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NUR 310 Health Assessment Exam 1
Information questions with correct
answers
What are the different parts of The Nursing Process? - correct answer -Assessment, Diagnosis/Analysis, Planning, Implementation, and Evaluation What happens in the "Assessment" portion of The Nursing Process? (This is the first step) - correct answer -Nurse collects data, and health assessment data is characterized as either subjective or objective What is subjective data? - correct answer -Data that includes interpretations and information provided by an individual about himself or herself
- typically gathered from health history; pt. presents this information to you (ex: "I feel nauseous") What is objective data? - correct answer -Data that is measurable and observable
- typically obtained through physical examination or lab/diagnostic tests
- can be observed by someone else **ALWAYS verify information from the patient!! What is a health database? - correct answer -The patient's laboratory and diagnostic studies, and objective and subjective data collected by the nurse What happens during the "Diagnosis/Analysis" portion of The Nursing Process? (this is the second step) - correct answer -the nurse analyzes the data collected during the assessment using clinical judgement; nursing diagnosis is formed here; nurse collaborates with patient to develop the plan of care and will identify both actual and potential problems What happens during the "Planning" step of The Nursing Process? (third step) - correct answer -The nurse establishes priorities based on the patient outcomes and
starts to identify interventions that will allow those outcomes to be met within a timeframe
- identifies priorities: 1st, 2nd, 3rd level First level priority problems - correct answer -emergent, life-threatening, and immediate, such as establishing an airway or supporting breathing Second-level priority problems - correct answer -those that are next in urgency requiring your prompt intervention to prevent further deterioration. (mental status change, acute pain, acute urinary elimination problem, untreated medical problems, abnormal lab test results Third-level priority problems - correct answer -those that are important to the patient's health but can be addressed after more urgent health problems are addressed. (Knowledge deficit, altered family processes, and low self esteem) What happens during the "Implementation" stage of The Nursing Process? (fourth step) - correct answer -the nurse will DO something
- implement evidence-based interventions in a safe and timely manner using collaboration and delegation What happens during the "Evaluation" stage of The Nursing Process? (fourth and final step) - correct answer -The nurse will refer to established outcomes to:
- evaluation individual's condition and progress toward outcomes
- identify reasons for failure to achieve expected outcomes
- take corrective action to modify plan of care
- Document evaluation in plan of care medical diagnosis - correct answer -has an actual pathophysiology; (ex: broken arm, depression); the basis on which a nursing diagnosis can be made nursing diagnosis - correct answer -NOT medical; decisions nurses make in response to a medical diagnosis
- reaction can occur within minutes or hours Why should gloves be worn, according to the CDC? - correct answer -1) to reduce the risk of acquiring infections from patients
- to prevent the transmission of flora from health care workers to patients
- to reduce transient contamination of the hands of personnel by flora that can be transmitted from one patient to another **Gloves should NOT be worn from room out into the hallway What are the different aspects of The Process of Communication? - correct answer - Sending (nurse conscious of messages sent), Receiving (receiver uses his or her own interpretations to process sent messages), Internal Factors (nurse maintains respect, empathy, listening factors, self-awareness), External factors (nurse should make sure the physical setting is comfortable) What should be done to prepare for the physical assessment? - correct answer -1) organize the examination
- prepare the environment
- prepare the patient What are the four assessment techniques in order? - correct answer -Inspection, Palpation, Percussion, Auscultation What is the assessment order for the abdomen? - correct answer -Inspection, Auscultation, Percussion, Palpation What should be done during the "inspection" portion of the physical assessment? - correct answer -look carefully and thoroughly at the patient; this offers an overall impression of the patient and severity of the situation
- most revealing and provides a LOT of info
- note symmetry b/w right and left side, skin characteristics, shape of chest, facial features, patient mood
what should be done during the "Palpation" portion of the physical assessment? - correct answer -touch to assess for findings such as texture, temperature, moisture, tenderness, and edema what are the finger pads used to palpate for? - correct answer -- pulses, lymph nodes, small lumps, skin texture, edema what are the palmar surfaces of the fingers and finger joints used to palpate for? - correct answer -firmness, contour, position size, paint and tenderness what is the douse (back side) of the hand used to palpate for? - correct answer - temperature what is the ulnar (outside) surface of the hand used to palpate for? - correct answer -vibratory tremors light palpation - correct answer -assessment of skin characteristics deep palpation - correct answer -firmer, deeper pressure; used to confirm superficial findings and to assess size, shape, and consistency od deep organs What should be done during the "percussion" step of the physical assessment? - correct answer -vibrations are produced through tapping of the skin with short, sharp strokes what does dense tissue vibrations percussions sound like? - correct answer -quiet, flat what does air/fluid sound like when percussed? - correct answer -loud tones what are the different types of sounds used to describe when percussing? - correct answer -resonance, hyperresonance, dull, flat, or tympanic
