibers.
34
Verbal Responses-Assisting in interview that
* Links events, makes associations, and implies cause
* Not based on direct observations but instead on inference or conclusion
* Your interpretation may be incorrect but helps prompt further discussion
* It seems that every time you feel the stomach pain, you have some type of stress in your life.
* Client: I don't want any more treatment, but I can't seem to tell the doctor I'm ready to stop.
* Response: Could it be that you're afraid of her reaction?
Interpretation
35
relating to or caused by an upright posture.
Orthostatic
36
nurse records that the patient’s pulse is 3+ or full and bounding. Which of the following could be the cause?
- anxiety
- shock
- bleeding
- dehydration
Anxiety
37
Which of the following statements regarding cultural/racial differences in the treatment of pain is true?
- White individuals receive more analgesic therapy than black or Hispanic individuals with similar symptoms.
- Black and Hispanic individuals have been found to have a higher pain tolerance than white individuals.
-Pain modulation is more highly developed
in black and Hispanic individuals.
-Neurotransmitters are more concentrated in white individuals than in black and Hispanic individuals.
White individuals receive more analgesic therapy than black or Hispanic individuals with similar symptoms.
38
When preparing the physical setting for an interview, the interviewer should:
- set the room temperature between 64° F and 66° F.
- reduce noise by turning the volume on the television or radio down.
- conduct the interview at eye level and at a distance of 4 to 5 feet.
- stand next to the patient to convey a professional demeanor.
conduct the interview at eye level and at a distance of 4 to 5 feet.
39
An example of objective data is:
A. a complaint of left knee pain.
B. crepitation in the left knee joint.
C. left knee has been swollen and hot for the past 3 days.
D. a report of impaired mobility from left knee pain as evidenced by an inability to walk, swelling, and pain on passive range of motion.
crepitation in the left knee joint.
40
Endogenous obesity is:
- due to inadequate secretion of cortisol by the adrenal glands.
- caused by excess adrenocorticotropin production by the pituitary gland.
- characterized by evenly distributed excess body fat.
- result of excessive secretion of growth hormone in adulthood
caused by excess adrenocorticotropin production by the pituitary gland.
41
is the process of analyzing health data and drawing conclusions to identify diagnoses.
Diagnostic reasoning
42
Which of the following is an example of objective data?
A. Alert and oriented Correct
B. Dizziness
C. An earache
D. A sore throat
Alert and oriented Correct
43
```
part of complete health history that includes
Self-esteem, self-concept
Activity and exercise
Sleep and rest
Nutrition and elimination
Interpersonal relationships/Domestic violence
Spiritual resources
Coping and stress management
Personal habits
Alcohol/illicit drug use
Environmental & work hazards
Intimate Partner Violence
```
Functional Assessment
44
Symptom Analysis that includes
What brings it on? What were you doing when you first noticed it? What makes it better? Worse?
Provocative or Palliative
45
Which of the following statements made by the interviewer would be an appropriate response?
- “I know just how you feel.”
- “If I were you, I would have the surgery.”
- “Why did you wait so long to make an appointment?”
- “Tell me what you mean by ‘bad blood.’
“Tell me what you mean by ‘bad blood.’
46
Physical appearance includes statements that compare appearance with:
- mood and affect.
- stated age
- gait
- nutrition
Stated age
47
What occurs during transduction (the first phase of nociceptive pain)?
- Pain signals move from the site of origin to the spinal cord.
- pain impulse moves from the spinal cord to the brain.
- The brain interprets the pain signal.
- Chemical mediators are neutralized to decrease the perception of pain.
Pain signals move from the site of origin to the spinal cord.
48
Verbal Responses-Assisting in interview that
Condenses facts and validates what was discussed during the interview
* Signals that termination of interview is imminent
* Both client and examiner should be active participants
* Review pertinent facts
* Allow client time to make corrections
Summary
49
Which of the following is included in documenting a history source?
- Appearance, dress, and hygiene
- Cognition and literacy level
- Documented relationship of support systems
- Reliability of informant
Reliability of informant
50
A funduscopic examination is an examination of the:
- inner ear
- pharynx
- internal structures of the eye
- nasal turbinates
internal structures of the eye
51
Specialized nerve endings that are designed to detect painful sensations are:
- synapses.
- dorsal horns.
- nociceptors
- c fibers
nociceptors
52
The_______ phase of an interview is the data-gathering phase.
working
53
An adult patient’s pulse is 46 beats per minute. The term used to describe this rate is:
- tachycardia.
- bradycardia.
- weak and thready
- sinus arithmia
Bradycardia
54
to augment pulse or blood pressure measurement, pain rating scale (in numbers or faces), monofilament to test sensation in the foot, and bladder scanner to assess urine retention.
Doppler sonometer
55
Which of the following is considered when preparing to examine an older adult?
- Base the pace of the examination on the patient’s needs and abilities.
