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Health |/Assessment |/Midterm |/exam |/with
|/correct |/answers
Subjective |/data |/- |/CORRECT |/ANSWERS |/✔✔What |/the |/patient |/tells |/you -interview |/helps |/collect |/this |/type |/of |/data -ex: |/pain Objective |/data |/- |/CORRECT |/ANSWERS |/✔✔What |/you |/observe -measurable Assessment |/- |/CORRECT |/ANSWERS |/✔✔Collect |/data, |/physical |/exam |/(objective), |/health |/history |/(subjective), |/review |/clinical |/records Diagnosis |/- |/CORRECT |/ANSWERS |/✔✔Interpret |/data, |/what |/is |/going |/on |/with |/my |/patient -identify |/clue |/clusters -make |/hypothesis -test |/hypothesis -derive |/diagnoses Planning |/- |/CORRECT |/ANSWERS |/✔✔Establish |/priorities, |/set |/goals |/and |/outcomes |/(individualize |/towards |/your |/patient)
Implementation |/- |/CORRECT |/ANSWERS |/✔✔Reassess |/patient |/to |/make |/sure |/plans |/are |/appropriate, |/deliver |/care, |/document -determine |/patient |/readiness -review |/planned |/interventions -collaborate |/with |/team |/members -coordinate |/care |/delivery Evaluation |/- |/CORRECT |/ANSWERS |/✔✔Follow-up |/with |/patient, |/did |/our |/plan |/work, |/why |/or |/why |/not Biomedical |/theory |/- |/CORRECT |/ANSWERS |/✔✔All |/events |/in |/life |/have |/a |/cause |/and |/effect -used |/by |/most |/educational |/programs |/(physicians, |/nurses, |/care |/providers) Natural/holistic |/theory |/- |/CORRECT |/ANSWERS |/✔✔Human |/life |/is |/only |/one |/aspect |/of |/nature -the |/forces |/of |/nature |/must |/be |/kept |/in |/a |/natural |/balance |/or |/harmony -yin/yang |/and |/hot/cold Yin/yang |/theory |/- |/CORRECT |/ANSWERS |/✔✔Health |/exists |/when |/you |/are |/in |/harmony
Delirium |/- |/CORRECT |/ANSWERS |/✔✔disturbance |/of |/consciousness |/or |/cognition |/that |/is |/acute |/in |/onset -An |/organic |/mental |/disorder |/--> |/meaning |/it |/is |/a |/result |/of |/an |/illness, |/drug, |/injury, |/etc. |/(not |/psychiatric) -confused |/state |/with |/distorted |/perceptions Manifestations |/of |/delirium |/- |/CORRECT |/ANSWERS |/✔✔-sudden |/onset -last |/hours |/to |/days |/(worse |/at |/night) -loss |/of |/memory |/and |/consciousness -tremors, |/spastic |/movements -speech |/is |/slurred, |/rambling, |/and |/incoherent -rapid |/mood |/swings, |/fearful |/and |/suspicious -hallucinations |/and |/delusions -associated |/factors: |/drugs, |/electrolyte |/imbalance, |/brain |/injury, |/fever, |/uremia, |/liver |/damage -it |/is |/reversible Alert |/- |/CORRECT |/ANSWERS |/✔✔Fully |/aware |/of |/external |/and |/internal |/stimuli Orientation |/- |/CORRECT |/ANSWERS |/✔✔Evaluate |/cognitive |/functioning
Alert |/and |/oriented |/x4 |/- |/CORRECT |/ANSWERS |/✔✔Person, |/place, |/time, |/situation lethargic |/(somnolent) |/- |/CORRECT |/ANSWERS |/✔✔drifts |/off |/to |/sleep |/when |/not |/stimulated obtunded |/- |/CORRECT |/ANSWERS |/✔✔sleeping |/most |/of |/the |/time, |/difficult |/to |/arouse stupor |/or |/semicoma |/- |/CORRECT |/ANSWERS |/✔✔responds |/only |/to |/persistent |/vigorous |/shake |/or |/pain coma |/- |/CORRECT |/ANSWERS |/✔✔no |/response |/to |/pain -ranges |/from |/"light |/coma" |/with |/some |/reflex |/action |/to |/"deep |/coma" |/which |/includes |/no |/motor |/activity Unrelated |/ 4 |/words |/test |/- |/CORRECT |/ANSWERS |/✔✔Used |/for |/patients |/with |/dementia/Alzheimer's |/to |/assess |/memory -4 |/words |/given |/(brown, |/honesty, |/tulip, |/eyedropper) |/and |/asked |/to |/recall |/at |/5, |/10, |/ 30 -if |/you |/do |/not |/pass |/the |/test, |/you |/can |/get |/a |/CT |/and |/see |/if |/there |/is |/plaque/etc. |/in |/the |/brain |/which |/can |/tell |/you |/if |/you |/have |/Alzheimer's/dementia
