Exam 1 Study Guide and practice questions Flashcards
(87 cards)
1
Q
What are the methods of physical examination?
A
Inspection
Auscultation
Palpation
Percussion
2
Q
Inspection (sounds associated with inspection and what they indicate)
A
what you see, smell, hear from patient - starts right when you enter room and continue the entire time you are with pt.
- good lighting
- adequate exposure
- Occasional use of instruments, including otoscope, ophthalmoscope, penlight, or nasal and vaginal specula, to enlarge your view
3
Q
Auscultation
A
n
4
Q
Palpation
A
Using parts of the hand to touch and feel for:
- texture (rough/smooth)
- temp
- moisture
- consistency (soft, hard, fluid-filled)
- mobility (fixed, moveable, still, vibrating)
- strength of pulses
- size
- shape
- degree of tenderness
5
Q
Percussion: purposes
A
a. eliciting pain
b. determining location, size and shape
c. determining density
d. detecting abnormal masses
e. eliciting reflexes
6
Q
What is inspection used to assess?
A
G
7
Q
What is auscultation used to assess?
A
G
8
Q
What is palpation used to asses?
A
G
9
Q
What is percussion used to asses?
A
G
10
Q
Inspection: How to perform/techniques
A
F
11
Q
Auscultation: How to perform/techniques
A
G
12
Q
Palpation: How to perform/techniques
A
G
13
Q
Percussion: How to perform/techniques
A
G
14
Q
Standard precautions when caring for patients:
A
hand hygiene
gloves
mask, eye protection, face shield
gown
15
Q
What are the normal values/ranges for vital signs?
A
G
16
Q
Subjective vs objective data
A
subjective = what client says (can not measure)
objective = what is observed (things you can measure)
17
Q
What are considerations when assessing mental status in older adults?
A
H
18
Q
How can you prevent bias?
A
G
19
Q
What is the purpose of general survey?g
A
V
20
Q
What information is obtained from general survey?
A
V
21
Q
What are the steps in the nursing process?
A
Assessment, diagnosis, outcomes, planning, intervention, evaluation
22
Q
Assessment: Attributes of this stage
A
Collecting subjective and objective data
23
Q
Diagnosis: Attributes of this stage
A
Analyzing subjective and objective data to make a professional nursing judgement
- nursing diagnosis
- collaborative problem or
- referral
24
Q
Outcomes: Attributes of this stage
A
a. Identify expected or unexpected outcomes
b. Ensure outcomes are realistic and measurable
c. short term and long term goal measurement criteria
25
Planning: Attributes of this stage
determining outcome criteria and developing a plan
- ID priorities based on patient care goals
- develop outcomes and set time frames to meet those outcomes
- Identify relevant interventions and utilize input from various members of the interdisciplinary health care team to plan patient care
- document the plan of care
26
Intervention: Attributes of this stage
B
27
Evaluation: Attributes of this stage
Assessing whether outcome criteria have been met and revising the plan as necessary
28
Stages of development: Erikson
notes
29
Stages of development: Piaget
notes
30
Stages of development: kohlberg
notes
31
Stages of development: Freud
notes
32
What is the purpose of documentation?
a. provides chronological source of client assessment and a progressive record of assessment finding that outline the client's course of care
b. ensures information about client is easily accessible
c. communication (prevents repetition, fragmentation, and delays in carrying out plan of care)
d. Establishes a basis for screening or validating proposed diagnoses.
e. source of information to help diagnose new problems.
f. offers as basis for determining education needs for patient
g. legal reasons
33
What is complete vs incomplete documentation?
By
34
Mental status terminology, descriptors for level of consciousness and attributes of each, assessment of judgement vs thought process vs orientation vs memory
V
35
Health history taking, what to do when you come across an abnormal finding, expanding questioning, traps of interviewing, open vs closed ended questions, steps of the interview/ordering - what do you do first?
F
36
Documentation of skin lesions, ABCDE, normal vs. abnormal findings, descriptors of skin lesions
G
37
Staging of pressure ulcers, know attributes/criteria for each stage
Hg
38
Prioritization of assessment needs: comprehensive vs emergent vs problem focused, etc.
G
39
Thyroid assessment, technique, normal vs abnormal findings, what to do with abnormal findings
G
40
BMI calculation, normal vs abnormal findings of BMI
G
41
Nutrition assessment, weight loss assessment, appropriate questioning
G
42
Pain assessment - measurement tools (numeric scale, Wong Baker Faces, FLACC, etc)
C
43
Acute vs chronic pain
G
44
COLDSPA
Character - describe the s/s
Onset - when did it begin?
Location - where is it? does it radiate? does it occur anywhere else?
Duration - how long does it last? does it reoccur?
Severity - 1-10
Pattern - what makes it better or worse
Associated factors / how it affects client - what other symptoms occur with it / how does it affect you?
45
Physiological signs of pain
G
46
Differentiation of conductive vs sensorineural hearing loss, techniques for assessing hearing, normal signs of aging in relation to hearing, terminology of hearing problems (I.e. Tinnitus, vertigo, etc.), equipment used, testing (ie Weber, Rinne, Whispered Voice, etc.)
