FIRST TEST Flashcards
(149 cards)
1
Q
circumstance when a person gives up the traits of his culture of origin as a result of context with another culture to variable degrees
A
acculturation
2
Q
gradual adoption and incorporation of characteristics of the prevailing culture
A
assimilation
3
Q
co existence of a difference in behavior, traditions, and customs; diversity of cultures resulting from cross-border population flows
A
cultural diversity
4
Q
intrusive application of the majority groups cultural view upon individuals and families
A
cultural imposition
5
Q
belief that the behaviors and practices of people should be judged only from the context of their cultural system
A
cultural relativism
6
Q
totality of socially transmitted behavioral patterns, arts, beliefs, values, customs, life ways, and all other products of human work and thought characteristic of a population or people that guide their worldview and decision making
A
culture
7
Q
a natural conscious and unconscious conditioning process of learning accepted cultural norms, values, and roles in society and achieving competence in ones culture through socialization
A
enculturation
8
Q
socially, culturally, and politically constructed group that holds in common a set of characteristics not shared by others with whom members of the group come into contact
A
ethnicity
9
Q
universal tendency of humans to think their ways of thinking, acting, and believing are the only right, proper, and natural ways
A
ethnocentrism
10
Q
oversimplified conception, opinion, or belief about some aspect of an individual or group
A
stereotyping
11
Q
group of people with a culture that differentiates them from the larger culture of which they are a part
A
subculture
12
Q
way individuals or groups of people look at the universe to form basic assumptions and values about their lives and the world around them
A
worldview
13
Q
socially constructed concept that has meaning to a larger group
A
race
14
Q
oral temp
A
96.6-99.9
15
Q
axillary temp
A
95.6-98.5
16
Q
rectal temp
A
97.4-100.3
17
Q
tympanic temp
A
98-100.9
18
Q
the nursing process
A
assessment diagnosis planning implementation evaluation
19
Q
collecting subjective and objective data
A
assessment
20
Q
analyze subjective and objective data to make a professional nursing judgment
nursing diagnosis, collaborative problem, or referral
A
diagnosis
21
Q
determining outcome criteria and developing a plan
A
planning
22
Q
carrying out the plan
A
implementation
23
Q
assessing whether outcome criteria have been met and revising the plan as necessary
A
evaluation
24
Q
holistic nursing assessment and medical assessment
A
holistic- physiologic, psychological, sociocultural, developmental, and spiritual data
medical- focuses primarily on the clients physiologic status
25
which phases of the nursing process involve assessment by the nurse
assessment is ongoing and continuous throughout all phases of the nursing process
26
explain how some steps overlap and may have to be repeated many times when caring for a client
steps overlap because you may have to move more quickly for some problems than others
assessment and evaluation goes in both directions because they are ongoing processes as well as separate
27
describe the steps of the analysis/diagnosis phase
```
identify abnormal data and strengths
cluster data
draw inferences and identify problem
propose possible nursing diagnosis
check for defining characteristics of diagnoses
confirm or rule out nursing diagnoses
document conclusions
```
28
involves collection of subjective data, past health history, family history, lifestyle and health practices, and objective data gathered during a step-by-step physical exam
initial comprehensive assessment
29
any problems that were initially detected in the clients body system or holistic health patterns are reassessed to determine any changes
ongoing assessment
30
performed when a comprehensive database exists for a client who comes to the healthcare agency with a specific health concern
focused or problem oriented assessment
31
immediate assessment is needed to provide prompt treatment
emergency assessment ; ABC!
32
steps of health assessment
collection of subjective data
collection of objective data
validation of data
documentation of data
33
pulse
60-100
34
respiration rate
12-20
35
4 phases of client interview
preintroductory
introductory
working
summary/closing
36
knowing some of the clients already documented biographical information may assist the nurse with conducting the interview
preintroductory
37
nurse explains the purpose of the interview, discusses the types of questions that will be asked, explains the reason for taking notes, and assures the client that confidential information will remain confidential
introductory
38
the nurses gets information about client: major biographical data, reason for seeking care, history of present health concerns, past health, family health, etc. nurse listens, observes cues, and uses critical thinking skills to interpret and validate information received
working phase
39
appearance, demeanor, facial expression, attitude, silence, listening
nonverbal communication
40
open-ended questions, closed ended questions, laundry list, rephrasing, well placed phrases, inferring, providing information
verbal communication
41
explain types of communication to avoid during the interview
nonverbal- excessive eye contact, distraction and distance, and standing
verbal- biased/leading questions, rushing through interview, reading the questions
42
describe ways to adapt the interview for the older client
check for hearing acuity, speak slowly, face client at all times, and position self so you are speaking on the side of the client that has the ear with better acuity.