What |/should |/you |/do |/before |/leaving |/a |/patient |/room |/to |/maintain |/patient |/safety? |/- |/CORRECT |/ANSWERS |/✔✔-perform |/HH |/before |/leaving |/room -make |/sure |/bed |/is |/locked, |/and |/bed |/rails |/are |/in |/proper |/position -call |/light |/in |/reach -provide |/education |/about |/not |/getting |/up |/if |/patient |/is |/unsteady |/on |/their |/feet -make |/sure |/room |/is |/a |/comfortable |/temperature hand |/hygiene |/- |/CORRECT |/ANSWERS |/✔✔single |/most |/important |/step |/to |/decrease |/microorganism |/transmission -before |/and |/after |/physical |/contact -after |/inadvertent |/contact |/with |/any |/bodily |/fluids, |/bloods, |/secretions, |/or |/excretions -after |/contacts |/with |/any |/equipment |/contaminated |/with |/body |/fluids -after |/removing |/gloves Gait |/in |/aging |/adult |/- |/CORRECT |/ANSWERS |/✔✔Often |/wider |/to |/compensate |/for |/diminished |/balance Body |/temperature |/in |/aging |/adult |/- |/CORRECT |/ANSWERS |/✔✔May |/not |/be |/a |/reliable |/indicator |/of |/overall |/health |/status
-they |/are |/less |/likely |/to |/have |/a |/fever, |/but |/at |/greater |/risk |/for |/hypothermia pulse |/in |/aging |/adult |/- |/CORRECT |/ANSWERS |/✔✔rhythm |/may |/be |/slightly |/irregular; |/dehydration -radial |/artery |/may |/feel |/stiff, |/rigid, |/and |/tortuous |/in |/older |/person, |/although |/does |/not |/necessarily |/imply |/vascular |/disease |/in |/heart |/or |/brain -increasingly |/rigid |/arterial |/wall |/needs |/faster |/upstroke |/of |/blood, |/so |/pulse |/is |/actually |/easier |/to |/palpate Blood |/pressure |/in |/aging |/adult |/- |/CORRECT |/ANSWERS |/✔✔Aorta |/and |/major |/arteries |/harden |/with |/age -as |/the |/heart |/pumps |/against |/a |/stiffer |/aorta, |/systolic |/pressure |/increases, |/leading |/to |/widened |/pulse |/pressure |/(this |/means |/BP |/increases |/and |/arteries |/stiffen) Respirations |/in |/aging |/adult |/- |/CORRECT |/ANSWERS |/✔✔Shallower |/breaths |/and |/increased |/RR |/due |/to |/a |/decrease |/in |/vital |/capacity |/and |/inspiratory |/reserve |/volume Weight |/in |/aging |/adult |/- |/CORRECT |/ANSWERS |/✔✔Decreases |/in |/80s |/and |/90s, |/distribution |/of |/fat |/changes |/as |/well
Temperature |/- |/CORRECT |/ANSWERS |/✔✔96.4-99.1 |/F |/(35.8-37.3 |/C) Pulse |/- |/CORRECT |/ANSWERS |/✔✔60-100 |/bpm Respiration |/rate |/- |/CORRECT |/ANSWERS |/✔✔12-20 |/bpm BP |/- |/CORRECT |/ANSWERS |/✔✔Less |/than |/120/ Pulse |/Oximetry |/(SpO2) |/- |/CORRECT |/ANSWERS |/✔✔97-100% Acute |/pain |/- |/CORRECT |/ANSWERS |/✔✔Short |/term |/(less |/than |/ 6 |/months) -self-limiting -follows |/predictable |/trajectory -dissipates |/after |/injury |/heals -ex: |/surgery, |/kidney |/stones, |/broken |/leg Acute |/pain |/behaviors |/- |/CORRECT |/ANSWERS |/✔✔guarding, |/grimacing, |/vocalizations, |/agitation, |/restlessness, |/stillness, |/diaphoresis, |/or |/changes |/in |/vital |/signs