What are the purposes of the Medical Record? - correct answer -Communication with Other Professionals Credentialing and Quality Assurance Legal Document Regulation and Legislation Financial Reimbursement Research Quality Precess and Performance Improvement What are the principles governing documentation? - correct answer -Confidentiality Accurate, Relevant and Consistent Auditable Clear, Consise, and Complete Legible/Readable Thoughtful Timely, Contemporaneous and Sequential Reflective of the Nursing Process Retreivable on a permanent basis in a nursing-specific manner What does the health history acronym PLEASE stand for? - correct answer -Past medical history Last Oral Intake Events leading up to illness Allergies and types of reactions Symptoms or chief complaint Each prescribed medication Complete Database (part of Health History) - correct answer -a broad, comprehensive assessment that includes a complete health history and a full physical exam
Focused (Problem-Centered) Database - correct answer -more targeted in scope and is based on the patient's specific health issues; used for a limited or short term issue (focuses on mainly one or two problems and body systems) Follow-Up Database - correct answer -involves evaluating any identified problem at regular & appropriate intervals. Asssessing what changes have occurred, if it is getting better or worse. Emergency Database - correct answer -urgent, rapid collection of crucial information during a life-threatening or unstable situation What are the phases of the nursing interview? - correct answer -Introduction, Working Phase, and Close of the Interview Describe the directive interview technique - correct answer -highly structured; nurse controls the elements of the interview; allows nurse to gain precise details about a patient's reported condition Describe the closed or direct interview technique - correct answer -this is when questions ask for specific information and usually yield a short one or two worded response or a forced choice, such as "yes" or "no" ex: How old are you? Describe the non directive interview technique - correct answer -nurse lets the patient control the pace and the information seeking route; useful for developing a rapport with the pt. and contains more open ended questions Describe the open-ended interview technique - correct answer -the nurse asks questions for narrative information and encourages the patient to respond in any way on their own terms (Ex: Describe how you are feeling) symptom - correct answer -subjective sensation that the person feels from the disorder
- education
- social and community aspects
- access to health care
- neighborhood and environment Gravida - correct answer -number of pregnancies term - correct answer -the number of term deliveries preterm - correct answer -the number of preterm deliveries abortions - correct answer -the number of elective or spontaneous living (in regards to obstetrical history) - correct answer -current number of living children What does the functional assessment do? - correct answer -It assesses a person's daily functioning What is ADLs in regards to the functional assessment? - correct answer -Activities of daily living (the ability to meet the needs of daily activities and life) What does the acronym FICA mean when assessing spirituality in Internal Factors? - correct answer -Faith Influence Community Address What does the acronym CAGE stand for when assessing substance use in Internal Factors? - correct answer -Questions to ask: C - Have you ever thought you should Cut down your drinking?
A - Have you every been Annoyed by criticism of your drinking? G - Have you ever felt Guilty about your drinking? E - Do you drink in the morning, an Eye opener? What are some examples of external factors? - correct answer -Occupational health, Living environment, relationships, abuse What is the General Survey used for? - correct answer -a study of the whole person, covering the general health state and any obvious physical characteristics that apply to the whole person, not just to one body system What will the nurse assess in the initial surgery and assessment? - correct answer - patient's:
- physical appearance
- behavior
- body structure
- mobility
- height, weight, BMI, vital signs, and pain measurements What should facial features look like? - correct answer -symmetrical with movement What is the nurse looking for while assessing appearance? - correct answer -facial features, emotional state, eye contact, level of consciousness, skin color What is the nurse looking for while assessing behavior? - correct answer -speech, mood and affect, personal hygiene, dress What is the nurse looking for when assessing body structure? - correct answer - posture, overall build, obvious physical deformities what is the nurse looking for when assessing mobility? - correct answer -gait (manner or style of walking), range of motion, involuntary movements
Healthy weight BMI - correct answer -18.5-24.9 kg/m Overweight BMI - correct answer -25 -29.9 kg/m Obese BMI - correct answer -30 kg/m and above What happens to patients who have a BMI of greater than 30? - correct answer - increased risk for hypertension, diabetes mellitus, cardiovascular disease, some cancers weight gain - correct answer -overabundant caloric intake, unhealthy eating habits, and sedentary lifestyle unexplained weight gain - correct answer -may indicate fluid retention (which could be a result of heart failure) Waist circumference - correct answer -a numerical measurement of the waist, used to assess an individual's abdominal fat and establish ideal body weight;
- excess abdominal fat is a risk factor for diabetes, hypertension, and cardiovascular accidents healthy waist circumference for men - correct answer -less than 40 inches healthy waist circumference for women - correct answer -less than 35 inches What are vital signs? - correct answer -temperature, pulse, respiration, blood pressure, and oxygen saturation what does the hypothalamus do? - correct answer -it is the body's thermostat; maintains a steady temperature and maintains homeostasis