43
provide client with simple, organized information in a structured format
ask simple, concise questions
do not hurry
dealing with an anxious client
44
approach client in a calm, reassuring, control manner
allow client to vent feelings
never allow the client to position himself between you and the door
avoid arguing and facilitate personal space
dealing with an angry client
45
express interest in understanding of the client and respond in neutral manner
dont try to communicate in upbeat, encouraging manner
dealing with a depressed client
46
provide structure and set limits
| differentiate between manipulation and a reasonable request
dealing with a manipulative client
47
set firm limits on overt sexual client behavior and avoid responding to subtle seductive behaviors
report inappropriate behaviors
if it continues, dont interact without a witness
encourage client to use more appropriate methods of coping
dealing with a seductive client
48
describe ways that ethnicity can affect communication patterns
language
variations use and meaning of nonverbal communication-eye contact, gestures
variations in disease/illness perception
variations in familys role in the decision making process: talking to the male instead of the female client
49
what are the 8 major categories of a complete client health history !!!
```
biographical data
reasons for seeking health care
history of present health concern
personal health history
family health history
ROS for current health prob
lifestyle and health practices profile
developmental level
```
50
how Is information obtained about the review of systems
through the clients subjective information and not the examiners observation
51
questions to ask to assess clients lifestyle and health practices
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description of typical day
nutrition and weight management
activity level and exercise
sleep and rest
substance use
self-care responsibilities
social activities
relationships
values and belief system
education and work
stress levels and coping styles
environment
```
52
explain how a nurse would use the COLDSPA mnemonic to analyze a client symptom
character- describe the sign or symptom
onset
location- where is it? does it radiate?
duration- how long does it last?
severity- how bad is it? how much does it bother you?
pattern- what makes it better or worse?
associated factors- what other symptoms occur with it how does it affect you
53
why is validating client data important
errors during assessment cause the nurses judgement to be made on unreliable data, which results in diagnostic errors
54
discuss situations that require client data to be rechecked or verified
gaps between the subjective and objective data-ex. client tells you he is very happy after finding out he has terminal cancer
gaps between what the client says at one time versus another time- ex. client says she's never had surgery but later says she has
findings that are highly inconsistent with other findings
55
use SBAR method to verbally report client data to another health care provider
Situation-state what you need to communicate the client data that you have assessed
Background-Describe events that led up to the current situation
Assessment- subjective and objective data you observed
Recommendations- suggest what you believe needs to be done for the client based on your findings
56
what is the purpose of the electronic health record
focuses on the total health- emotional, physical, social, spiritual- of the client and are designed to reach out beyond the health organization that originally obtains the client data. these records share data with other health care providers
nationwide access to client information compiled from data collected by a variety of health care providers
57
keep all documentation confidential
use correct spelling and only use abbreviations accepted by institution
use phrases instead of sentences
record clients understanding and perception of prob
write entries objectively without making premature diagnoses
avoid wordiness
safety guidelines for documenting data p. 50
58
purpose of accurate and timely documentation of client data
provide legal records of a clients care and to form a foundation for clients care while in the health care facility
59
what 3 things are crucial aspects of nursing health assessment
validation, documentation, and verbal communication
60
nursing assessment form that establishes comparability of nursing data across clinical populations, settings, geographic areas, and time.