Chronic |/pain |/- |/CORRECT |/ANSWERS |/✔✔Continues |/for |/longer |/than |/ 6 |/months |/and |/does |/not |/stop |/when |/injury |/heals -types |/--> |/malignant: |/cancer-related; |/non-malignant: |/arthritis, |/back |/pain, |/fibromyalgia Chronic |/pain |/behaviors |/- |/CORRECT |/ANSWERS |/✔✔bracing, |/rubbing, |/diminished |/activity, |/sighing, |/change |/in |/appetite, |/being |/with |/other |/people, |/movement, |/exercise, |/prayer, |/sleeping, |/or |/inactivity. Direct |/observation |/- |/CORRECT |/ANSWERS |/✔✔Observing |/the |/feeding/eating |/process |/can |/detect |/problems |/not |/readily |/identified |/through |/standard |/nutrition |/reviews -good |/for |/patients |/with |/dementia, |/eating |/disorders, |/unintentional |/weight |/loss, |/and |/failure |/to |/thrive |/children Food |/diary |/- |/CORRECT |/ANSWERS |/✔✔Best |/evaluation |/method |/for |/food |/intake -individual |/records |/everything |/eaten |/for |/a |/particular |/time |/span -more |/accurate |/if |/items |/are |/recorded |/right |/after |/eating -sources |/if |/error: |/noncompliance, |/atypical |/intake |/on |/recording |/days, |/and |/alteration |/of |/diet |/during |/recording |/period -good |/for |/patients |/with |/UNCONTROLLED |/DIABETES |/and |/the |/nurse |/needs |/to |/know |/what |/they |/eat |/on |/a |/daily |/and |/weekly |/basis
papule |/- |/CORRECT |/ANSWERS |/✔✔solid, |/elevated, |/circumscribed -caused |/by |/superficial |/thickening |/in |/epidermis -something |/you |/feel- |/less |/than |/ 1 |/cm |/(mole, |/wart) vesicle |/- |/CORRECT |/ANSWERS |/✔✔elevated |/cavity |/containing |/free |/fluid -up |/to |/ 1 |/cm |/"blister" -clear |/serum |/(blister, |/chickenpox, |/herpes |/simplex, |/herpes |/zoster, |/contact |/dermatitis) acne |/- |/CORRECT |/ANSWERS |/✔✔increase |/in |/sebaceous |/gland |/activity |/> |/increased |/oiliness |/and |/acne |/severe |/acne |/includes |/papule, |/pustules, |/and |/nodules -can |/be |/seen |/on |/face, |/back, |/chest, |/and |/shoulders Excessive |/bruising |/- |/CORRECT |/ANSWERS |/✔✔-Where |/on |/the |/body? -How |/did |/this |/happen? -How |/long |/have |/you |/had |/it? -different |/from |/baseline, |/abnormal |/places |/(ears, |/along |/spine |/from |/leaning |/on |/chair) -bruises |/in |/various |/stages |/of |/healing -consider |/frequent |/falls |/> |/dizziness |/or |/neurologic/cardiovascular |/origin?
-alcoholism/drug |/abuse |/or |/physical |/abuse? Why |/is |/a |/patient |/with |/bruising |/of |/the |/same |/color |/not |/as |/alarming |/as |/bruising |/of |/all |/different |/colors |/all |/over |/the |/body? |/- |/CORRECT |/ANSWERS |/✔✔think |/about |/abuse Striae |/- |/CORRECT |/ANSWERS |/✔✔Type |/of |/pigment |/change -silvery-white, |/linear, |/jagged |/marks |/about |/1-6 |/cm |/long -they |/occur |/when |/elastic |/fibers |/in |/the |/reticular |/layer |/of |/the |/skin |/are |/broken |/after |/rapid |/or |/prolonged |/stretching |/(such |/as |/pregnancy |/or |/excessive |/weight |/gain) -recent |/= |/pink-blue, |/then |/they |/turn |/silver-white Bronchophony |/- |/CORRECT |/ANSWERS |/✔✔Ask |/the |/person |/to |/repeat |/"99" |/and |/auscultate bronchophony |/(normal) |/- |/CORRECT |/ANSWERS |/✔✔Soft |/muffled |/and |/indistinct -you |/can |/head |/the |/sound |/through |/the |/stethoscope |/but |/cannot |/distinguish |/exactly |/what |/is |/being |/said bronchophony |/(abnormal) |/- |/CORRECT |/ANSWERS |/✔✔Pathology |/that |/increases |/lung |/density |/enhances |/transmission |/of |/voice |/sounds -you |/auscultate |/a |/clear |/"99"