- avoid physical touch to avoid making the older adult uncomfortable.
- be aware that loss will result in poor coping mechanisms
- Confusion is a normal, expected finding in an older adult
Base the pace of the examination on the patient’s needs and abilities.
56
part of complete health history that includes
Record who furnishes information, usually the person, although source may be relative or friend:
Source & Reliability
57
A nursing diagnosis is best described as:
A. a determination of the etiology of disease.
B. a pattern of coping.
C. an individual’s perception of health.
D. a concise statement of actual or potential health concerns or level of wellness.
a concise statement of actual or potential health concerns or level of wellness.
58
The examiner should use handwashing instead of an alcohol-based hand Rub:
- if the patient has an infection with Mycobacterium tuberculosis
- if the patient has an infection with Clostridium difficile
- if the patient has an infection with hepatitis B virus
- if the patient is HIV positive.
if the patient has an infection with Clostridium difficile
59
Facial expression, mood & affect, speech & speech pattern, dress, personal hygiene.
Behavior:
60
older adult patient with dementia has a pain rating of 5 on the Pain Assessment in Advanced Dementia (PAINAD) scale. The nurse should:
- reassess the pain level in 3 to 4 hours.
- administer prescribed pain medication
- . ask the patient to verify the pain rating.
- use only nonpharmacologic pain relief interventions
administer prescribed pain medication.
61
A patient seeks care for "debilitating headaches that cause excessive absences at work." On further exploration, the nurse asks, "What makes the headaches worse?" With this question, the nurse is seeking information about:
- the patient's perception of pain.
- the nature or character of the headache.
- aggravating factors.
- relieving factors.
aggravating factors.
62
Viewing the world from another person’s inner frame of reference is called:
- reflection.
- empathy.
- clarification.
- sympathy.
empathy.
63
Verbal Responses-Assisting in interview that
* Useful when person's word choice is ambiguous or confusing
* Summarize person's words, simplify the statement, and ensure that you are on the right track
• Response: The heaviness in your chest occurs with walking up 1 flight of stairs or more than 1 block, but it
stops when you rest. Is that correct?
• Client: Yes, that's it.
Clarification
64
At the end of the examination, the examiner should:
- complete documentation before leaving the examination
- have findings confirmed by another provider
- compare objective and subjective data for discrepancies
- review the findings with the patient
review the findings with the patient
65
Assessment of self-esteem and self-concept is part of the functional assessment. Areas covered under self-esteem and self-concept include:
- education, financial status, and value-belief system.
- exercise and activity, leisure activities, and level of independence.
- family role, interpersonal relations, social support, and time spent alone.
- stressors, coping mechanisms, and change in past year.
education, financial status, and value-belief system.
66
The dorsa of the hands are used to determine:
- vibration
- temperature
- position of organ
- fine tactile discrimination.
Temp
67
According to the holistic model, a NARROW definition of holistic health includes:
- an optimal functioning of mind, body, and spirit within the environment.
- the absence of disease.
- the response of the whole person to actual or potential problems.
- the internal and external environment
the absence of disease.
68
Verbal Responses-Assisting in interview that
* Informing person
* Sharing factual and objective information
* You order your dinner from the menu provided, and it takes approximately 30 minutes to arrive.
* You may not eat or drink for 12 hours before your blood test because the food may change the results.
Explanation
69
To examine a toddler, the nurse should:
- remove the child’s clothing at the beginning of the examination.
- ask the child to decide whether parents or siblings should be present.
- perform the assessment from head to toes
- allow the child to sit on the parent’s lap.
allow the child to sit on the parent’s lap.
70
The "review of systems" in the health history is:
- an evaluation of past and present health state of each body system.
- a documentation of the problem as perceived by the patient.
- a record of objective findings.
- a short statement of general health status.
an evaluation of past and present health state of each body system.
71
Verbal Responses-Assisting in interview that
• Encourages client to say more
• Shows person you are interested
* mm-hmmm, go on, uh-huh
* Maintaining eye contact, shifting forward
* Nodding yes
Facilitation,
72
PQRSTU is a mnemonic that helps the clinician to remember to address characteristics specific to:
- severity of dementia.
- substance use and abuse.
- pain presentation.
- the ability to perform activities of daily living (ADLs).
pain presentation.
73
(To tap) Assessment of tissue density, fluid, or pain
Percussion:
74
The general survey consists of four distinct areas. These areas include:
- mental status, speech, behavior, and mood and affect.
- gait, range of motion, mental status, and behavior.
- physical appearance, body structure, mobility, and behavior.
- level of consciousness, personal hygiene, mental status and physical condition
physical appearance, body structure, mobility, and behavior.
75
(To listen) Evaluation of sounds
Auscultation:
76
Which of the following is the most reliable indicator for chronic pain?