What is the conversion of temperature from celsius to Fahrenheit? - correct answer - C= (F-32) x 5/ 9 what is the conversion of Fahrenheit to Celsius? - correct answer -F = (9 / 5 x C) + 32 normal oral temperature - correct answer -37° C (98.6° F) what is the range of normal temperature? - correct answer -36° to 38° C or 96.8° to 100.4° F rectal route - correct answer -subtract 1° F (b/c it is 1° F higher than oral) axillary and temporal temperature route - correct answer -add 1° F (b/c they both measure 1° F lower than oral) tympanic route - correct answer -consistent with oral; subtract 1° hypothermia - correct answer -low body temperature caused by prolonged exposure to a cold environment hyperthermia - correct answer -also called pyrexia or fever; elevated body temperature that may occur during infection, tissue breakdown, or neurological disorders low grade fever - correct answer -100.4-101.4°F high grade fever - correct answer -higher than 103.1°F what is the most accurate information of core temperature? - correct answer -rectal route
What are the levels of quality of a pulse? - correct answer -0 = absent +1 = weak, thready, diminished +2 = normal, brisk pulse (expected) +3 = increased, strong pulse (more full than normal) +4 = a bounding, full volume pulse what should a normal artery feel like? - correct answer -smooth, straight, and resilient radial pulse - correct answer -located in groove on the thumb side of the forearm just below the wrist brachial pulse - correct answer -located in the bend of the elbow on the inner aspect of the arm b/w the biceps and triceps muscle femoral pulse - correct answer -located halfway between the pubis and interior superior iliac spines; * use firm pressure to locate popliteal pulse - correct answer -located behind the knee in the popliteal fossa; difficult to palpate posterior tibial pulse - correct answer -located in the groove behind the ankle bond and Achilles tendon dorsalis pedis pulse - correct answer -located on the top of the foot b/w extensor tendons of the first and second toes in cardiac emergencies, which pulses are assessed and why? - correct answer -the carotid and femoral pulses; because they are larger, closer to heart, and more accurate to reflect heart's activity pulse deficit - correct answer -indirect evaluation of the ability of each heart contraction to eject enough blood into peripheral circulation to create a pulse
Pulse Oxygen saturation (SPO2) - correct answer -percentage to which hemoglobin is filled with oxygen pulse oximetry - correct answer -noninvasive technique to measure oxygen saturation of arterial blood (clip on device placed on person's finger) normal arterial saturations - correct answer -95-100% hypoxia - correct answer -oxygen sat level less than 90% respiration - correct answer -the act of breathing rate of respirations - correct answer -the respiratory rate is a count of each inspiration-expiration pair in 1 minute (count for 30 seconds and multiply by 2 if rhythm is regular) normal respiratory rate - correct answer -12-20 breaths/minute tachypnea - correct answer -rapid, persistent respiratory rate greater than 20 breaths/min bradypnea - correct answer -persistent respiratory rate less than 12 breaths/minute apnea - correct answer -absence of spontaneous respirations for more than 10 seconds depth of respirations - correct answer -measured by an even, quiet, and regular breathing pattern dyspnea - correct answer -difficult breathing
what could contribute to falsely high BP readings? - correct answer -a cuff that is too loose or too narrow how should a patient be positioned while taking their blood pressure? - correct answer -they can be lying supine or sitting; arm should be at heart level and palm upward. If patient is sitting, feet should be FLAT on the floor and uncrossed legs Korotkoff sounds - correct answer -sounds heard when blood pressure is being auscultated what are the five phases of Korotkoff sounds? - correct answer -1) first appearance of faint but clear tapping sounds; first tapping sound is systolic pressure
- muffled or swishing sounds due to turbulence of blood flow
- distinct, loud tapping sounds as blood flows relatively freely through an open artery
- abrupt, muffling sound as cuff pressure falls below vessel pressure
- last sound heart before a period of continuous silence; last sound heard is the diastolic pressure how should you access orthostatic (postural) vital signs? - correct answer -assess the BP and the heart rate with the patient supine, sitting, and standing waiting at least 1 to 2 minutes after each position change to access the readings orthostatic hypotension - correct answer -occurs with an increased heart rate or a drop in SBP or 15 mmHg or greater; or a drop in DBP of 10 mmHg or greater What is the normal degree of the nails? - correct answer -160 degrees pallor - correct answer -paleness/light skin; no circulation to skin whatsoever; CIRUCLATION related cyanosis - correct answer -blueish, mottled discoloration of skin; RESPIRATORY RELATED
erythema - correct answer -caused by inflammation; skin is an intense red color ecchymosis - correct answer -bruises jaundice - correct answer -yellow discoloration of the skin due to liver failure; increase in levels of bilirubin (byproduct of the breakdown of red blood cells); seen in sclera and hard palate what should skin texture feel like? - correct answer -smooth, firm, soft and flexible with an even surface what does skin and hair feel like in a pt with hyperthyroidism? - correct answer - velvety skin; silky hair what does skin and hair feel like in a pt with hypothyroidism? - correct answer - rough, dry, flaky skin; dry and brittle hair diaphoresis - correct answer -profuse perspiration from an increased metabolic rate that occurs in fever, thyroid disorders, and increased activity What does the mnemonic ABCDE stand for when assessing abnormal characteristics of lesions? - correct answer -A - Asymmetry B - Border C - Color D - Diameter over 6 mm E - Elevation and enlargement vascular lesions - correct answer -result of blood leaking from blood vessels into dermis petechiae - correct answer -tiny red dots on the skin