-palpable |/vibration Increased |/tactile |/fremitus |/- |/CORRECT |/ANSWERS |/✔✔Consolidation percussion |/- |/CORRECT |/ANSWERS |/✔✔tapping |/client's |/skin |/with |/short, |/sharp |/strokes |/to |/assess |/underlying |/structures direct |/percussion |/(immediate) |/- |/CORRECT |/ANSWERS |/✔✔the |/striking |/hand |/directly |/contacts |/the |/body |/wall indirect |/percussion |/(mediate) |/- |/CORRECT |/ANSWERS |/✔✔using |/both |/hands, |/the |/striking |/hand |/contacts |/stationary |/hand |/fixed |/on |/person's |/skin resonant |/- |/CORRECT |/ANSWERS |/✔✔normal |/lung |/tissue tympani |/- |/CORRECT |/ANSWERS |/✔✔stomach, |/intestine |/(air-filled) |/(drum |/like) dull |/- |/CORRECT |/ANSWERS |/✔✔indicated |/diminished |/air |/exchange, |/abnormal |/density |/present -dense |/organs, |/fluid |/filled |/organs |/(liver, |/full |/bladder)
flat |/- |/CORRECT |/ANSWERS |/✔✔high, |/muscle, |/bone, |/tumor |/(no |/air) Hyperresonance |/- |/CORRECT |/ANSWERS |/✔✔Indicates |/hyperinflation |/or |/too |/much |/air |/present -seen |/in |/percussion |/or |/COPD |/and |/emphysema |/patients What |/does |/percussing |/enable |/an |/examiner |/to |/do? |/- |/CORRECT |/ANSWERS |/✔✔-map |/location |/and |/size |/of |/organs -signal |/DENSITY |/of |/a |/structure |/by |/a |/characteristic |/note -detect |/superficial |/abnormal |/mass |/--> |/percussion |/vibrations |/penetrate |/about |/ 5 |/cm |/deep |/(deeper |/masses |/= |/no |/change |/in |/percussion) -elicit |/pain |/if |/underlying |/structure |/is |/inflamed |/(because |/we |/are |/causing |/vibration) -elicit |/deep |/tendon |/reflexes |/using |/percussion |/hammer COPD |/assessment |/nursing |/observations |/- |/CORRECT |/ANSWERS |/✔✔The |/anteroposterior |/(AP) |/diameter |/is |/equal |/to |/the |/transverse |/diameter, |/resulting |/in |/"barrel |/chest" -ribs |/are |/horizontal -chest |/appears |/as |/if |/held |/in |/continuous |/respiration -neck |/muscles |/are |/hypertrophied |/from |/aiding |/in |/forced |/respiration's |/across |/obstructed |/airways
-normal |/inhale |/and |/exhale -no |/retractions |/of |/muscles -no |/dyspnea -no |/tachypnea/bradypnea -in |/range |/respiration |/(12-20 |/per |/min) Primary |/muscles |/used |/during |/respiration |/(normal) |/- |/CORRECT |/ANSWERS |/✔✔-inspiratory: |/diaphragm |/and |/intercostals |/are |/primary |/muscles |/of |/respiration -relaxed: |/expirations |/are |/passive Primary |/muscles |/used |/during |/respiration |/(abnormal) |/- |/CORRECT |/ANSWERS |/✔✔People |/with |/COPD |/often |/sit |/in |/tripod |/position, |/leaning |/forward |/with |/arms |/braced |/against |/their |/knees, |/chair, |/or |/bed -this |/gives |/them |/leverage |/so |/the |/abdominal, |/intercostal, |/and |/neck |/muscles |/can |/all |/aid |/in |/respiration What |/is |/the |/proper |/way |/to |/auscultate |/breath |/sounds? |/- |/CORRECT |/ANSWERS |/✔✔-auscultate |/the |/lung |/fields |/over |/the |/anterior |/chest |/from |/the |/spices |/in |/the |/supraclavicular |/areas |/down |/to |/the |/6th |/rib -progress |/from |/side |/to |/side |/as |/you |/move |/downward -listen |/to |/one |/full |/respiration |/in |/each |/location -use |/the |/sequence |/indicated |/for |/percussion
Auscultation |/"APE |/TO |/MAN" |/- |/CORRECT |/ANSWERS |/✔✔1. |/aortic
- |/pulmonic
- |/Erb's |/point
- |/tricuspid
- |/Mitral |/(apical) aortic |/- |/CORRECT |/ANSWERS |/✔✔2nd |/intercostal |/space |/at |/right |/of |/sternal |/border -ONLY |/ONE |/ON |/RIGHT |/SIDE pulmonic |/- |/CORRECT |/ANSWERS |/✔✔2nd |/or |/3rd |/intercostal |/space |/at |/left |/sternal |/border -CAN |/HEAR |/S2 |/LOUDEST erb's |/point |/- |/CORRECT |/ANSWERS |/✔✔3rd |/to |/5th |/intercostal |/space |/at |/left |/sternal |/border -can |/hear |/S1 |/and |/S2 |/at |/same |/amplitude tricuspid |/- |/CORRECT |/ANSWERS |/✔✔4th |/or |/5th |/intercostal |/space |/at |/left |/lower |/sternal |/border