includes specialized information such as cognitive patterns, communication patterns, physical function, activity patterns
nursing minimum data set
61
helps cluster data, focuses on nursing diagnoses, assists in validating nursing diagnosis labels, and combines assessment with problem listing in one form
information is given to multiple care givers
integrated cue checklist
62
lists information that alerts the nurse to specific problems or symptoms
requires nurse to place check marks in boxes instead of writing narrative
cued or checklist forms
63
provides total picture including specific complaints and symptoms in the clients own words
calls for narrative description of problem and listing of topics
open ended forms - traditional form
64
unpleasant sensory and emotional experience, which we primarily associate with tissue damage or describe in terms of such damage
pain
65
what happens if acute pain isn't treated correctly
it results in physiologic, psychological, and emotional distress that can lead to chronic pain
66
in physiologic response to pain, what is decreased
decreased gastric and intestinal motility
decreased urinary output
decreased in cognitive function
67
usually associated with specific cause or injury and described as a constant pain that persists for more than 6 months
chronic nonmalignant pain
68
compression of peripheral nerves or meninges or from the damage to these structures following surgery, chemotherapy, radiation, or tumor growth and infiltration
cancer pain
69
defined by its high resistance to pain relief
intractable pain
70
injured tissue releases chemicals that affect nociceptors sending pain message up sensory neuron
transduction
71
pain impulses from the nociceptors relays the pain from spinal cord to the brain
transmission
72
pain perceived in the brain
perception
73
pain message is inhibited by brain stem neuron which releases of endogenous neurotransmitters
modulation
74
pain comes from internal organs
visceral pain
75
pain comes from the skin, muscles, and soft tissues
somatic pain
76
7 dimensions of pain
physical, sensory, behavioral, sociocultural, cognitive, affective, spiritual
77
patients perception of the pain and the bodys reaction to the stimulus
physical dimension
78
the quality of pain and how severe the pain is perceived to be. patients perception of the pains location, intensity, and quality
sensory dimension
79
verbal and nonverbal behaviors that the patient demonstrates in response to the pain
behavioral dimensions
80
influences of the patients social context and cultural background on the patients pain experience
sociocultural dimensions
81
concerns beliefs, attitudes, intentions, and motivation related to pain and its management
cognitive dimension
82
feelings, sentiments, and emotions related to the pain experience; pain can affect the emotions and the emotions can affect the perception of pain
affective dimension
83
meaning and purpose that the person attributes to the pain, self, others, and the divine
spiritual dimension
84
pain is natural
use mind over body; positive thinking
pain is honorable
stigma against narcotic use may result in underreporting of pain
asian and asian american
85
pain is a challenge to be fought
pain is inevitable and is to be endured
pain may be punishment from god
god and prayer will help more than medicine
african american
86
pain must be endured as part of preparing for the next life in the cycle of reincarnation
must remain conscious when nearing death to experience the events of dying and perhaps rebirth
hindu
87
may not ask for medication due to respect for caregivers who should know their needs.
metaphors and images from nature are used to describe pain
native americans
88
pain is very expressive, esp in women. men are often more stoic to avoid appearing weak
"" is natural but may be the result of sinful or immoral behaviors
hispanic
89
pain is expressed openly, with much complaining
| "" must be shared, recognized, and validated by others so that the experience Is affirmed
jewish
90
what pain scale should you use for a non responsive client
hierarchy of pain assessment techniques
91
what scale is best for older adults with no cognitive impairments
numeric pain intensity scale
92
numeric pain intensity scale
0-10 0= no pain and 10=worst possible pain
93
simple descriptive pain intensity scale
no pain to the worst pain possible
94
wong baker pain rating
faces
very smiley- no pain at all
sad face with tears- hurts worst
95
FLACC behavioral scale
face, legs, activity, cry, consolability
0- normal
1-moderate
2-highest score; not normal
96
interviewing a client for their subjective experience to pain
history of present health concern
personal health history
family history
lifestyle and health practices
97
physical assessment of a client experiencing pain
```
observe posture
observe facial expressions
assess FLACC
inspect joints and muscles
observe skin for scars, discoloration
observe vital signs
```
98
raises blood glucose levels and can be converted into energy quickly; stored in the liver
carbohydrates
99
soluble and insoluble that helps to promote normal bowel function, reduce cholesterol levels, control blood sugar levels, and aid in weight management
fiber
100
stored in the muscles, skin, bone, blood, cartilage, and lymph tissue; provide structure to and regulate the cells, tissues, and organs, and to provide transport and storage of atoms and small molecules within cells and throughout the body
proteins
101
protects internal organs, lubricates skin to slow water loss, aids in absorption of fat-soluble vitamins