F
47
Lymph node assessment - locations, how to perform, normal vs abnormal findings, documentation
G
48
AUDIT, CAGE, PHQ, GAD-7, how to use, why used, normal vs abnormal score
G
49
Headache assessment - characteristics of each type and how to differentiate
G
50
Steps of health assessment
1. Prepare for the assessment (review record, review clients status with other healthcare team members, education about client's diagnosis and tests performed)
2. Collection of subjected and objective data
3. Validation of assessment data
4. Documentation of the data
5. Analysis of the data
51
phases of interview
introductory
working
summary and closing
52
types of percussion
direct
blunt
indirect or mediate
53
sounds elicited by percussion
```
resonance
hyper resonance
tympany
dullness
flatness
```
54
how to perform auscultatoin
eliminate distracting noise
expose part being auscultated
diaphragm
55
when auscultating, what parts of the stethoscope do you use for high pitched sounds and low pitched sounds
high pitched - diaphragm
| low pitched - bell
56
Steps of validation
1. Verify that subjective and objective data are reliable and accurate
2. deciding whether data require validation
3. determining ways to validate the data
4. ID areas where data is missing
57
What are examples of data that require validation?
a. discrepancies or gaps between subjective and objective data
b. discrepancies in what the client says at one time vs another time
c. abnormal / inconsistent findings
58
What are 6 essential components of the diagnostic phase?
1. group and analyze
2. validate
3. cluster - data to make inferences
4. generate - hypoth. about clients info
5. formulate - prof. clinical judgement
6. validate
59
organis disorders
due to brain disease of known specific cause (delerium, dementia, alc. and drug intoxication and withdrawal)
60
PROPOSED DSM-5 DEFINITION OF MENTAL DISORDER
behavioral or psychological syndrome or pattern that occurs in an individual that reflects an underlying psychobiologic dysfunction
61
What are the four main headings of mental status assessment? (ABCT)
appearance
behaviors
cognition
thought processes
62
when is a full mental status examination necessary
patients whose initial screening suggests an anxiety disorder or depression
behavioral changes (memory loss, inappropriate social interaction)
brain lesions (trauma, tumor, CVA, stroke)
aphasia
symptoms of psychiatric mental illness, especially with acute onset
63
mini mental state exam
concentrates only on cognitive functioning, not on mood or thought processes
- 11 questions, 5-10 minutes
64
thought process:
way person thinks should be logical, goal directed, coherent, and relevant; should complete thoughts
65
thought content
what person says should be consistent and logical
66
perceptions
person should be consistently aware of reality; perceptions should be congruent with yours
67
how would you diagnose substance abuse
GOLD STANDARD OF DIAGNOSIS IS WELL DEFINED IN DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, FIFTH EDITION (DSM-V)
68
substance abuse: cage questionnaire
refers to cut down, annoyed, guilty, eye-opener
69
substance abuse: audit questionnaire
a quantitative form that has the advantage of letting the examiner document a number for a response so it is not open to individual interpretation
-- helps detect less severe alcohol problems as well as alcohol abuse disorders
70
What are the 3 domains that audit questionairres come in
1. alcohol consumption
2. drinking behavior / dependence
3. adverse consequences from alcohol
71
pulse amplitude 0-3
0 = absent
1 = weak, diminished (easy to obliterate
2. normal (obliterate with moderate pressure
3. bounding (unable to obliterate or requires firm pressure)
72
factors affecting blood pressure
```
cardiac output
elasticity of arteries
blood volume
blood velocity (HR)
blood viscosity (thickness)
```
73
palpation techniques: fingertips
best for fine tactile discrimination of skin texture, swelling, pulsation, determining presence of lump
74
palpation techniques: fingers and thumbs
detection of position, shape, and consistency of an organ or mass
75
palpation techniques: dorsa hand and fingers
best for determining temperature because skin here is thinner than on palms
76
palpation techniques: base of fingers or ulnar surface of hands
best for vibration
77
percussion definition
Tapping person’s skin with short, sharp strokes to assess underlying structure
- mapping location and size of organs
78
how deep do percussion vibrations penetrate
Percussion vibrations penetrate about 5 cm deep
| - deeper mass would give no change in percussion
79
what are the 2 methods of percussion
1. direct, sometimes called immediate, the striking hand directly contacts body wall
2. indirect, or mediate, using both hands, the striking hand contacts stationary hand fixed on persons skin
80
nociception
the term used to describe how noxious stimuli are perceived as pain
81
nociception phases (4)
transduction
transmission
perception
modulation
82
nociception: transduction
occurs when a noxious stimulus in form of traumatic or chemical injury, burn, incision, or tumor takes place in periphery
- - injured tissues then release a variety of chemicals, including substance P, histamine, prostaglandins, serotonin, and bradykinin
- -- neurotransmitters that propagate pain message along sensory afferent nerve fibers to spinal cord
these fibers terminate in dorsal horn of spinal cord
83
nociception: transmission
pain impulse moves from level of spinal cord to brain
84
nociception: perception
indictates conscious awareness of painful sensation
85
nociception: modulation
pain is inhibited
-- descending pathways from brainstem to spinal cord produce third set of neurotransmitters that slow down or impede pain impulse producting an alagesic effect
86
acute pain
```
cause generally known
short term (3-6 months)
anxiety
responds well to meds
red tissue
RICE
```
87
chronic pain
```
cause often unknown
long term +6 months
depression
does not respond to meds
white tissue
MEAT (movement, exercise, analgesics, treatment)
```