- Magnetic resonance imaging (MRI) results
- Patient self-report
- Tissue enzyme levels
- Blood drug levels
Patient self-report
77
Symptom Analysis that includes
Exactly when did it first occur?
Onset
78
When addressing a toddler during the interview, the health care provider should:
- ask the child, before the caretaker, about symptoms.
- use nonverbal communication.
- use short, simple, concrete sentences.
- use detailed explanations.
use short, simple, concrete sentences.
79
Neuropathic pain implies an abnormal:
- degree of pain interpretation.
- processing of the pain message.
- transmission of pain signals.
- modulation of pain signals.
processing of the pain message.
80
What type of database is most appropriate when rapid collection of data is required and often compiled concurrently with lifesaving measures?
A. Episodic
B. Follow-up
C,Emergency
D. Complete
Emergency
81
```
What type of database is most appropriate for an individual who is admitted to a long-term care facility?
A. Episodic
B. Follow-up
C. Emergency
D. Complete
```
Complete
82
Nonverbal communication is the primary form of communication for which group of individuals?
- Infants
- Preschoolers
- Adolescents
- Older adults
Infants
83
When taking a health history from an adolescent, the interviewer should:
- ask about violence and abuse before asking about alcohol and drug use.
- have at least one parent present during the interview.
- interview the youth alone with a parent in the waiting area.
- ask every youth about the use of condoms.
interview the youth alone with a parent in the waiting area.
84
(To touch) Fingertip vs. dorsal vs. fingertips
Palpation:
85
Gait, range of motion.
Mobility:
86
Verbal Responses-Assisting in interview that
* Echoes client's words by repeating part of what person has just said
* Can help express feelings behind words
* Mirroring client's words can help person elaborate on problem
* Client: It's so hard having to stay in bed during my pregnancy. I have kids at home I'm worried about.
* Response: You feel worried and anxious about your children?
Reflection
87
Symptom Analysis that includes
. How bad is it (on a scale of 1 to 10)? Is it getting better, worse, staying the same?
Severity Scale
88
part of complete health history that includes
```
Childhood illnesses
Accidents or injuries
Serious or chronic illnesses
Hospitalizations
Operations
Obstetric history
Immunizations
Last examination date
Allergies: food, drugs, latex, environment
Current medications (Rx & OTC)
```
Past Health
89
Amplitude is:
- the intensity (soft or loud) of sound.
- the length of time the note lingers.
- number of vibrations per second.
- the subjective difference in a sound’s distinctive overtones.
the intensity (soft or loud) of sound.
90
Stature, nutrition, symmetry, Posture, Position, body build, physical deformities
Body Structure
91
The CAGE test is a screening questionnaire that helps to identify:
- unhealthy lifestyle behaviors.
- personal response to stress.
- excessive or uncontrollable drinking.
- depression
excessive or uncontrollable drinking.
92
A complete database is:
A. used to collect data rapidly and is often compiled concurrently with lifesaving measures.
B, used for a limited or short-term problem usually consisting of one problem, one cue complex, or one body system.
C. used to evaluate the cause or etiology of disease.
D. used to perform a thorough or comprehensive health history and physical examination.
used to perform a thorough or comprehensive health history and physical examination
93
When performing percussion, the examiner:
- strikes the flank area with the palm of hand
- strikes the stationary finger at the distal interphalangeal joint.
- strikes the stationary finger at the proximal interphalangeal joint
- taps fingertips over bony processes.
Strikes the stationary finger at the distal interphalangeal joint.
94
Verbal Responses-Assisting in interview that
Communicates that client has time to think
• Silence can be uncomfortable for novice examiner, but interruption can make client lose his or her train of thought
• Provides you with chance to observe client and note nonverbal cues
* Waiting for response without interruption
* Sitting quietly; don't fidget
* Counting silently 1 to 10
Silence
95
```
part of complete health history that includes
General overall health
Skin/Hair
Head
Eyes/Ears
Nose & Sinuses
Mouth & Throat
Neck
Breast & Axilla
Respiratory system
Cardiovascular
Peripheral vascular
Gastrointestinal
Genitourinary system: Male & female
Sexual Health
Musculoskeletal
Neurologic
Hematologic
Endocrine
```
review of systems
96
To perform accurate assessment of respirations, the examiner should:
- inform the person of the procedure and count for 1 minute.
- count for 15 seconds while keeping fingers on the pulse and then multiply by four.
- count for 30 seconds after completing a pulse assessment and multiply by two.
- assess respirations for a full 2 minutes if an abnormality is suspected.
Count for 30 seconds after completing a pulse assessment and multiply by two.
97
A patient admitted to the hospital with asthma has the following problems identified based on an admission health history and physical assessment. Which problem is a first-level priority?
A.Ineffective self–health management
B. Risk for infection
C. Impaired gas exchange
D. Readiness for enhanced spiritual well-being
Impaired gas exchange