fats
102
necessary as a component of bile salts that aid in digestion, serves as an essential element in all cell membranes, is found in brain and nerve tissue, and is essential for the production of several hormones such as estrogen, testosterone, and cortisone
cholesterol
103
require for energy to be released from carbs, proteins, and fats; necessary for the formation of RBC and proper functioning of the nervous system
vitamin
104
promotes growth and maintaining health ; found in all body fluids and tissues
minerals
105
peanuts, tree nuts, cows milk, egg, wheat, soy, fish, shellfish, sesame
most foods that cause allergic reactions
106
most common food intolerance
lactose intolerance
107
cultural competence assessment
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Awareness
Skill
Knowledge
Encounters
Desire
```
108
whats the difference between general routine screening and focuses speciality assessment of culture
every nurse-client needs to include a cultural assessment because it affects every part of a persons health. its important to dialogue with clients to learn about their culture and preferences . nurse should read literature to learn more and provide culturally competent nursing care
109
herbalists; prevent yin/yang, hot/cold foods and conditions, wear amulets, acupuncture, cupping, moxibustion
asian
110
magico herbalist, hoodoo, also known as old lady, granny; magical and herbal mix of herbs, roots, and rituals, talismans or amulets
african
111
medicine men or shamans; respect for nature and avoid evil spirits, use masks, herbs, sand paintings, amulets
native american/ alaska native traditions
112
folk healers; hold/cold balance for diet, herbs, amulets, prayers to god and saints and spiritual reparations for sins, avoiding evil eye caused by jealousy or envy
hispanic
113
homeopathic physicians, physicians, and other health professionals; maintain physical and emotional well being with proper science based modern nutrition, exercise, cleanliness, belief in and faith in god
western european traditions
114
nurse must know how to assess what is normal and abnormal for persons who seek care; allows nurse to integrate cultural assessment into the health assessment of each client
cultural competence
115
hispanic women are more at risk for
cervical cancer
116
african americans are more at risk for
heart problems/diseases, asthma, hypertension
117
substance abuse, violence, hiv risk, depressive symptoms, and socioeconomic conditions are directly linked to health disparities among
latinas
118
set of symptoms associated with the loss of cognitive functioning-thinking, remembering, reasoning-to such an extent that it interferes with a persons daily life
dementia
119
gradual destruction of the brain nerve cells and a shrinking brain
alz
120
what is the AUDIT tool and what are the ranges
alcohol use disorder
8 or more are recommended as indicator of harmful alc use
the greater the score, the more alc use
121
quick inventory of depressive symptomatology
```
depression
0-5= no risk
6-10= mild
11-15= moderate
16-20= severe
21-27= very severe
```
122
SAD
suicide risk
123
clients who are unresponsive and and not responding to questions
glasgow coma scale
124
assessing a patient who indicates depression
PHQ-2 =2 or higher is a depressed patient
| followed by PHQ-9 if depression is indicated =10 or higher detects more depressed patients than the original test
125
detect alcohol dependence in trauma center population
CAGE
126
if you suspect depression in older clients
geriatric depression scale
127
mental status assessment
SLUMS
128
confusion assessment
CAM
129
glasgow coma scale score
10 or lower- needs emergency attention
| 7 or lower- in coma
130
have fewer sweat glands and therefore, less body odor than most
asians and native americans
131
who attempts suicide more frequently
women but men are more successful ; older caucasian males
132
client opens eyes, answers questions, and falls back asleep
lethargy
133
client opens eyes to loud voice, responds slowly with confusion, and seems unaware of environment
obtunded
134
client awakens to vigorous shake or painful stimuli but returns to unresponsive sleep
stupor
135
client remains unresponsive to all stimuli; eyes stay closed
coma
136
voice volume disorder caused by laryngeal disorders or impairment of cranial nerve X
dysphonia
137
irregular, uncoordinated speech caused by multiple sclerosis
cerebellar dysarthria
138
defect in muscular control of speech related to lesions of the nervous system, parkinson disease, or cerebellar disease
dysarthria
139
difficulty producing or understanding language caused by motor lesions in the dominant cerebral hemisphere
aphasia
140
rapid speech that lacks meaning, caused by lesion in the posterior superior temporal lobe
wernicke aphasia
141
slowed speech with difficult articulation, but fairly clear meaning, caused by a lesion in the posterior inferior frontal lobe
broca aphasia
142
ratings of pulse
0 absent
1+ weak
2+ normal
3+ bounding
143
temp that needs to be evaluated for geriatric patients
96.6 - 99.5
144
each person has unique characteristics and experiences that affect subsequent actions
penders health promotion model
145
change following a health recommendation would be beneficial to the individual at a level of acceptable cost
health belief model
146
step by step physical assessment and subjective data gathering
intital comprehensive
147
socially constructed concept ; not physical appearance
race
148
red, beefy tongue
vitamin b
149
pitting edema
end stage renal disease
